In normal human gestations during the first and the second trimester, the uterine spiral arteries are converted into utero-placental arteries (high capacity/low resistance vessels) through a replacement of the muscolo-elastic components of the arterial walls. The physiological changes in the spiral arteries are revealed in an increase of the end diastolic component of the uterine blood flow. This can be easily detected by Doppler velocimetry of the uterine arteries and its branches (Ferrazzi et al., 1999).Ischemic changes occur more frequently in the placentas from women whose pregnancy is complicated with preeclampsia (PET) or intrauterine growth restriction (IUGR) than in those with other complications of pregnancy (Hofstatter et al., 1996).It has long been assumed that in insufficient uterine, placental and fetal circulations result in adverse pregnancy outcome and these abnormalities can be defined with the use of Doppler ultra sonography. Indeed, observational studies have clearly established an association between abnormal velocity waveforms and adverse perinatal outcome such as intrauterine growth restriction, foetal asphyxia and perinatal mortality (North et al., 1999).This study was done on 150 primigravida, sure of dates, in the third trimester with singleton pregnancy attending ante-natal clinic and delivery ward at Obstetrics and Gynecology departments and Pathology departments at Zagazig University Hospitals. They were divided into three groups, 50 cases each.(1) The control group ( Normal pregnancy):Healthy pregnant women without medical or obstetric complications and all laboratory investigations were normal.(II) Patients with severe pre-eclampsia:(III) Patients with Intra-uterine growth restriction:This group included pregnancies complicated with IUGR, but without any symptoms of pre-eclampsia or pre-existing hypertension.All patients were subjected to:I- History, general and obstetric examinations.II- Routine laboratory investigations.III- Ultrasonographic and Doppler studies included uterine artery Doppler velocimetry.IV- Histopathology of the placenta.All cases were evaluated for the assessment of:* Maternal complications.* Mode of delivery.* Perinatal outcome.The correlation between uterine artery Doppler indices and histopathologic changes of placentas was studied and the data obtained were collected, tabulated and statistically analyzed.The results of the present study showed:I- Uterine artery Doppler indices were significantly higher in PET and IUGR groups than control group.II- As regard to histopathological findings of placentas, minimal hypoxic damage (MHD) significantly more frequently found in the groups with pre-eclampsia and IUGR than in the group with uncomplicated pregnancy. The difference between the groups with pre-eclampsia and IUGR was also significant (P < 0.01).III- Infarcts (regardless of their number) were found significantly more common in pre-eclampsia group. There was no difference between the groups in the prevalence of solitary infracts, but multiple infracts were significantly more common in pre-eclampsia group than in IUGR group.IV- At increased UARI, histopathological findings of placentas showed that minimal hypoxic damage was significantly more frequent in the group of placentas with IUGR.V- In the presence of normal UARI, there was statistically no significant difference between the groups in the prevalence of minimal hypoxic damage.VI- The comparison of placental findings in the presence of increased and normal UARI regardless of the complication of pregnancy showed that minimal hypoxic damage and infracts were significantly more frequently seen in the placentas with increased UARI.VII- As regard perinatal outcome, the present study showed that the presence of abnormal uterine artery Doppler velocimetry was associated with significantly higher rate of preterm delivery.VIII- The presence of abnormal uterine artery Doppler velocimetry was associated with significantly higher rate of neonate in need of NICU admission,Conclusion1- The hypoxic changes occurred significantly more frequently in placentas From pregnancies complicated with pre-eclampsia and IUGR than in those From uncomplicated pregnancy.2- The presence of Abnormal Doppler velocimetry of the uterine arteries in pregnancies with fetal intrauterine growth restriction and pregnancies with severe pre eclampsia, may be in fact an important indicator of hypoxic or ischemic placental lesions.3- Because there are close relationship between IUGR, pre-eclampsia and impaired trophoblast invasion, the pregnancies with high uterine artery RI and persistent early diastolic notch, should be observed for fetal morbidity and mortality.In normal human gestations during the first and the second trimester, the uterine spiral arteries are converted into utero-placental arteries (high capacity/low resistance vessels) through a replacement of the muscolo-elastic components of the arterial walls. The physiological changes in the spiral arteries are revealed in an increase of the end diastolic component of the uterine blood flow. This can be easily detected by Doppler velocimetry of the uterine arteries and its branches (Ferrazzi et al., 1999).Ischemic changes occur more frequently in the placentas from women whose pregnancy is complicated with preeclampsia (PET) or intrauterine growth restriction (IUGR) than in those with other complications of pregnancy (Hofstatter et al., 1996).It has long been assumed that in insufficient uterine, placental and fetal circulations result in adverse pregnancy outcome and these abnormalities can be defined with the use of Doppler ultra sonography. Indeed, observational studies have clearly established an association between abnormal velocity waveforms and adverse perinatal outcome such as intrauterine growth restriction, foetal asphyxia and perinatal mortality (North et al., 1999).This study was done on 150 primigravida, sure of dates, in the third trimester with singleton pregnancy attending ante-natal clinic and delivery ward at Obstetrics and Gynecology departments and Pathology departments at Zagazig University Hospitals. They were divided into three groups, 50 cases each.(1) The control group ( Normal pregnancy):Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.5) Diagnosis was reached by thoracoscopic pleural biopsy in 27 patients with overall sensitivity (90%), amoung them 7/8 patients (87.5%) tuberculous pleural effusion, 19/21 patients (90.5%) malignant pleural effusion and one patient with rheumatoid arthritis. Thoacoscopy was negative in 3/30 patients (10%); one patient in tuberculous group was diagnosed by Abrams’needle, one patient with metastatic carcinoma was diagnosed by cytological examination of pleural fluid and the third patient with lymphoma was diagnosed by bronchoscopic biopsy and CT-guided. 2/30 cases were persistent pneumothorax post thoracoscopy, these two cases were shown to have metastatic carcinoma to the pleura.Comparison of the diagnostic yield of different diagnostic tool versus the diagnostic yield of medical thoracoscopy in the studied patients:1) Pleural fluid cytology was positive in 8/21 patients (38%) with malignancy while thoracoscopic biopsy was positive in 19/21 patients (90.5%) with the same group (p<0.001).2) Abrams’ needle biopsy and thoracoscopy were positive in 7/8 patients (87.5%) with tuberculosis with non significant difference, while Abrams was positive in 14/21 patients (66.7%) of malignant group when compared to thoracoscopy which revealed positive in 19/21 patients (90.5%) of the same group with statistically significant improved yield with thoracoscopy (p0.05).3) CT guided biopsy was inferior with significant statistical difference to thoracoscopy in the diagnosis of tuberculous effusions, as it diagnosed 3 patients (37.5%) while thoracoscopy was positive in 7 patients (87.5%) of the same group (p0.05).4) As regard the total sensitivity of both Abrams’ biopsy and CT guided biopsy; it was 87.5% in TB, 75% in primary lung cancer, 80% in metastatic carcinoma, 50% in hematological malignancy, 100% in mesothelioma and 80.95% in total malignancy.5) Thoracoscopy was the only positive tool in the case of rheumatoid arthritis.Comparison of the diagnostic yield of Abrams’ needle biopsy versus CT guided biopsy in different groups:Abrams’ needle biopsy is superior significantly to CT guided biopsy in the diagnosis of tuberculous effusions (pConclusion1. The available Abrams’ needle biopsy is still an excellent and relatively safe procedure in the diagnosis of exudative pleural effusion especially tuberculous one.2. Percutaneous CT-guided cutting needle biopsy is safe and less invasive and diagnostic tool in patients with exudative pleural effusion.3. CT-guided biopsy is the diagnostic modality of choice in patients with mesothelioma and should precede thoracoscopy in those patients.4. CT-guided biopsy and Abrams’ needle biopsy are complementary to each others in the diagnosis of malignant pleural effusion especially mesothelioma.Recommendation1. Abrams’ needle biopsy should never be neglected as an invaluable diagnostic tool in the diagnosis of exudative pleural effusion that never to be abandoned.2. Based on routine investigations and clinical suspicions, the priority of CT-guided or blind Abrams’ pleural biopsies should be individualized as shown in the following algorithm (fig-11).3. Multiple CT-guided cutting needle pleural biopsies are advisable to be tried in patients with exudative pleural effusion as this guided technique may improve the total sensitivity of this procedure.4. The conclusion of the current study should be challenged widely on larger groups of patients for each of the items included.Fig (6): The suggested algorithm of diagnosis of exudative pleural effusionsSummaryThirty patients with exudative pleural effusions were 17 males and 13 females. Their age ranged from 18-77 years, according to Light’s criteria, were fit for pleural biopsy and didn’t have any of the following; bleeding disorders, positive culture of pleural fluid, frank pus, chylothorax, recent history of chest trauma, recent abdominal operation or recent coronary artery bypass, were selected from Patients with pleural effusions, who were admitted at Chest and Internal Medicine Departments, Zagazig University Hospitals, in the period from July 2004 to August 2005, and subjected to the following:1) Thorough medical history2) Full clinical examination.3) Plain Chest X- ray (postero-anterior and lateral views).4) Hematological investigations including:a) Complete blood picture.b) Liver function tests (total proteins, albumin, SGOT, SGPT, and total and direct bilirubin).c) Kidney function tests (blood urea and serum creatinine).d) Prothrombin time and partial thromboplastin time.e) Erythrocyte sedimentation rate (ESR).f) Fasting blood sugar; simultaneous with measurement of pleural fluid glucose level.g) Serum LDH simultaneous with measurement of pleural fluid value of LDH.h) Bone marrow biopsy from the sternum, under local anesthesia, was done in one case which diagnosed as chronic lymphocytic leukemia.5) Sputum analysis: was done for 5 patients with expectoration• Z.N. staining.• Cytological examination for malignant cells.6) Tuberculin skin test. (Mantoux method)7) Serological studies including some selected tests:a) Serum rheumatoid factor (RF).b) Serum antinuclear antibody (ANA)8) Pelvi-abdominal ultrasound.9) Ultrasound guided thoracocentesis.10) Pleural fluid analysis:(pH, protein, glucose, LDH, total and differential leukocytic count, gram stain, culture and sensitivity for aerobic, anaerobic organisms and AFB, ZN staining and cytological examination for malignant cells)11) Blind pleural biopsy by Abrams’ needle: biopsy taken was sent for culture for AFB and histopathological examination.12) Contrast enhanced CT chest.13) CT guided pleural biopsy: from the maximum area of parietal pleural thickening detected in CT chest and sent for histopathological examination.14) Fiberoptic bronchoscope: was done for 8 patients with parenchymal lesions detected in radiological examination and one patient with hemoptysis. The biopsy was sent for histopathological examination and BAL was sent for both ZN staining and cytological examination.15) Medical thoracoscope: with biopsy taken using the ”Storz” rigid thoracoscope 9 mm diameter was performed. The procedure of thoracoscopy was done under local anaesthesia and through a single puncture, that was made before for Abrams’ needle, at the posterior axillary line in the 6th-8th intercostal space while the patient lying in the lateral decubitus position with affected hemithorax up.The results of current study were as follow:1) The final diagnosis as established by different diagnostic tools was reached in 30 cases (100%) and distributed as follow; 8 patients (26.7%) with tuberculosis, one patient (3.3%) with rheumatoid arthritis, 4 patients (13.3%) with primary lung cancer (3 adenocarcinoma and 1 small cell carcinoma), 10 patients (33.3%) with metastatic carcinoma, 2 patients (6.7%) with hematological malignancies (one lymphoma and the other leukemia), and 5 patients (16.7%) with mesothelioma.2) Pleural fluid cytology achieved the diagnosis in 8 /21cases with sensitivity (38 %) of malignant pleural effusion, among them 2 cases (50%) with primary lung cancer, 5 cases (50%) with metastatic carcinoma and one case (20%) with mesothelioma.3) Abrams’ pleural biopsy yielded an overall sensitinity in 21 patients (70%) was obtained. It was positive (pathology and culture for AFB) in 7 patients of tuberculous pleural effusion (87.5%), while the corresponding result for malignancy was 14 patients (66.7%) which distributed as follow; 3 patients (75%) with primary lung cancer, 8 patients (80%) with metastatic carcinoma and 3 patients (60%) with malignant pleural mesothelioma.4) The magnitude of the maximum site of the parietal pleural thickening, detected by CT chest, ranged from 2-28 mm (9.4 ± 6). CT guided cutting needle biopsy from the maximum site of the parietal pleural thickening was positive for the diagnosis in 15/30 patients with overall sensitivity (50%) and was distributed as follow; 3 patients (37.5%) with tuberculosis, and 12 patients (57.1%) with malignant group that distributed as follow; 2 cases (50%) with primary lung cancer, 5 patients (50%) with metastatic carcinoma, 4 cases (80%) with malignant pleural mesothelioma and 1 case (50%) with hematological malignancy (lymphoma). No complication was reported in the procedure of CT-guided cutting needle biopsy.The three studied groups regarding clinical chorioamnionitis revealed no statistically significant difference.Regarding neonatal outcome of studied groups, patients with a negative amniotic fluid culture but positive PCR (group 2) had a significantly higher rate of adverse outcome including low gestational age at birth, low birth weight, and significant neonatal morbidity than those with a negative amniotic fluid culture and negative PCR (group 1). However, no differences were found between patients with a negative culture but positive PCR (group 2) and those with a positive amniotic fluid culture regardless the results of PCR (group 3).SUMMARYPreterm premature rupture of membrane occurs in 3% of pregnancies and is responsible for approximately one-third of all preterm births.Preterm PROM is an important cause of perinatal morbidity and mortality.Recent studies suggest an association between Intrauterine infection and both preterm delivery and morbidity of preterm infant. U. Urealyticum is the microorganism most frequently isolated from amniotic fluid of women with preterm labour and PROM.U. urealyticum has been implicated in the genesis of clinical chorioamnioitis, puerperal endometritis, neonatal sepsis and bronchopulmonary dysplasia (chronic lung disease).U. urealyticum isolation in clinical specimens remains a challenge, microbial culture for this organism require special culture conditions and results are generally not availably in time for clinical management decisions.Recently PCR has became an optimal method for the rapid detection of U. urealyticum in clinical specimen.The aim of our study was to determine the frequency and clinical significance for the detection of U. urealyticum in patients with preterm premature rupture of membranes.Our study included 100 patients with preterm premature rupture of membranes with gestational age less than 35 weeks and singleton gestation.Patients participated in our study underwent full history taking and clinical examination.Amniotic fluid was collected by transabdominal amniocentesis guided by ultrasonography and was immediately examined for WBC,s count and sent for microbiologic culture. An aliquot of fluid was stored at -70°C for PCR examination.According to the results of amniotic fluid cultures and PCR for U. urealyticum patients divided into 3 groups:o Group 1: (n.=59) Those with a negative amniotic fluid culture and a negative PCR assay.o Group 2 (n.=15): Those with a negative amniotic fluid culture but a positive PCR for Ureaplasma urealyticum.o Group 3 (n.=26): Those with a positive amniotic fluid culture for microorganisms regardless of the results of PCR.Regarding maternal age of the studied groups, There was no significant differences in the mean age at amniocentesis among the 3 group of patients.The difference in the gestational age at amniocentesis among the 3 groups of patients was not statistically significant, however patients with a positive amniotic fluid culture regardless PCR (group 3) showed the lowest mean gestational age at amniocentesis among the 3 studied groups.Patients with a negative amniotic fluid culture but a positive PCR (group 2) had a significantly higher amniotic fluid white blood cell count than those with a negative amniotic fluid culture and a negative PCR. However, there was no significant difference in the amniotic fluid white blood cell count between patients with a negative amniotic fluid culture but positive PCR and those with a positive amniotic fluid culture.The three studied groups regarding clinical chorioamnionitis revealed no statistically significant difference.Regarding neonatal outcome of studied groups, patients with a negative amniotic fluid culture but positive PCR (group 2) had a significantly higher rate of adverse outcome including low gestational age at birth, low birth weight, and significant neonatal morbidity than those with a negative amniotic fluid culture and negative PCR (group 1). However, no differences were found between patients with a negative culture but positive PCR (group 2) and those with a positive amniotic fluid culture regardless the results of PCR (group 3).SUMMARYPreterm premature rupture of membrane occurs in 3% of pregnancies and is responsible for approximately one-third of all preterm births.Preterm PROM is an important cause of perinatal morbidity and mortality.Recent studies suggest an association between Intrauterine infection and both preterm delivery and morbidity of preterm infant. U. Urealyticum is the microorganism most frequently isolated from amniotic fluid of women with preterm labour and PROM.U. urealyticum has been implicated in the genesis of clinical chorioamnioitis, puerperal endometritis, neonatal sepsis and bronchopulmonary dysplasia (chronic lung disease).U. urealyticum isolation in clinical specimens remains a challenge, microbial culture for this organism require special culture conditions and results are generally not availably in time for clinical management decisions.Recently PCR has became an optimal method for the rapid detection of U. urealyticum in clinical specimen.The aim of our study was to determine the frequency and clinical significance for the detection of U. urealyticum in patients with preterm premature rupture of membranes.Our study included 100 patients with preterm premature rupture of membranes with gestational age less than 35 weeks and singleton gestation.Patients participated in our study underwent full history taking and clinical examination.Amniotic fluid was collected by transabdominal amniocentesis guided by ultrasonography and was immediately examined for WBC,s count and sent for microbiologic culture. An aliquot of fluid was stored at -70°C for PCR examination.According to the results of amniotic fluid cultures and PCR for U. urealyticum patients divided into 3 groups:o Group 1: (n.=59) Those with a negative amniotic fluid culture and a negative PCR assay.o Group 2 (n.=15): Those with a negative amniotic fluid culture but a positive PCR for Ureaplasma urealyticum.o Group 3 (n.=26): Those with a positive amniotic fluid culture for microorganisms regardless of the results of PCR.Regarding maternal age of the studied groups, There was no significant differences in the mean age at amniocentesis among the 3 group of patients.The difference in the gestational age at amniocentesis among the 3 groups of patients was not statistically significant, however patients with a positive amniotic fluid culture regardless PCR (group 3) showed the lowest mean gestational age at amniocentesis among the 3 studied groups.Patients with a negative amniotic fluid culture but a positive PCR (group 2) had a significantly higher amniotic fluid white blood cell count than those with a negative amniotic fluid culture and a negative PCR. However, there was no significant difference in the amniotic fluid white blood cell count between patients with a negative amniotic fluid culture but positive PCR and those with a positive amniotic fluid culture.The three studied groups regarding clinical chorioamnionitis revealed no statistically significant difference.Regarding neonatal outcome of studied groups, patients with a negative amniotic fluid culture but positive PCR (group 2) had a significantly higher rate of adverse outcome including low gestational age at birth, low birth weight, and significant neonatal morbidity than those with a negative amniotic fluid culture and negative PCR (group 1). However, no differences were found between patients with a negative culture but positive PCR (group 2) and those with a positive amniotic fluid culture regardless the results of PCR (group 3).SUMMARYPreterm premature rupture of membrane occurs in 3% of pregnancies and is responsible for approximately one-third of all preterm births.Preterm PROM is an important cause of perinatal morbidity and mortality.Recent studies suggest an association between Intrauterine infection and both preterm delivery and morbidity of preterm infant. U. Urealyticum is the microorganism most frequently isolated from amniotic fluid of women with preterm labour and PROM.U. urealyticum has been implicated in the genesis of clinical chorioamnioitis, puerperal endometritis, neonatal sepsis and bronchopulmonary dysplasia (chronic lung disease).U. urealyticum isolation in clinical specimens remains a challenge, microbial culture for this organism require special culture conditions and results are generally not availably in time for clinical management decisions.Recently PCR has became an optimal method for the rapid detection of U. urealyticum in clinical specimen.The aim of our study was to determine the frequency and clinical significance for the detection of U. urealyticum in patients with preterm premature rupture of membranes.Our study included 100 patients with preterm premature rupture of membranes with gestational age less than 35 weeks and singleton gestation.Patients participated in our study underwent full history taking and clinical examination.Amniotic fluid was collected by transabdominal amniocentesis guided by ultrasonography and was immediately examined for WBC,s count and sent for microbiologic culture. An aliquot of fluid was stored at -70°C for PCR examination.According to the results of amniotic fluid cultures and PCR for U. urealyticum patients divided into 3 groups:o Group 1: (n.=59) Those with a negative amniotic fluid culture and a negative PCR assay.o Group 2 (n.=15): Those with a negative amniotic fluid culture but a positive PCR for Ureaplasma urealyticum.o Group 3 (n.=26): Those with a positive amniotic fluid culture for microorganisms regardless of the results of PCR.Regarding maternal age of the studied groups, There was no significant differences in the mean age at amniocentesis among the 3 group of patients.The difference in the gestational age at amniocentesis among the 3 groups of patients was not statistically significant, however patients with a positive amniotic fluid culture regardless PCR (group 3) showed the lowest mean gestational age at amniocentesis among the 3 studied groups.Patients with a negative amniotic fluid culture but a positive PCR (group 2) had a significantly higher amniotic fluid white blood cell count than those with a negative amniotic fluid culture and a negative PCR. However, there was no significant difference in the amniotic fluid white blood cell count between patients with a negative amniotic fluid culture but positive PCR and those with a positive amniotic fluid culture.The three studied groups regarding clinical chorioamnionitis revealed no statistically significant difference.Regarding neonatal outcome of studied groups, patients with a negative amniotic fluid culture but positive PCR (group 2) had a significantly higher rate of adverse outcome including low gestational age at birth, low birth weight, and significant neonatal morbidity than those with a negative amniotic fluid culture and negative PCR (group 1). However, no differences were found between patients with a negative culture but positive PCR (group 2) and those with a positive amniotic fluid culture regardless the results of PCR (group 3).