Population trends in prenatal detection of transposition of great arteries: impact of obstetric screening ultrasound guidelines

OBJECTIVES

Dextro-transposition of the great arteries (d-TGA) is one of the most common critical neonatal heart defects, with a low detection rate antenatally. We sought to evaluate trends in the prenatal detection of d-TGA with or without ventricular septal defect (VSD) in Alberta over the past 13 years, examining the potential impact of ultrasound guidelines incorporating screening of cardiac outflow tracts, updated in 2009-2010 and in 2013, and factors affecting detection of the condition.

METHODS

All fetuses and neonates with d-TGA, with or without VSD, encountered between 2003 and 2015 in the province of Alberta, were identified retrospectively. Clinical records including obstetric ultrasound reports were reviewed. Pregnancy outcome, common referral indications and associated maternal and fetal pathology in affected pregnancies were assessed.

RESULTS

From 2003 to 2015, 127 cases with d-TGA were encountered in Alberta, of which 47 (37%) were detected prenatally. Prenatal detection improved over the study period, from 14% in 2003-2010, to 50% in 2011-2013, and to 77% in 2014-2015. Of the 47 fetuses with a prenatal diagnosis of d-TGA, an indication for fetal echocardiography included abnormal or poorly visualized cardiac outflows with normal four-chamber view in 46 (98%). Comorbidities were identified in 12 mothers, only five of which represented an additional reason for fetal echocardiography referral, and four fetuses had extracardiac pathology.

CONCLUSION

Substantial improvement in the prenatal detection of d-TGA has been observed in Alberta over the past few years, owing to improved screening of cardiac outflow tracts on routine obstetric ultrasound examination in otherwise healthy pregnancies, and has been temporally associated with updated obstetric ultrasound guidelines suggesting that these contributed to optimized screening of affected pregnancies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Role of antioxidant enzyme expression in the selective cytotoxic response of glioma cells to gamma-linolenic acid supplementation

We hypothesized that the cytotoxic effect of GLA observed in glioma but not normal glial cells reflects differences in GLA metabolism and/or antioxidant enzyme levels between these cells. The PUFA content of unsupplemented glioma cells was approximately 50% of that seen in unsupplemented astrocytes. Supplementation with 20 microM GLA for 24 h led to a 230 and 22% increase in glioma and astrocyte PUFA content, respectively, such that both supplemented cell types contained similar levels of PUFA. No major differences were seen in terms of GLA metabolites retained in the cells or secreted into the media following incubation with [(3)H]-GLA. No significant differences were observed in activity of MnSOD or CuZn-SOD between the cells. However, CAT and GPx activity in the glioma cells was significantly higher and lower, respectively, than observed in normal astrocytes. GLA supplementation resulted in a significant increase in CAT activity in normal astrocytes; glioma CAT activity was unchanged. No significant change was seen in the other antioxidant enzymes following GLA supplementation. These results suggest that the cytotoxic effect of GLA on glioma cells reflects both increased PUFA content and an inability to upregulate CAT.

Establishment and characterization of first trimester human trophoblast cells with extended lifespan

We established trophoblast cell cultures with extended lifespans by introducing into first trimester human trophoblasts the gene encoding simian virus 40 large T antigen. The transfected trophoblasts were characterized according to their expression of various morphological and functional markers. Both parental (HTR-8) and transfected (HTR-8/SVneo) lines were morphologically similar and positive for cytokeratin, confirming their epithelial (trophoblastic) identity. Whereas the parental cells senesced after 12-14 passages, the transfectants have been in culture for over 32 passages. Human chorionic gonadotrophin was detected only in the HTR-8/SVneo cells and not in the parental cells. Both lines required at least 5% serum in order to sustain growth in vitro and responded to transforming growth factor-beta (TGF-beta) with reduced [3H]-thymidine incorporation in a dose-dependent manner. Treatment with TGF-beta also resulted in decreased secretion of plasminogen activators (PAs) and reduced PA activity by both lines. Both cell lines secreted mostly 72-kDa type IV collagenase as determined by substrate gel zymography, but the level of secretion of this enzyme was not significantly affected by TGF-beta in either line. Even though both lines exhibited similar in vitro invasive abilities, only the invasiveness of the parental cells was reduced by TGF-beta. Neither parental or transfected cells were capable of growth in soft agar and no sign of tumor formation was evident more than 5 months after subcutaneous inoculation of the transfected cells into nude mice. These results indicate that apart from their ability to sustain prolonged growth in culture, the transfected HTR-8/SVneo cells share a number of phenotypic properties with the parental trophoblast cells. For this reason, these transfected trophoblasts may prove to be an important tool for the study of placental function and/or tumor progression.

Prophylactic oral naltrexone with epidural morphine: effect on adverse reactions and ventilatory responses to carbon dioxide

The influence of two different doses of oral naltrexone on the adverse effects and the analgesia of epidural morphine were compared in a double-blind, placebo-controlled study. Forty-five patients undergoing cesarean section were provided postoperative analgesia with 4 mg epidural morphine. Five minutes later they received 6 mg naltrexone, 9 mg naltrexone, or placebo as an oral solution. Pain relief was assessed by the Visual Analog Scale (VAS) and by direct questioning of the patients. Requirement for additional analgesics and side effects were noted. Respiratory effects of epidural morphine and naltrexone were assessed using the ventilatory responses to CO2 and by monitoring O2 saturation (Spo2) using pulse oximetry. All patients in the placebo group had adequate analgesia. One of the 15 patients who received naltrexone 6 mg had inadequate analgesia versus five of the 15 patients who received naltrexone 9 mg (P less than 0.05), 9 mg versus placebo. Ten patients (67%) in the placebo group had pruritus while no patient in the 6 mg naltrexone group and one patient in the 9 mg group experienced mild pruritus (P less than 0.05), placebo versus other two groups. The CO2 response slopes were depressed compared to control values from 6-16 h in the placebo group, from 6-12 h in the 6 mg naltrexone group. No significant depression was noted in the 9 mg naltrexone group. The authors conclude that oral naltrexone 6 mg significantly reduces the incidence of pruritus associated with epidural morphine without affecting analgesia and that 9 mg naltrexone is associated with shorter duration of analgesia than 6 mg naltrexone.

Bupivacaine/butorphanol/epinephrine for epidural anesthesia in obstetrics: maternal and neonatal effects

The effects of epidural bupivacaine/butorphanol with and without 1:300,000 epinephrine on maternal analgesia, uterine activity, progress of labor, fetal heart rate, maternal blood pressure, newborn Apgar scores, neonatal acid base status and the neurologic and adaptive capacity scores (NACS) were compared in 33 parturients during labor and delivery. Patients in Group I (n = 17) received 0.25% bupivacaine plus 1 mg butorphanol plus 1:300,000 epinephrine, and those in Group II (n = 16) received the same agents without the epinephrine. Addition of epinephrine to bupivacaine/butorphanol did not have any adverse effects on uterine activity, duration of first or second stages of labor or fetal heart rate parameters. The incidence of maternal hypotensive episodes did not differ significantly between the two groups of patients. Apgar scores, neonatal acid base status and the NACS were equally good and did not differ significantly between the two groups. Duration of analgesia was significantly longer in Group I as compared to Group II patients (177.5 +/- 11 versus 131.8 +/- 10 minutes, p less than 0.01). It is concluded that addition of epinephrine 1:300,000 to bupivacaine/butorphanol during epidural anesthesia in the normal parturient has no adverse effects on the mother, fetus or neonate or on the progress of labor and it significantly prolongs the duration of analgesia.

Epidural morphine or butorphanol augments bupivacaine analgesia during labor

To determine the efficacy and the safety of epidural morphine or butorphanol combined with bupivacaine, 40 healthy parturients were studied during labor and delivery. All patients received an epidural test dose of 2 ml of 0.5% bupivacaine. Patients were then randomly assigned to receive one of four epidural regimens in a double-blind fashion: 0.25% bupivacaine + 1 mg butorphanol (Group I), 0.25% bupivacaine + 2 mg butorphanol (Group II), 0.25% bupivacaine + 2 mg morphine (Group III), or 0.25% bupivacaine alone (Group IV). Each group consisted of ten patients. All subsequent epidural injections were with plain 0.25% bupivacaine. Duration of analgesia was significantly longer for groups I, II, and III when compared to group IV (p less than or equal to .01); 139 +/- 111, 141 +/- 14, 199 +/- 29, and 96 +/- 6 minutes, X +/- SEM respectively. Quality of analgesia was significantly better in groups I, II, and III when compared with group IV. There were no differences between groups in duration of first and second stages of labor, uterine activity, or method of delivery. Thirty percent of patients in the morphine group (group III) developed mild pruritus that did not require any treatment. All neonates were vigorous at 5 minutes and had good Apgar Scores, umbilical cord acid base status, and Neurological Adaptive Capacity Scores. The authors conclude that adding small doses of either morphine or butorphanol to epidural bupivacaine during labor is effective and safe. Butorphanol may be preferable since none of the patients experienced pruritus.