BACKGROUND Non-central cord insertion has been associated with diminished chorionic vascular distribution in singleton placentas. The choriovascular correlates of peripheral cord insertion in diamniotic-monochorionic twin placentas remain undetermined. AIM To study the association between type of cord insertion and choriovascular distribution of both twin territories in diamniotic-monochorionic twin placentas. DESIGN A prospective cohort of 138 monochorionic placentas was examined at Women and Infants Hospital between 2009 and early 2011. Thirty-five cases (25%), including disrupted placentas, placentas from higher order multiples and placentas from pregnancies complicated by twin-to-twin transfusion syndrome, were excluded. The correlation between cord insertion type and superficial choriovascular distribution was studied in the remaining 103 dye-injected diamniotic-monochorionic placentas. Cord insertion was categorized as paracentral, marginal or velamentous. The choriovascular distribution of each individual twin territory was assessed by analysis of number and density (number per surface area) of perforating chorionic arteries (PCA). RESULTS In contrast with singleton placentas, there was no correlation between cord insertion type and a twin's own choriovascular distribution in diamniotic-monochorionic placentas. However, a strong correlation was found between the choriovascular distribution of one twin and the cord insertion type of the opposite twin. For a twin with paracentral or marginal cord insertion, the PCA density was significantly higher if the co-twin had a velamentous cord insertion than if the co-twin had a paracentral cord insertion (P < 0.001 and P < 0.05, respectively). Similarly, the PCA density of a twin with velamentous cord insertion tended to be higher if the co-twin had a velamentous, rather than paracentral cord insertion (P = 0.09). CONCLUSIONS This is the first study to suggest that in diamniotic-monochorionic twin gestations, the choriovascular architecture correlates with the cord insertion type of the co-twin. In general, velamentous cord insertion is associated with expanded choriovascular distribution in the opposite twin territory. Our observations may reflect novel manifestations of twin interdependence in monochorionic pregnancies.

Laparoscopic hernia repair offers the potential for more rapid recovery in patients compared with standard anterior herniorrhaphy. Whether the procedure can be performed safely and effectively has yet to be determined. Long-term success will depend on the ability to adhere to the basic principles of traditional hernia repair, maintain low recurrence rates, and achieve rapid return of the patient to work. Inguinal anatomy as viewed through the laparoscope is unfamiliar to most surgeons. The potential for complications requiring laparotomy is increased with laparoscopic hernia repair and dissection in this region requires precise knowledge of the anatomic relationships. Photographic representations of cadaver dissections of the intra-abdominal inguinal region are displayed, and detailed descriptions applicable anatomic structures are presented. A laparoscopic approach for the repair of inguinal and femoral hernia is provided, based on sound comprehension of anatomic relationships.

OBJECTIVE: The purpose of this study was to construct new reference ranges for serial measurements of commonly used umbilical artery Doppler indices (pulsatility index, resistance index, and systolic:diastolic ratio). STUDY DESIGN: This was a prospective longitudinal study of the umbilical artery Doppler indices that were obtained serially at the free-loop of umbilical cord at 4-week intervals at 19 to 42 weeks of gestation in 130 low-risk singleton pregnancies. A total of 513 observations were used to construct the reference ranges with the use of multilevel modeling. RESULTS: Longitudinally established percentiles of Doppler indices from the present study show a continuous reduction throughout the second half of pregnancy without any plateau or increase near term, as reported previously. There was a significant negative association between Doppler indices and placental weight and neonatal birth weight, but not with gender. The intraobserver coefficients of variation for the umbilical artery pulsatility index, resistance index, and systolic:diastolic ratio were 10.5%, 6.8 %, and 13.0 %, respectively. CONCLUSION: New reference ranges for umbilical artery Doppler indices that are based on longitudinal observations appear to be slightly different from cross-sectional studies and are more appropriate for serial evaluation of fetal hemodynamics.

We assessed fetoplacental blood volume flow and placental resistance prospectively with Doppler sonography in 74 normal human fetuses of 19 to 42 wk gestation to determine the changes in placental perfusion with gestational age. Placental blood volume flow was assessed from the umbilical vein as the product of the mean flow velocity integral and the cross-sectional area of the umbilical vein. Placental resistance was assessed as the ratio of maximum systolic and minimum diastolic blood flow velocities from an umbilical artery. Umbilical vein blood volume flow increased exponentially (r = 0.86) with gestational age from 19 wk to term, and did not decrease in postdate fetuses. Umbilical vein blood volume flow increased linearly with fetal weight (r = 0.77), although volume flow per unit body weight changed little with gestational age. Umbilical artery velocity ratio decreased progressively, indicating diminishing placental resistance with gestational age, but did not correlate closely with umbilical vein blood volume flow. We submit that fetoplacental blood volume flow can be readily calculated directly from the umbilical vein with Doppler ultrasound and may provide a better index of placental perfusion than the umbilical artery velocity ratio.

A total of 145 pregnancies clinically suspected of being small-for-dates was studied at presentation with a single measurement of the fetal abdominal circumference and Doppler studies of the umbilical and arcuate arteries. The abdominal circumference measurement gave the best prediction of the small-for-gestational-age (SGA) baby (sensitivity 73%, umbilical artery sensitivity 47%, arcuate artery sensitivity 29%). The umbilical artery measurement gave the best prediction of antenatal fetal compromise; the performance of the tests was compared for a fixed sensitivity of 100%(i.e. all cases of antenatal compromise would be detected), the specificity of the umbilical artery measurement was 77%, abdominal circumference measurement 12% and arcuate artery measurement 2%. In our data, umbilical artery studies were not a sensitive predictor of the SGA baby but they did give an accurate prediction of the potentially compromised SGA fetus.

The metabolism of some aromatic amines by amine oxidase activities in human umbilical artery homogenates has been studied. The inhibitory effects of clorgyline showed that 5-hydroxytryptamine (5-HT) and tryptamine, 1 mM, were predominantly substrates for monoamine oxidase (MAO) type A, whereas MAO-A and B were both involved in the metabolism of beta-phenylethylamine (PEA), 100 microM, and tyramine, 1 mM. About 20-30% of tyramine and PEA metabolism was resistant to 1 mM clorgyline, but sensitive to inhibition by semicarbazide, 1 mM, indicating the presence of a semicarbazide-sensitive amine oxidase (SSAO). Benzylamine, 1 mM, appeared to be metabolized exclusively by SSAO with a Km (161 microM) at pH 7.8 similar to that found for SSAO in other human tissues. Tyramine and PEA were relatively poor substrates for SSAO, with very high apparent Km values of 17.6 and 13.3 mM, respectively, when determined in the presence of clorgyline, 10(-3) M, added to inhibit any metabolism of those amines by MAO activities. However, kinetic studies with benzylamine indicated that clorgyline, 10(-3) M, also appears to inhibit SSAO competitively such that the true Km values for tyramine and PEA may be about 60% of those apparent values given above. No evidence for the metabolism of 5-HT or tryptamine by SSAO was obtained. The aliphatic amine methylamine was recently shown to be a specific substrate for SSAO in umbilical artery homogenates. We have used benzylamine and methylamine as SSAO substrates in histochemical studies to localize SSAO in tissue sections.(ABSTRACT TRUNCATED AT 250 WORDS)

We present the first steps in the elaboration of an approach of extracellular matrix-targeted local drug delivery (ECM-LDD), designed to provide a high concentration, ubiquitous distribution, and long-term retention of a drug within the vessel wall after local intravascular delivery. The approach is based on the concept of a bifunctional drug comprising a "therapeutic effector" and an "affinity vehicle," which should bind to an abundant component of the vessel wall. The aim of the present study was to select molecules suitable for the role of affinity vehicles for ECM-LDD and to study their intravascular delivery and retention ex vivo and in an animal model. By use of fluorescence microscopy, the following molecules were selected on the basis of strong binding to cross sections of human vessels: protamine, polylysine, polyarginine, a glycosaminoglycan-binding peptide from vitronectin, and a synthetic dendrimer. With polylysine as a prototypic affinity vehicle, we showed that after intravascular delivery, polylysine was concentrated throughout a luminal layer of the vascular wall to an extremely high concentration of 20 g/L and was retained therein for at least 72 hours of perfusion without noticeable losses. Low molecular weight (fluorescein) and high molecular weight (hirudin) compounds could be chemically conjugated to polylysine and were retained in the vessel wall after intravascular delivery of the conjugates. In conclusion, by use of the ECM-LDD method, an extremely high concentration and long-term retention of locally delivered drug can be reached. Polycationic molecules can be considered as potential affinity vehicles for ECM-LDD.