Valvoplastia aórtica por cateter-balão em emergência materno-fetal na adolescência

O aumento do débito cardíaco durante a gravidez é causa de insuficiência cardíaca em portadoras de estenose valvar aórtica grave. A valvoplastia aórtica percutânea tem sido associada a graves complicações e reestenose valvar em curto prazo. O presente caso mostrou que a valvoplastia aórtica percutânea permitiu o alcance do parto com sobrevida da mãe e do feto, e que a interrupção do tratamento no pós-parto resultou em morte materna no puerpério tardio.

Disfunção do homoenxerto pulmonar utilizado na reconstrução do trato de saída do ventrículo direito

FUNDAMENTO: O homoenxerto pulmonar tem sido utilizado como uma opção na correção de cardiopatia congênita com obstrução da via de saída do ventrículo direito. Os resultados em longo prazo, no entanto, mostram-se pouco satisfatórios. OBJETIVO: Identificar os fatores de risco associados à disfunção e à falência do homoenxerto pulmonar. MÉTODOS: Estudo em crianças submetidas à ampliação da via de saída do ventrículo direito com homoenxerto pulmonar. As variáveis clínicas, cirúrgicas, evolutivas e de aspectos morfológicos da prótese foram analisadas como fatores de risco. RESULTADOS: A amostra final de 75 pacientes com idade mediana na cirurgia de 22 meses, variando de 1-157 meses, apresentou 13 pacientes (17,0%) que desenvolveram disfunção do homoenxerto, caracterizado por estenose ou insuficiência pulmonar grave. O tempo de ocorrência entre o implante do homoenxerto e a detecção da disfunção foi de 45 ± 20 meses. Quando o tamanho do homoenxerto foi menor de 21 mm e o escore Z da valva pulmonar foi menor do que zero, ou maior do que três, foram considerados fatores de risco para a ocorrência de disfunção. CONCLUSÃO: O homoenxerto pulmonar de tamanho menor do que 21 mm e a valva pulmonar inadequada para idade e peso do paciente são fatores determinantes para disfunção da prótese.

Curva de referência da área do septo interventricular fetal pelo método STIC: estudo preliminar

FUNDAMENTO: A detecção precoce de alterações septais, tais como a hipertrofia septal comumente presente em fetos de mães diabéticas, contribuiria para a redução das altas taxas de mortalidade infantil. OBJETIVO: Determinar intervalos de referência para a área do septo interventricular fetal por meio da ultrassonografia tridimensional (US3D) utilizando o método STIC (Spatio-Temporal Image Correlation). MÉTODOS: Realizou-se um estudo de corte transversal com 69 gestantes normais entre a 18ª e 33ª semanas de gestação. Utilizou-se como referência o plano de quatro câmaras com a ROI (Região de Interesse) posicionada a partir dos ventrículos, sendo a área do septo delimitada de modo manual. Para se avaliar a correlação da área do septo interventricular com a idade gestacional (IG), construíram-se diagramas de dispersão e calculou-se o coeficiente de correlação de Pearson (r), sendo o ajuste realizado pelo coeficiente de determinação (R²). Foram calculadas médias, medianas, desvios-padrão (dp), valores máximo e mínimo. Para o cálculo da reprodutibilidade intraobservador, utilizou-se o coeficiente de correlação intraclasse (CCI). Obteve-se a medida da espessura do septo interventricular e ela foi correlacionada com a IG e a área septal obtida pelo modo renderizado em 52 pacientes utilizando-se o CCI. RESULTADOS: A área do septo interventricular foi altamente correlacionada com a idade gestacional (r = 0,81), e a média aumentou de 0,47 cm² na 18ª para 2,42 cm² na 33ª semana de gestação. A reprodutibilidade intraobservador foi excelente com CCI = 0,994. Não se observou correlação significativa entre a medida do septo interventricular e a IG (R² = 0,200), assim como não houve correlação com a área do septo obtida pelo modo renderizado com CCI = 0,150. CONCLUSÃO: Intervalos de referência para a área do septo interventricular entre a 18ª e 33ª semanas de gestação foram determinados e se mostraram altamente reprodutíveis.

Restrição materna de polifenóis e dinâmica ductal fetal na gestação normal: um ensaio clínico aberto

FUNDAMENTOS: Recentemente demonstramos reversão da constrição ductal fetal após redução da ingesta materna de alimentos ricos em polifenóis (ARP), por sua ação inibidora da síntese das prostaglandinas. OBJETIVOS: Testar a hipótese de que fetos normais no 3º trimestre também melhoram a dinâmica ductal após restrição materna de polifenóis. MÉTODOS: Ensaio clínico aberto com 46 fetos com idade gestacional (IG) > 28 semanas submetidos a dois estudos Dopplerecocardiográficos com intervalo de duas semanas, sendo os examinadores cegados para os hábitos alimentares maternos. Um questionário de frequência alimentar validado para esse objetivo foi aplicado e uma dieta com alimentos pobres em polifenóis (< 30 mg/100 mg) foi orientada. Um grupo controle de 26 fetos no 3º trimestre foi submetido ao mesmo protocolo. Utilizou-se o teste-t para amostras independentes. RESULTADOS: A IG média foi 33 ± 2 semanas. A média do consumo materno diário de polifenóis (CMDP) foi 1277 mg, caindo para 126 mg após orientação (p = 0,0001). Ocorreu diminuição significativa nas Velocidades Ductais Sistólica (VSD) e Diastólica (VDD) e na relação dos diâmetros ventriculares (VD/VE), assim como aumento do índice de pulsatilidade (IP) [VSD = 1,2 ± 0,4 m/s (0,7-1,6) para 0,9 ± 0,3 m/s (0,6-1,3) (p = 0,018);VDD = 0,21 ± 0,09 m/s (0,15-0,32) para 0,18 ± 0,06 m/s (0,11-0,25) (p = 0,016); relação VD/VE = 1,3 ± 0,2 (0,9-1,4) para 1,1 ± 0,2 (0,8 - 1,3) (p = 0,004); IP do ducto = 2,2 ± 0,03 (2,0-2,7) para 2,4 ± 0,4 (2,2-2,9) (p = 0,04)]. A IG média dos controles foi de 32 ± 4 semanas, não ocorrendo diferenças significativas no CMDP, nas velocidades ductais, no IP do ducto e na relação VD/VE. CONCLUSÃO: A restrição da ingesta de alimentos ricos em polifenóis no 3º trimestre por duas semanas melhora a dinâmica do fluxo no ducto arterioso fetal e as dimensões do VD.

Mudanças morfológicas no trato digestório e composição da dieta de larvas e juvenis do linguado catathyridium jenynsii no reservatório de Itaipu, rio Paraná, Brasil

O objetivo deste trabalho foi caracterizar a dieta e a morfologia do trato digestório do linguado, Catathyridium jenynsii (Günther, 1862) (Achiridae), em seus estágios iniciais de vida. Para análise do trato digestório, foi utilizado um exemplar de cada estágio larval, de pré-flexão até pós-flexão, e juvenil. Um total de 256 larvas e 16 juvenis, pertencentes a cinco classes de comprimento padrão, foi analisado quanto à dieta. Os dados foram coletados no reservatório de Itaipu, rio Paraná, Brasil, de setembro/2001 a março/2002 e setembro/2002 a fevereiro/2003. Para análise dos dados, foram aplicados os métodos de ocorrência e numérico para a determinação da frequência de ocorrência e numérica de cada item alimentar nas diferentes classes de comprimento padrão. A região anterior do trato digestório de C. jenynsii, começou a diferenciar-se em estômago partir de 4,70 mm CP (não apresentou cecos pilóricos). Desde o estágio de pré-flexão, verificou-se três dobras intestinais e várias estrias no trato digestório. A análise da dieta revelou que as larvas menores (classe 1) apresentaram uma dieta distinta, com dominância de cladóceros (especialmente Bosmina hagmanni e Bosminopsis deitersi). Para a classe 2, o copépodo Notodiaptomus sp. foi importante tanto em número quanto em ocorrência, entretanto B. hagmanni, ainda teve participação significativa na dieta. Já as larvas maiores (classes 3, 4) e juvenis (classe 5) apresentaram uma dieta similar, consumindo principalmente os copépodos (Notodiaptomus sp.). Portanto, neste estudo as larvas de C. jenynsii podem ser consideradas zooplanctívoras, já que em todos os estágios de desenvolvimento, cladóceros e copédodos dominaram a dieta. As alterações na dieta acompanharam as modificações morfológicas dos estágios iniciais de C. jenynsii.

Cultured human fetal astrocytes can be induced by interferon-gamma to express HLA-DR.

Interferon-gamma (IFN-gamma) modulates the expression of Class II major histocompatibility antigens (MHC), thus providing a potential regulatory mechanism for local immune reactivity in the context of MHC-restricted antigen presentation. Within the central nervous system (CNS), the expression of MHC Class II antigens has been demonstrated on human reactive astrocytes and glioma cells. In order to investigate the modulation of HLA-DR on normal astrocytes, two cell lines were grown from a 20-week-old fetal brain. In situ none of the fetal brain cells expressed HLA-DR as determined by immunohistology on frozen tissue sections. The two cell lines, FB I and FB II, expressed GFAP indicating their astrocytic origin. FB I was HLA-DR negative at the first tissue culture passages, but could be induced to express HLA-DR when treated with 500 U/ml IFN-gamma. FB II was spontaneously HLA-DR positive in the early passages, lost the expression of this antigen after 11 passages and could also be induced to express HLA-DR by IFN-gamma. The induction of HLA-DR expression was demonstrated both by a binding RIA and by immunoprecipitation using a monoclonal antibody (MAB) directed against a monomorphic determinant of HLA-DR. The HLA-DR alloantigens were determined on FB II cells after IFN-gamma treatment, by immunofluorescence and by cytotoxicity assays, and were shown to be DR4, DR6, Drw52, DRw53 and DQwl. These results show that human fetal astrocytes can be induced to express HLA-DR by IFN-gamma in vitro and support the concept that astrocytes may function as antigen-presenting cells.

Developmental expression of glial fibrillary acidic protein and glutamine synthetase in serum-free aggregating cell cultures of fetal rat telencephalon.

Serum-free aggregating cell cultures of fetal rat telencephalon were examined by a combined biochemical and double-labeling immunocytochemical study for the developmental expression of glial fibrillary acidic protein (GFAP) and glutamine synthetase (GS). It was found that these two astroglial markers are co-expressed at different developmental stages in vitro. During the phase of cellular maturation (i.e. between days 14 and 34), GFAP levels and GS activity increase rapidly and in parallel. At the same time, the number of immunoreactive cells increase while the long and thick processes staining in early cultures gradually disappear. The present results demonstrate that in this particular cell culture system only one type of astrocytes develops which expresses both GFAP and GS and which attains a relatively high degree of maturation.

Maternal coping, appraisals and adjustment following diagnosis of fetal anomaly.

OBJECTIVE: So far, associations between appraisals, maternal adjustment and coping following diagnosis of fetal anomaly have not been investigated in women who continue with their pregnancy. METHOD: This study measured maternal coping and adjustment after and appraisal of a diagnosis of fetal anomaly in 40 mothers who had continued with their pregnancy using a cross-sectional questionnaire design. RESULTS: Based on retrospective reporting, 35% of participants met full diagnostic criteria for post-traumatic stress disorder after having received the diagnosis. Women were significantly more depressed (p < 0.001) and anxious (p < 0.001) and reported significantly less positive affect (p < 0.05) after having received the diagnosis in comparison to the time after childbirth. There were no significant differences between emotion-focused and problem-focused coping. Stressful life events, women's age, number of people providing support and problem-focused coping explained 57.6% of variance in anxiety and depression after childbirth. Satisfaction with social support, emotion-focused coping and problem-focused coping significantly explained 40.6% of variance in positive affect after childbirth. CONCLUSION: Following a prenatal diagnosis and for the remainder of their pregnancy, particular attention should be paid to older mothers, those experiencing additional stressful life events and those who are socially isolated, as these women may experience greater distress after childbirth.

An alteration in the levels of populations of CD4+ Treg is in part responsible for altered cytokine production by cells of aged mice which follows injection with a fetal liver extract.

We have shown previously that a fetal sheep liver extract (FSLE) containing significant quantities of fetal ovine gamma globin chain (Hbgamma) and LPS injected into aged (>20 months) mice could reverse the altered polarization (increased IL-4 and IL-10 with decreased IL-2 and IFNgamma) in cytokine production seen from ConA stimulated lymphoid cells of those mice. The mechanism(s) behind this change in cytokine production were not previously investigated. We report below that aged mice show a >60% decline in numbers and suppressive function of both CD4(+)CD25(+)Foxp3(+) Treg and so-called Tr3 (CD4(+)TGFbeta(+)), and that their number/function is restored to levels seen in control (8-week-old) mice by FSLE. In addition, on a per cell basis, CD4(+)CD25(-)Treg from aged mice were >4-fold more effective in suppression of proliferation and IL-2 production from ConA-activated lymphoid cells of a pool of CD4(+)CD25(-)T cells from 8-week-old mice than similar cells from young animals, and this suppression by CD25(-)T cells was also ameliorated following FSLE treatment. Infusion of anti-TGFbeta and anti-IL-10 antibodies in vivo altered Treg development following FSLE treatment, and attenuated FSLE-induced alterations in cytokine production profiles.

Evaluation of prenatal ultrasound diagnosis of fetal abdominal wall defects by 19 European registries.

OBJECTIVES: To evaluate the current effectiveness of routine prenatal ultrasound screening in detecting gastroschisis and omphalocele in Europe. DESIGN: Data were collected by 19 congenital malformation registries from 11 European countries. The registries used the same epidemiological methodology and registration system. The study period was 30 months (July 1st 1996-December 31st 1998) and the total number of monitored pregnancies was 690,123. RESULTS: The sensitivity of antenatal ultrasound examination in detecting omphalocele was 75% (103/137). The mean gestational age at the first detection of an anomaly was 18 +/- 6.0 gestational weeks. The overall prenatal detection rate for gastroschisis was 83% (88/106) and the mean gestational age at diagnosis was 20 +/- 7.0 gestational weeks. Detection rates varied between registries from 25 to 100% for omphalocele and from 18 to 100% for gastroschisis. Of the 137 cases of omphalocele less than half of the cases were live births (n = 56; 41%). A high number of cases resulted in fetal deaths (n = 30; 22%) and termination of pregnancy (n = 51; 37%). Of the 106 cases of gastroschisis there were 62 (59%) live births, 13 (12%) ended with intrauterine fetal death and 31 (29%) had the pregnancies terminated. CONCLUSIONS: There is significant regional variation in detection rates in Europe reflecting different policies, equipment and the operators' experience. A high proportion of abdominal wall defects is associated with concurrent malformations, syndromes or chromosomal abnormalities, stressing the need for the introduction of repeated detailed ultrasound examination as a standard procedure. There is still a relatively high rate of elective termination of pregnancies for both defects, even in isolated cases which generally have a good prognosis after surgical repair.

Central and Cortical Gray Mater Segmentation of Magnetic Resonance Images of the Fetal Brain

Motivation. The study of human brain development in itsearly stage is today possible thanks to in vivo fetalmagnetic resonance imaging (MRI) techniques. Aquantitative analysis of fetal cortical surfacerepresents a new approach which can be used as a markerof the cerebral maturation (as gyration) and also forstudying central nervous system pathologies [1]. However,this quantitative approach is a major challenge forseveral reasons. First, movement of the fetus inside theamniotic cavity requires very fast MRI sequences tominimize motion artifacts, resulting in a poor spatialresolution and/or lower SNR. Second, due to the ongoingmyelination and cortical maturation, the appearance ofthe developing brain differs very much from thehomogenous tissue types found in adults. Third, due tolow resolution, fetal MR images considerably suffer ofpartial volume (PV) effect, sometimes in large areas.Today extensive efforts are made to deal with thereconstruction of high resolution 3D fetal volumes[2,3,4] to cope with intra-volume motion and low SNR.However, few studies exist related to the automatedsegmentation of MR fetal imaging. [5] and [6] work on thesegmentation of specific areas of the fetal brain such asposterior fossa, brainstem or germinal matrix. Firstattempt for automated brain tissue segmentation has beenpresented in [7] and in our previous work [8]. Bothmethods apply the Expectation-Maximization Markov RandomField (EM-MRF) framework but contrary to [7] we do notneed from any anatomical atlas prior. Data set &Methods. Prenatal MR imaging was performed with a 1-Tsystem (GE Medical Systems, Milwaukee) using single shotfast spin echo (ssFSE) sequences (TR 7000 ms, TE 180 ms,FOV 40 x 40 cm, slice thickness 5.4mm, in plane spatialresolution 1.09mm). Each fetus has 6 axial volumes(around 15 slices per volume), each of them acquired inabout 1 min. Each volume is shifted by 1 mm with respectto the previous one. Gestational age (GA) ranges from 29to 32 weeks. Mother is under sedation. Each volume ismanually segmented to extract fetal brain fromsurrounding maternal tissues. Then, in-homogeneityintensity correction is performed using [9] and linearintensity normalization is performed to have intensityvalues that range from 0 to 255. Note that due tointra-tissue variability of developing brain someintensity variability still remains. For each fetus, ahigh spatial resolution image of isotropic voxel size of1.09 mm is created applying [2] and using B-splines forthe scattered data interpolation [10] (see Fig. 1). Then,basal ganglia (BS) segmentation is performed on thissuper reconstructed volume. Active contour framework witha Level Set (LS) implementation is used. Our LS follows aslightly different formulation from well-known Chan-Vese[11] formulation. In our case, the LS evolves forcing themean of the inside of the curve to be the mean intensityof basal ganglia. Moreover, we add local spatial priorthrough a probabilistic map created by fitting anellipsoid onto the basal ganglia region. Some userinteraction is needed to set the mean intensity of BG(green dots in Fig. 2) and the initial fitting points forthe probabilistic prior map (blue points in Fig. 2). Oncebasal ganglia are removed from the image, brain tissuesegmentation is performed as described in [8]. Results.The case study presented here has 29 weeks of GA. Thehigh resolution reconstructed volume is presented in Fig.1. The steps of BG segmentation are shown in Fig. 2.Overlap in comparison with manual segmentation isquantified by the Dice similarity index (DSI) equal to0.829 (values above 0.7 are considered a very goodagreement). Such BG segmentation has been applied on 3other subjects ranging for 29 to 32 GA and the DSI hasbeen of 0.856, 0.794 and 0.785. Our segmentation of theinner (red and blue contours) and outer cortical surface(green contour) is presented in Fig. 3. Finally, torefine the results we include our WM segmentation in theFreesurfer software [12] and some manual corrections toobtain Fig.4. Discussion. Precise cortical surfaceextraction of fetal brain is needed for quantitativestudies of early human brain development. Our workcombines the well known statistical classificationframework with the active contour segmentation forcentral gray mater extraction. A main advantage of thepresented procedure for fetal brain surface extraction isthat we do not include any spatial prior coming fromanatomical atlases. The results presented here arepreliminary but promising. Our efforts are now in testingsuch approach on a wider range of gestational ages thatwe will include in the final version of this work andstudying as well its generalization to different scannersand different type of MRI sequences. References. [1]Guibaud, Prenatal Diagnosis 29(4) (2009). [2] Rousseau,Acad. Rad. 13(9), 2006, [3] Jiang, IEEE TMI 2007. [4]Warfield IADB, MICCAI 2009. [5] Claude, IEEE Trans. Bio.Eng. 51(4) (2004). [6] Habas, MICCAI (Pt. 1) 2008. [7]Bertelsen, ISMRM 2009 [8] Bach Cuadra, IADB, MICCAI 2009.[9] Styner, IEEE TMI 19(39 (2000). [10] Lee, IEEE Trans.Visual. And Comp. Graph. 3(3), 1997, [11] Chan, IEEETrans. Img. Proc, 10(2), 2001 [12] Freesurfer,http://surfer.nmr.mgh.harvard.edu.

Inexperienced sonographers can successfully visualize and assess a three-dimensional image of the fetal face using a standardized ultrasound protocol

Introduction: A standardized three-dimensional ultrasonographic (3DUS) protocol is described that allows fetal face reconstruction. Ability to identify cleft lip with 3DUS using this protocol was assessed by operators with minimal 3DUS experience. Material and Methods: 260 stored volumes of fetal face were analyzed using a standardized protocol by operators with different levels of competence in 3DUS. The outcomes studied were: (1) the performance of post-processing 3D face volumes for the detection of facial clefts; (2) the ability of a resident with minimal 3DUS experience to reconstruct the acquired facial volumes, and (3) the time needed to reconstruct each plane to allow proper diagnosis of a cleft. Results: The three orthogonal planes of the fetal face (axial, sagittal and coronal) were adequately reconstructed with similar performance when acquired by a maternal-fetal medicine specialist or by residents with minimal experience (72 vs. 76%, p = 0.629). The learning curve for manipulation of 3DUS volumes of the fetal face corresponds to 30 cases and is independent of the operator's level of experience. Discussion: The learning curve for the standardized protocol we describe is short, even for inexperienced sonographers. This technique might decrease the length of anatomy ultrasounds and improve the ability to visualize fetal face anomalies.

Cholinergic neurons of fetal rat telencephalon in aggregating cell culture respond to NGF as well as to protein kinase C-activating tumor promoters.

Serum-free aggregating cell cultures of fetal rat telencephalon treated with the potent tumor promoter phorbol 12-myristate 13-acetate (PMA) showed a dose-dependent, persistent stimulation of the enzymes choline acetyltransferase (ChAT), glutamic acid decarboxylase and glutamine synthetase. After elimination of the proliferating cells by treatment of the cultures with Ara-C (0.4 microM) only the cholinergic marker enzyme, ChAT, could be stimulated by tumor promoters. The non-promoting phorbol ester, 4 alpha-phorbol 12,13-didecanoate proved to be inactive in these cultures, whereas the potent non-phorbol tumor promoter, mezerein, produced an even greater stimulatory effect than PMA. Since PMA and mezerein are potent and specific activators of protein kinase C, the present results suggest a role for this second messenger in the development of cholinergic telencephalon neurons. Stimulation of ChAT required prolonged exposure (48 h) of the cultures to PMA and the responsiveness of the cholinergic neurons to the tumor promoters decreased with progressive cellular maturation. The cholinergic telencephalon neurons showed the same pattern of responsiveness for tumor promoters as for nerve growth factor (NGF). However, the combined treatment with NGF and either PMA or mezerein produced an additive stimulatory effect, suggesting somewhat different mechanisms of action.