Impact of HAART Therapy and HIV Infection over Fetal Growth-An Anthropometric Point of View.

Human immunodeficiency virus (HIV) infection cannot be completely eliminated from the body because the virus integrates its genetic code into that of the host cell. The prevalence of pregnancy in women with HIV infection has increased due to the efficacy of antiretroviral therapy (ART). Placental insufficiency is associated with a reduction in blood flow and circulatory redistribution, resulting in fetal hypoxia and nutrient deprivation as a consequence of an altered placental function, and it can result in a lower birthweight. The aim of the study was to determine the combined effect of HIV infection and ART on the anthropometric parameters of infants born to HIV-positive pregnant women under ART compared to the values of these parameters in a control group of infants born to healthy mothers. There are no significant differences between the two groups in terms of gestational age at birth. We found a statistically significant lower birth weight in infants born from HIV-positive mothers under ART, with 3041 g in the control group compared to 2758 g in the group of HIV positive pregnant women (p < 0.01). There were statistically significant differences in all anthropometric parameters, these showing higher values in the control group (seronegative pregnant women).

Uterine Fibroids and Pregnancy: A Review of the Challenges from a Romanian Tertiary Level Institution.

BACKGROUND AND OBJECTIVES: Uterine fibroids are relatively common in reproductive-age women and are directly linked to pregnancy. There are many debates about performing a myomectomy at the same time as a caesarian section (CS) in such cases due to the risk of a hemorrhage. Our study aims to investigate fibroid features and their evolution in pregnancy, complications of a myomectomy during CS and maternal and fetal obstetric outcomes of pregnancies with fibroids. MATERIALS AND METHODS: We realize a prospective study that includes 57 patients with fibroids in pregnancy diagnosed in January 2017-June 2019. We analyze the number, the location and the growth of fibroids during pregnancy and the maternal and fetal outcome. We appreciate the bleeding in patients with a myomectomy and without a myomectomy during CS, using hemoglobin values before and after birth. RESULTS: Most of the patients present single fibroids that are 30-160 mm in size, located on the anterior uterine wall. Vaginal delivery is used in 7% of women, whereas 85.96% deliver by CS. In addition, 68% of fibroids are diagnosed in the first trimester. In most cases, the fibroid has maximum growth in the second trimester of pregnancy. The myomectomy rate for fibroids during CS is 24.48. Hemoglobin values showed no statistically significant difference between the two groups with and without myomectomy. The operating time is double for the group with a myomectomy associated with a CS. The results of the obstetric outcomes are abortion in 7% of all patients, whereas premature delivery and births at term are 9.43% and 90.57%, respectively. CONCLUSIONS: The decision of performing a myomectomy during pregnancy can be a challenge and must be performed for selected cases. This procedure may have several benefits, such as avoiding another operation to remove fibroids.

A Rare Cause of Massive Hematuria: Placenta Percreta With Bladder Invasion.

BACKGROUND/AIM: Placenta percreta is a rare event, but it poses serious problems due to potential hemorrhagic events. We report a particular case of placenta percreta with massive hematuria due to maternal bladder invasion, and describe the surgical protocol performed that resulted in an excellent outcome. CASE REPORT: A 33-year-old patient, at 27th weeks gestational age, presented in the emergency room of the Urology Department with urinary blood clot acute retention, because of massive hematuria from a placenta percreta with bladder invasion. After extracting the clots from the bladder, and coagulation of an area of venous ectasies of the posterior wall, hematuria ceased, but appeared after two days, necessitating again the bladder clots removal and coagulation. A surgical team with gynecologists, urologists, anesthesiologists and a neonatologist was composed, and after bilateral ureteral double J insertion, cesarean section was performed followed by hemostatic hysterectomy and partial cystectomy, bilateral internal iliac artery ligature and repair of the bladder wall. The postoperative evolution was without incidents; the Foley catheter was removed in the 14th postoperative day. CONCLUSION: In the context of a massive hematuria of a pregnant woman, the urologist must always consider a diagnosis of complicated placenta percreta.

Fetal cardiac evaluation in HIV-positive women under HAART therapy in a Romanian hospital.

Human immunodeficiency virus (HIV) is an RNA (ribonucleic acid) virus that causes acquired immunodeficiency syndrome (AIDS). This disease has a major socioeconomical impact. The aim of the present study was to assess the fetal heart structure and function in HIV-positive pregnant women on highly active antiretroviral therapy (HAART). This is a prospective study conducted between January, 2018 and December, 2019. The hearts of fetuses from 14 HIV-positive pregnant women on HAART were assessed. Statistically significant sex-related cardiac changes in HIV-exposed uninfected fetuses of pregnant women on HAART were found. A narrow aorta was detected in female fetuses and a smaller left ventricular transverse diameter in male fetuses. Overall, the myocardial performance index remained unaltered. The impact of antiretroviral therapy on fetal heart seems to be sex-related. Accurate and complete information about the risks and benefits of antiretroviral treatment and management strategies to improve fetal outcomes may also ensure better compliance of the mothers to this treatment.

Follicle-stimulating hormone receptor gene polymorphisms of ovarian reserve markers in Romanian population.

Association between phenotype and follicle-stimulating hormone (FSH) receptor and FSH beta chain genotype was evaluated in women with ovarian dysfunction. FSH receptor gene single nucleotide polymorphisms (SNPs) were analyzed by restricted fragment length polymorphism (RFLP) technique. Three groups were analyzed: two groups formed of poor responders (women with ovarian dysfunctions caused by endometriosis and patients who underwent ovarian stimulation protocols) and a third good responders group (normal-ovulatory women who gave birth to naturally conceived children). A higher average level of basal FSH values were found in mutants in the A919G/Ala307Thr/rs6165 or A2039G/Asn680Ser/rs6166 tests (7.16±1.09; P=0.659). Anti-mullerian hormone (AMH) below 1.2 ng/ml was associated with a higher frequency of mutations: 33.3% A919G/Ala307Thr and A2039G/Asn680Ser (P=0.137) and also in 66.6% FSH receptor less frequent polymorphism (c.-29G>A) rs 1394205 (P=0.522). The age, day 3 FSH, and AMH levels are widely used to investigate female infertility. However, we have not yet found the ideal biomarker to determine the best outcome and treatment plan for our patients. We cconsider that genetic markers will become the future in the personalization of controlled ovarian stimulation treatment in the upcoming period.

Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series.

BACKGROUND: There is no clear consensus on the management of caesarean scar pregnancy (CSP), a complex and life-threatening condition. The objective of this study was to present a novel approach to management of CSP that combines medical therapy of multidose methotrexate and mifepristone with active surgical management by uterine curettage and consecutive local haemostasis. CASE PRESENTATION: We report on a prospective case series of six women with first trimester pregnancy, in whom the diagnosis of CSP was confirmed by 2D and color Doppler transvaginal ultrasound and serial hormone chorionic gonadotropin (hCG) testing. Women were between 23 and 36 years old and had at least one previous delivery by caesarean. At admission, gestational age ranged between 6 to 14 weeks, and serum hCG levels between 397 and 23,000 mUI/ml. Upon decision of pregnancy termination, medical management was undertaken in all cases and 1 mg/kg systemic Methotrexate was administered between 1 and 5 daily doses. Mifepristone was part of the treatment in cases with live pregnancy. Surgical management was employed for the cases were an embryo was seen by ultrasound, being prompted by inadequate response to Methotrexate and/or signs of miscarriage with vaginal bleeding. Curettage combined with local isthmic balloon or vaginal pack tamponade prevented further complications. High treatment rates with preservation of fertility was achieved in all patients except one who underwent hysterectomy for invasive placentation. Ultrasound and hCG levels surveillance ensured that the resolution of pregnancy was achieved. CONCLUSION: Women with history of delivery by caesarean section should be carefully monitored in future pregnancies for prompt diagnosis of CSP. Early diagnosis of CSP allows selection of successful conservative therapy. Through this case series we contribute with our experience to the body of knowledge about the management of this serious complication of early pregnancy.

Recommendations for good practice in ultrasound: oocyte pick up†.

STUDY QUESTION: What is good practice in ultrasound (US), and more specifically during the different stages of transvaginal oocyte retrieval, based on evidence in the literature and expert opinion on US practice in ART? SUMMARY ANSWER: This document provides good practice recommendations covering technical aspects of US-guided transvaginal oocyte retrieval (oocyte pick up: OPU) formulated by a group of experts after considering the published data, and including the preparatory stage of OPU, the actual procedure and post-procedure care. WHAT IS KNOWN ALREADY: US-guided transvaginal OPU is a widely performed procedure, but standards for best practice are not available. STUDY DESIGN SIZE DURATION: A working group (WG) collaborated on writing recommendations on the practical aspects of transvaginal OPU. A literature search for evidence of the key aspects of the procedure was carried out. Selected papers (n = 190) relevant to the topic were analyzed by the WG. PARTICIPANTS/MATERIALS SETTING METHODS: The WG members considered the following key points in the papers: whether US practice standards were explained; to what extent the OPU technique was described and whether complications or incidents and how to prevent such events were reported. In the end, only 108 papers could be used to support the recommendations in this document, which focused on transvaginal OPU. Laparoscopic OPU, transabdominal OPU and OPU for IVM were outside the scope of the study. MAIN RESULTS AND THE ROLE OF CHANCE: There was a scarcity of studies on the actual procedural OPU technique. The document presents general recommendations for transvaginal OPU, and specific recommendations for its different stages, including prior to, during and after the procedure. Most evidence focussed on comparing different equipment (needles) and on complications and risks, including the risk of infection. For these topics, the recommendations were largely based on the results of the studies. Recommendations are provided on equipment and materials, possible risks and complications, audit and training. One of the major research gaps was training and competence. This paper has also outlined a list of research priorities (including clarification on the value or full blood count, antibiotic prophylaxis and flushing, and the need for training and proficiency). LIMITATIONS REASONS FOR CAUTION: The recommendations of this paper were mostly based on clinical expertise, as at present, only a few clinical trials have focused on the oocyte retrieval techniques, and almost all available data are observational. In addition, studies focusing on OPU were heterogeneous with significant difference in techniques used, which made drafting conclusions and recommendations based on these studies even more challenging. WIDER IMPLICATIONS OF THE FINDINGS: These recommendations complement previous guidelines on the management of good laboratory practice in ART. Some useful troubleshooting/checklist recommendations are given for easy implementation in clinical practice. These recommendations aim to contribute to the standardization of a rather common procedure that is still performed with great heterogeneity. STUDY FUNDING/COMPETING INTERESTS: The meetings of the WG were funded by ESHRE. The other authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER: NA.ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.

The Need for Cervical Cancer Control in HIV-Positive and HIV-Negative Women from Romania by Primary Prevention and by Early Detection Using Clinically Validated HPV/DNA Tests.

BACKGROUND: In Romania, a country with no organized national surveillance program regarding cervical cancer, the early diagnosis of HPV (Human Papilloma Virus) infections is a major requirement, especially in HIV-infected women. The objective of this study was to determine the HPV prevalence and type distribution in young HIV-positive women and to assess the difference in the risk factors for developing cervical cancer compared to those of HIV-negative women. METHOD: We conducted one cross-sectional cohort study from June 2013-September 2014, including 1,032 women: 992 HIV- women who were 36.5 years old (limits: 17 ÷ 84) and 40 HIV + women who were 22.9 years old (limits: 17 ÷ 30) with iatrogenic HIV infected. We detected HPV types with the Linear Array HPV Genotyping test (Roche, Romania). RESULTS: DNA/HPV was detected in 18/40 (45%) of the HIV+ patients and in 350/992 (35.2%) of the HIV- patients (OR = 1.5, 95%CI 0.76÷2.96). After age adjustment, the overall HPV prevalence was 51.6% in HIV+ versus 63.2% in HIV- women aged under 25, and 22.2% in HPV+ versus 47.2% in HIV- women aged 25-34. We detect HIV being a risk factor for acquiring multiple HPV type infections (OR = 2.30, 95% CI 0.88÷5.97). The eight most common HPV types (high-risk, and low-risk) for women below age 30, HIV+ / - were: HPV 16, 18, 31, 51, 58, 68, and 6 and 82 respectively. To assess the risk factors of HIV-positive women for acquiring HPV infection, we analyzed the CD4/µL, ARN/HIV copies/µL, the age group, the number of sexual partners, smoking, and the type of HPV infection (single versus multiple infections). We found that the number of sexual partners and smoking are statistically significant risk factors. CONCLUSION: Even though there are no significant differences regarding the prevalence of HPV infection in HIV + versus HIV - patients, multiple infections were more frequent in the first group. In our study group young HIV-infected patients under HAART therapy, high number of sexual partners (more than 3) and smoking were detected to be risk factors. Future organized screening for HPV infection using sensitive and specific methods are necessary at the national level in Romania.

Safety Indices during Fetal Echocardiography at the Time of First-Trimester Scan Are Machine Dependent.

The aim of our study was to evaluate the thermal index (TI) and mechanical index (MI), during the assessment of the fetal heart at the time of first-trimester scan, with different ultrasound machines. This was part of an observational study conducted in patients undergoing routine first-trimester screening. Cases were examined with Voluson E8 or 730Pro scanners using 2-8 MHz transabdominal probes. TI and MI were retrieved from the saved displays while in gray mode, color flow mapping and pulsed-wave (PW) Doppler examinations of the fetal heart and also from the ductus venosus (DV) assessment. We evaluated 552 fetal cardiac examinations, 303 (55%) performed with Voluson E8 and 249 (45%) with Voluson 730Pro ultrasound machines. The gray-scale exam of the heart and the PW Doppler DV assessment had TI values significantly lower for the Voluson E8 group (median, 0.04 vs. 0.2 and 0.1 vs. 0.2, respectively). The MI values from gray-scale and color flow mapping of the heart were significantly lower (median, 0.6 vs, 1.2 and 0.7 vs. 1) and for PW Doppler exam of the tricuspid flow were significantly higher (median 0.4 vs. 0.2) in the Voluson E8 group. The TI values from Doppler examinations of the heart, either color flow or PW imaging and MI values from DV assessment were not significantly different between the two groups. A different (newer) generation of ultrasound equipment provides lower or at least the same safety indices for most of the first-trimester heart examinations.

Factors affecting the feasibility of routine first-trimester fetal echocardiography.

OBJECTIVES: The purpose of our study was to assess the factors that may improve the feasibility of routine fetal echocardiography at the time of the first-trimester scan. METHODS: In this prospective study, we included 616 healthy singleton fetuses. Examinations were performed transabdominally by a single sonographer at the beginning of his training in first-trimester screening. The fetal heart was examined by high-definition color Doppler imaging to obtain the 4-chamber view, right and left ventricular outflow tracts, and 3-vessel and trachea view. Logistic regression was used to investigate the effect on the ability to visualize different cardiac structures. RESULTS: The frequency of successful heart examinations increased significantly with the number of scans performed (P < .05). The sonographer needed 180 examinations before he could successfully examine the heart in at least 80% of cases. Significant factors that increased the probability of adequate echocardiography were the length of the heart examination and the experience of the sonographer (P< .05) but not transducer-heart distance, maternal body mass index, fetal crown-rump length, placenta interposition, or restrictive fetal position. Visualization of the left ventricular outflow tract could be improved by increasing the experience of the sonographer and decreasing the transducer-heart distance. Also, visualization of the 3-vessel and trachea view depended on the length of the heart examination, the experience of the sonographer, an anterior position of the placenta, and a restrictive fetal position. CONCLUSIONS: Competence in color flow mapping assessment of the fetal heart at gestational ages of 11 weeks to 13 weeks 6 days is achieved only after extensive supervised training.

HPV prevalence and type distribution in women with or without cervical lesions in the Northeast region of Romania.

BACKGROUND: Cervical cancer is a major public health problem worldwide. While Romania has the highest incidence of cervical cancer in Europe, the prevalence of HPV has not been evaluated. We report the first data on HPV prevalence and type distribution in Northeast Romania. METHODS: HPV prevalence and genotype distribution was investigated in 514 consecutively women with or without cervical lesions in Northeast Romania. Genotyping was performed with Linear Array Genotyping/Roche kit. RESULTS: In our study group, 192/514 (37.4%) patients were positive for HPV (infected with single and with multiple HPV types). Most frequent types were: 16 (10.5%), 53 (5.44%), 51 (5.05%), 52 (4.08%) 18 (2.91%) and 31 (2.73%). CONCLUSIONS: Infection with high risk types of HPV is common in Northeast Romania. Enhanced and systematic screening for cervical cancer is needed. Our results call for the implementation of a National HPV vaccine program in Romania.

Management of the electronic patient records in the web based platform for diagnosis and medical decision for optimization in healthcare-PROMED.

The paper describes a research-development which had the objective to implement and manage the Electronic Patient Record in a multifunctional pilot platform named PROMED. The Electronic Patient Record implemented by PROMED platform is mainly aimed to facilitate both patient and health providers access to the health records and to provide an optimization of diagnostic and decision in healthcare services based on patients' medical history and medical statistics. The project promotes modern information and communication technologies for increasing quality and efficiency of healthcare services in an information based society. The PROMED platform is expected to contribute specifically to the improvement of the healthcare services in Romania by offering a solution for the integration of the main stakeholders involved in national healthcare system: patients, health service providers and public health authorities. The pilot system is first implemented in the "Cuza Voda" Obstetrics and Gynecology Hospital in Iassy, an important universitary and cultural city in the North East of Romania.

[Prune-belly syndrome prenatal diagnosis]. / Sindromul prune-belly diagnosticat la 19 saptamani de amenoree.

We present the ultrasonographic diagnosis at the 19th gestational week in a case of Prune-belly syndrome which consists in abdominal wall distension with deficiency of the abdominal wall musculature, urinary tract abnormalities (specially mega bladder), and in males, cryptorchidism. The pathologic examination found the patient devoid of striated muscles anterior abdominal wall, hypertrophy of the urinary bladder, and urethral atresia. The Prune-belly is accessible to antenatal diagnosis and the variable prognosis does not always justify abortion.