Skip to main content Accessibility help
×
Hostname: page-component-78c5997874-ndw9j Total loading time: 0 Render date: 2024-11-09T09:53:53.281Z Has data issue: false hasContentIssue false

Chapter 5 - The Microcirculation

from Section 1 - Physiology of Normal Pregnancy

Published online by Cambridge University Press:  28 April 2018

Christoph Lees
Affiliation:
Imperial College London
Wilfried Gyselaers
Affiliation:
Hasselt Universiteit, Belgium
Get access
Type
Chapter
Information
Publisher: Cambridge University Press
Print publication year: 2018

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

De Backer, D, Ospina-Tascon, G, Salgado, D, Favory, R, Creteur, J, Vincent, JL, Monitoring the microcirculation in the critically ill patient: current methods and future approaches. Intensive Care Med, 2010; 36(11):1813–25.Google Scholar
Boron, W, Boupaep, E, Medical Physiology, 2e Updated Edition. 2012.Google Scholar
Sakai, T, Hosoyamada, Y, Are the precapillary sphincters and metarterioles universal components of the microcirculation? An historical review. J Physiol Sci, 2013; 63(5):319–31.CrossRefGoogle ScholarPubMed
De Backer, D, Hollenberg, S, Boerma, C, et al. How to evaluate the microcirculation: report of a round table conference. Crit Care, 2007; 11(5): R101.Google Scholar
Salmon, AH, Satchell, SC, Endothelial glycocalyx dysfunction in disease: albuminuria and increased microvascular permeability. J Pathol, 2012;226(4): 562–74.Google Scholar
Woodcock, TE, Woodcock, TM, Revised Starling equation and the glycocalyx model of transvascular fluid exchange: an improved paradigm for prescribing intravenous fluid therapy. Br J Anaesth, 2012;108(3):384–94.Google Scholar
Chappell, D, Jacob, M, Role of the glycocalyx in fluid management: Small things matter. Best Pract Res Clin Anaesthesiol, 2014;28(3):227–34.CrossRefGoogle ScholarPubMed
Donati, A, Damiani, E, Domizi, R, et al. Alteration of the sublingual microvascular glycocalyx in critically ill patients. Microvasc Res, 2013;90:86–9.Google Scholar
De Backer, D, Ortiz, JA, Salgado, D, Coupling microcirculation to systemic hemodynamics. Curr Opin Crit Care, 2010;16(3):250–4.Google Scholar
Trzeciak, S, Dellinger, RP, Parrillo, JE, et al. Early microcirculatory perfusion derangements in patients with severe sepsis and septic shock: relationship to hemodynamics, oxygen transport, and survival. Ann Emerg Med, 2007; 49(1):8898, 98 e12.CrossRefGoogle ScholarPubMed
Ince, C, The rationale for microcirculatory guided fluid therapy. Curr Opin Crit Care, 2014; 20(3):301–8.CrossRefGoogle ScholarPubMed
Veenstra, G, Ince, C, Boerma, EC, Direct markers of organ perfusion to guide fluid therapy: when to start, when to stop. Best Pract Res Clin Anaesthesiol, 2014; 28(3):217–26.CrossRefGoogle ScholarPubMed
Allen, J, Howell, K, Microvascular imaging: techniques and opportunities for clinical physiological measurements. Physiol Meas, 2014; 35(7):R91–R141.Google Scholar
Grassi, W, De Angelis, R, Capillaroscopy: questions and answers. Clin Rheumatol, 2007; 26(12):2009–16.Google Scholar
Ingegnoli, F, Gualtierotti, R, Lubatti, C, et al. Nailfold capillary patterns in healthy subjects: a real issue in capillaroscopy. Microvasc Res, 2013;90:90–5.Google Scholar
Michoud, E, Poensin, D, Carpentier, PH, Digitized nailfold capillaroscopy. Vasa, 1994; 23(1):3542.Google Scholar
Roustit, M, Cracowski, JL, Non-invasive assessment of skin microvascular function in humans: an insight into methods. Microcirculation, 2012;19(1):4764.Google Scholar
Antonios, TF, Rattray, FE, Singer, DR, Markandu, ND, Mortimer, PS, MacGregor, GA. Maximization of skin capillaries during intravital video-microscopy in essential hypertension: comparison between venous congestion, reactive hyperaemia and core heat load tests. Clin Sci (Lond), 1999; 97(4):523–8.Google Scholar
Aykut, G, Veenstra, G, Scorcella, C, Ince, C, Boerma, C. Cytocam-IDF (incident dark field illumination) imaging for bedside monitoring of the microcirculation. Intensive Care Med Exp, 2015; 3(1):40.Google Scholar
Goedhart, PT, Khalilzada, M, Bezemer, R, Merza, J, Ince, C. Sidestream Dark Field (SDF) imaging: a novel stroboscopic LED ring-based imaging modality for clinical assessment of the microcirculation. Opt Express, 2007;15(23):15101–14.Google Scholar
Groner, W, Winkelman, JW, Harris, AG, et al. Orthogonal polarization spectral imaging: a new method for study of the microcirculation. Nat Med, 1999;5(10):1209–12.CrossRefGoogle ScholarPubMed
Mathura, KR, Vollebregt, KC, Boer, K, De Graaff, JC, Ubbink, DT, Ince, C. Comparison of OPS imaging and conventional capillary microscopy to study the human microcirculation. J Appl Physiol (1985), 2001;91(1):74–8.Google Scholar
Lehmann, C, Abdo, I, Kern, H, et al. Clinical evaluation of the intestinal microcirculation using sidestream dark field imaging–recommendations of a round table meeting. Clin Hemorheol Microcirc, 2014;57(2):137–46.Google Scholar
Nilsson, J, Eriksson, S, Blind, PJ, Rissler, P, Sturesson, C. Microcirculation changes during liver resection–a clinical study. Microvasc Res, 2014;94:4751.Google Scholar
Weber, MA, Milstein, DM, Ince, C, Oude Rengerink, K, Roovers, JP. Vaginal microcirculation: Non-invasive anatomical examination of the micro-vessel architecture, tortuosity and capillary density. Neurourol Urodyn, 2015;34(8), 723–9.CrossRefGoogle ScholarPubMed
Weber, MA, Milstein, DM, Ince, C, Roovers, JP. Is pelvic organ prolapse associated with altered microcirculation of the vaginal wall? Neurourol Urodyn, 2016; 35(7):764–70.CrossRefGoogle ScholarPubMed
Ijaz, S, Milstein, DM, Ince, C, Roovers, JP. Impairment of hepatic microcirculation in fatty liver. Microcirculation, 2003; 10(6):447–56.Google Scholar
Abdo, I, Yang, W, Winslet, MC, Seifalian, AM. Microcirculation in pregnancy. Physiol Res, 2014;63(4):395408.CrossRefGoogle ScholarPubMed
Cornette, J, Herzog, E, Buijs, EA, et al. Microcirculation in women with severe pre-eclampsia and HELLP syndrome: a case-control study. BJOG, 2014; 121(3):363–70.CrossRefGoogle ScholarPubMed
Top, AP, Tasker, RC, Ince, C, The microcirculation of the critically ill pediatric patient. Crit Care, 2011; 15(2):213.CrossRefGoogle ScholarPubMed
Bezemer, R, Bartels, SA, Bakker, J, Ince, C. Clinical review: Clinical imaging of the sublingual microcirculation in the critically ill–where do we stand? Crit Care, 2012; 16(3):224.CrossRefGoogle ScholarPubMed
Mik, EG, Johannes, T, Fries, M, Clinical microvascular monitoring: a bright future without a future? Crit Care Med, 2009;37(11):2980–1.Google Scholar
Lee, DH, Cornette, J, Herzog, E, Buijs, EA. Deeper penetration of erythrocytes into the endothelial glycocalyx is associated with impaired microvascular perfusion. PLoS One, 2014. 9(5): e96477.Google Scholar
Boerma, EC, Mathura, KR, van der Voort, PH, Spronk, PE, Ince, C. Quantifying bedside-derived imaging of microcirculatory abnormalities in septic patients: a prospective validation study. Crit Care, 2005:9(6):R6016.Google Scholar
Hubble, SM, Kyte, HL, Gooding, K, Shore, AC. Variability in sublingual microvessel density and flow measurements in healthy volunteers. Microcirculation, 2009;16(2):183–91.CrossRefGoogle ScholarPubMed
van Elteren, HA, Ince, C, Tibboel, D, Reiss, IK, de Jonge, RC. Cutaneous microcirculation in preterm neonates: comparison between sidestream dark field (SDF) and incident dark field (IDF) imaging. J Clin Monit Comput, 2015; 16(2): 183–91.CrossRefGoogle ScholarPubMed
van den Berg, VJ, van Elteren, HA, Buijs, EA, et al. Reproducibility of microvascular vessel density analysis in Sidestream dark-field-derived images of healthy term newborns. Microcirculation, 2015;22(1):3743.Google Scholar
Bezemer, R, Dobbe, JG, Bartels, SA, et al. Rapid automatic assessment of microvascular density in sidestream dark field images. Med Biol Eng Comput, 2011;49(11):1269–78.Google Scholar
Dobbe, JG, Streekstra, GJ, Atasever, B, van Zijderveld, R, Ince, C. Measurement of functional microcirculatory geometry and velocity distributions using automated image analysis. Med Biol Eng Comput, 2008. 46(7): 659–70.Google Scholar
Humeau, A, Steenbergen, W, Nilsson, HStrömberg, T.Laser Doppler perfusion monitoring and imaging: novel approaches. Med Biol Eng Comput, 2007;45(5):421–35.Google Scholar
Riva, C, Ross, B, Benedek, GB, Laser Doppler measurements of blood flow in capillary tubes and retinal arteries. Invest Ophthalmol, 1972;11(11):936–44.Google Scholar
Roustit, M, Blaise, SMillet, CCracowski, JL. Reproducibility and methodological issues of skin post-occlusive and thermal hyperemia assessed by single-point laser Doppler flowmetry. Microvasc Res, 2010;79(2):102–8.Google Scholar
Roustit, M, Cracowski, JL, Assessment of endothelial and neurovascular function in human skin microcirculation. Trends Pharmacol Sci, 2013;34(7):373–84.Google Scholar
Cracowski, JL, Minson, CTSalvat-Melis, MHalliwill, JR. Methodological issues in the assessment of skin microvascular endothelial function in humans. Trends Pharmacol Sci, 2006;27(9):503–8.Google Scholar
Eriksson, S, Nilsson, J, Sturesson, C, Non-invasive imaging of microcirculation: a technology review. Med Devices (Auckl), 2014;7:445–52.Google Scholar
Leutenegger, M, Martin-Williams, E, Harbi, P, et al. Real-time full field laser Doppler imaging. Biomed Opt Express, 2011;2(6):1470–7.CrossRefGoogle ScholarPubMed
Serov, A, Lasser, T, High-speed laser Doppler perfusion imaging using an integrating CMOS image sensor. Opt Express, 2005;13(17):6416–28.CrossRefGoogle ScholarPubMed
Briers, JD, Laser Doppler, speckle and related techniques for blood perfusion mapping and imaging. Physiol Meas, 2001;22(4):R3566.Google Scholar
Forrester, KR, Tulip, J, Leonard, C, Stewart, C, Bray, RC. A laser speckle imaging technique for measuring tissue perfusion. IEEE Trans Biomed Eng, 2004;51(11):2074–84.Google Scholar
Mahe, G, Humeau-Heurtier, A, Durand, S, Leftheriotis, G, Abraham, P. Assessment of skin microvascular function and dysfunction with laser speckle contrast imaging. Circ Cardiovasc Imaging, 2012;5(1):155–63.Google Scholar
O’Doherty, J, McNamara, P, Clancy, NT, Enfield, JG, Leahy, MJ. Comparison of instruments for investigation of microcirculatory blood flow and red blood cell concentration. J Biomed Opt, 2009;14(3):034025.Google Scholar
Roustit, M, Millet, C, Blaise, S, Dufournet, B, Cracowski, JL. Excellent reproducibility of laser speckle contrast imaging to assess skin microvascular reactivity. Microvasc Res, 2010;80(3):505–11.Google Scholar
Tew, GA, Klonizakis, M, Crank, H, Briers, JD, Hodges, GJ. Comparison of laser speckle contrast imaging with laser Doppler for assessing microvascular function. Microvasc Res, 2011;82(3):326–32.Google Scholar
Cracowski, JL, Roustit, M, Pharmacology of the human skin microcirculation. Microvasc Res, 2010;80(1):1.Google Scholar
Buise, MP, Ince, C, Tilanus, HW, Klein, J, Gommers, D, van Bommel, J. The effect of nitroglycerin on microvascular perfusion and oxygenation during gastric tube reconstruction. Anesth Analg, 2005;100(4):1107–11.Google Scholar
Holzle, F, Loeffelbein, DJ, Nolte, D, Wolff, KD. Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry. J Craniomaxillofac Surg, 2006;34(1):2533.Google Scholar
Knobloch, K, Lichtenberg, A, Pichlmaier, M, et al. Microcirculation of the sternum following harvesting of the left internal mammary artery. Thorac Cardiovasc Surg, 2003;51(5):255–9.Google Scholar
Knobloch, K, Lichtenberg, A, Pichlmaier, M, Tomaszek, S, Krug, A, Haverich, A. Palmar microcirculation after harvesting of the radial artery in coronary revascularization. Ann Thorac Surg, 2005;79(3):1026–30; discussion 1030.Google Scholar
Ladurner, R, Feilitzsch, M, Steurer, W, Coerper, S, Königsrainer, A, Beckert, S. The impact of a micro-lightguide spectrophotometer on the intraoperative assessment of hepatic microcirculation: a pilot study. Microvasc Res, 2009;77(3):387–8.CrossRefGoogle ScholarPubMed
Sommer, B, Berschin, G, Sommer, HM, Microcirculation Under an Elastic Bandage During Rest and Exercise – Preliminary Experience With the Laser-Doppler Spectrophotometry System O2C. J Sports Sci Med, 2013;12(3):414–21.Google Scholar
Nagel, E, Vilser, W, Fink, A, Riemer, T. [Static vessel analysis in nonmydriatic and mydriatic images]. Klin Monbl Augenheilkd, 2007;224(5):411–6.Google ScholarPubMed
Smith, W, Wang, JJ, Wong, TY, et al. Retinal arteriolar narrowing is associated with 5-year incident severe hypertension: the Blue Mountains Eye Study. Hypertension, 2004;44(4):42–7.Google Scholar
Vilser, W, Nagel, E, Lanzl, I, Retinal Vessel Analysis–new possibilities. Biomed Tech (Berl), 2002;47 Suppl 1 Pt 2:682–5.Google Scholar
Lim, M, Sasongko, MB, Ikram, MK, et al. Systemic associations of dynamic retinal vessel analysis: a review of current literature. Microcirculation, 2013;20(3):257–68.Google Scholar
Brueckmann, A, Seeliger, C, Lehmann, T, Schleußner, E, Schlembach, D. Altered Retinal Flicker Response Indicates Microvascular Dysfunction in Women With Preeclampsia. Hypertension, 2015;66(4):900–5.Google Scholar
Kneser, M, Kohlmann, T, Pokorny, J, Tost, F. Age related decline of microvascular regulation measured in healthy individuals by retinal dynamic vessel analysis. Med Sci Monit, 2009;15(8):CR43641.Google Scholar
Pemp, B, Weigert, G, Karl, K, et al. Correlation of flicker-induced and flow-mediated vasodilatation in patients with endothelial dysfunction and healthy volunteers. Diabetes Care, 2009;32(8):1536–41.Google Scholar
Cecconi, M, De Backer, D, Antonelli, M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med, 2014;40(12):1795–815.Google Scholar
Hayes, MA,Timmins, AC, Yau, EH, Palazzo, M, Hinds, CJ, Watson, D. Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med, 1994;330(24):1717–22.Google Scholar
ARISE Investigators; ANZICS Clinical Trials Group, Peake, SL, et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med, 2014;371(16):1496–506.Google Scholar
ProCESS Investigators, Yealy, DM, Kellum, JA, et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med, 2014;370(18):1683–93.Google Scholar
Cornette, J, Buijs, EA, Duvekot, JJ,et al. Haemodynamic effects of intravenous nicardipine in severe pre-eclamptic women with a hypertensive crisis. Ultrasound Obstet Gynecol, 2015;47(1): 8995.Google Scholar
Perez-Barcena, J, Romay, E, Llompart-Pou, JA, et al. Direct observation during surgery shows preservation of cerebral microcirculation in patients with traumatic brain injury. J Neurol Sci, 2015;353(1–2):3843.Google Scholar
Sarmento, SG, Santana, EF, Campanharo, FF, et al. Microcirculation Approach in HELLP Syndrome Complicated by Posterior Reversible Encephalopathy Syndrome and Massive Hepatic Infarction. Case Rep Emerg Med, 2014;2014:389680.Google Scholar
Ait-Oufella, H, Bourcier, S, Lehoux, S, Guidet, B. Microcirculatory disorders during septic shock. Curr Opin Crit Care, 2015;21(4):271–5.Google Scholar
Ait-Oufella, H, Lemoinne, S, Boelle, PY, et al. Mottling score predicts survival in septic shock. Intensive Care Med, 2011;37(5):801–7.Google Scholar
Bateman, RM, Walley, KR, Microvascular resuscitation as a therapeutic goal in severe sepsis. Crit Care, 2005;9 Suppl 4:S2732.Google Scholar
De Backer, D, Creteur, J, Preiser, JC, Dubois, MJ, Vincent, JL. Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med, 2002;166(1):98104.Google Scholar
De Backer, D, Donadello, K, Sakr, Y, et al. Microcirculatory alterations in patients with severe sepsis: impact of time of assessment and relationship with outcome. Crit Care Med, 2013;41(3):791–9.Google Scholar
Donati, A, Domizi, R, Damiani, E, Adrario, E, Pelaia, P, Ince, C. From macrohemodynamic to the microcirculation. Crit Care Res Pract, 2013;2013:892710.Google Scholar
Donati, A, Tibboel, D, Ince, C. Towards integrative physiological monitoring of the critically ill: from cardiovascular to microcirculatory and cellular function monitoring at the bedside. Crit Care, 2013;17 Suppl 1: S5.Google Scholar
Sakr, Y, Dubois, MJ, De Backer, D, Creteur, J, Vincent, JL. Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med, 2004;32(9):1825–31.Google Scholar
Top, AP, Ince, C, de Meij, N, van Dijk, M, Tibboel, D. Persistent low microcirculatory vessel density in nonsurvivors of sepsis in pediatric intensive care. Crit Care Med, 2011;39(1):813.Google Scholar
Cornette, J, Roos-Hesselink, J. Normal cardiovascular adaptation to pregnancy, in Evidence-Based Cardiology Consult, Stergiopoulos, K., Editor. 2014, Springer: London. 423–32.Google Scholar
Duvekot, JJ, Peeters, LL, Maternal cardiovascular hemodynamic adaptation to pregnancy. Obstet Gynecol Surv, 1994;49(12 Suppl):S114.Google Scholar
Melchiorre, K, Sharma, R, Thilaganathan, B, Cardiac structure and function in normal pregnancy. Curr Opin Obstet Gynecol, 2012;24(6):413–21.Google Scholar
Cantwell, R, Clutton-Brock, T, Cooper, G. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG, 2011;118 Suppl 1:1203.Google ScholarPubMed
de Jonge, A, Mesman, JA, Manniën, J. Severe adverse maternal outcomes among women in midwife-led versus obstetrician-led care at the onset of labour in the Netherlands: A nationwide cohort study. PLoS One, 2015;10(5):e0126266.Google Scholar
Schutte, JM, Steegers, EA, Schuitemaker, NW. Rise in maternal mortality in the Netherlands. BJOG, 2010;117(4):399406.CrossRefGoogle ScholarPubMed
van Roosmalen, J, Zwart, J, Severe acute maternal morbidity in high-income countries. Best Pract Res Clin Obstet Gynaecol, 2009;23(3):297304.CrossRefGoogle ScholarPubMed
Perel, P, Roberts, I, Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev, 2012;6:CD000567.Google Scholar
Santry, HP, Alam, HB, Fluid resuscitation: past, present, and the future. Shock, 2010;33(3):229–41.Google Scholar
Smorenberg, A, Ince, C, Groeneveld, AJ, Dose and type of crystalloid fluid therapy in adult hospitalized patients. Perioper Med (Lond), 2013;2(1):17.Google Scholar
Pranskunas, A, Koopmans, M, Koetsier, PM, Pilvinis, V, Boerma, EC. Microcirculatory blood flow as a tool to select ICU patients eligible for fluid therapy. Intensive Care Med, 2013;39(4):612–9.Google Scholar
Linder, HR, Reinhart, WH, Hänggi, W, Katz, M, Schneider, H. Peripheral capillaroscopic findings and blood rheology during normal pregnancy. Eur J Obstet Gynecol Reprod Biol, 1995;58(2):141–5.Google Scholar
Ohlmann, P, Jung, F, Mrowietz, C, Alt, T, Alt, S, Schmidt, W. Peripheral microcirculation during pregnancy and in women with pregnancy induced hypertension. Clin Hemorheol Microcirc, 2001;24(3):183–91.Google Scholar
George, RB, Munro, A, Abdo, I, McKeen, DM, Lehmann, C. An observational assessment of the sublingual microcirculation of pregnant and non-pregnant women. Int J Obstet Anesth, 2014;23(1):23–8.Google Scholar
Hasan, KM, Manyonda, IT, Ng, FS, Singer, DR, Antonios, TF. Skin capillary density changes in normal pregnancy and pre-eclampsia. J Hypertens, 2002;20(12):2439–43.Google Scholar
Nama, V, Antonios, TF, Onwude, J, Manyonda, IT. Capillary remodeling in normal pregnancy: Can it mediate the progressive but reversible rise in blood pressure? Novel insights into cardiovascular adaptation in pregnancy. Pregnancy Hypertens, 2012;2(4): 380–6.Google Scholar
Ramsay, JE, Simms, RJ, Ferrell, WR, et al. Enhancement of endothelial function by pregnancy: inadequate response in women with type 1 diabetes. Diabetes Care, 2003;26(2):475–9.Google Scholar
Khan, F, Belch, JJ, MacLeod, M, Mires, G. Changes in endothelial function precede the clinical disease in women in whom preeclampsia develops. Hypertension, 2005;46(5):1123–8.Google Scholar
Khan, F, Mires, G, Macleod, M, Belch, JJ, et al. Relationship between maternal arterial wave reflection, microvascular function and fetal growth in normal pregnancy. Microcirculation, 2010;17(8):608–14.Google Scholar
Eneroth-Grimfors, E, Lindblad, LE, Westgren, M, Ihrman-Sandahl, C, Bevegård, S. Noninvasive test of microvascular endothelial function in normal and hypertensive pregnancies. Br J Obstet Gynaecol, 1993;100(5):469–71.Google Scholar
Lupton, SJ, Chiu, CL, Hodgson, LA, et al. Changes in retinal microvascular caliber precede the clinical onset of preeclampsia. Hypertension, 2013;62(5):899904.CrossRefGoogle ScholarPubMed

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×