Thrombosed Arteriovenous Malformation of Umbilical Cord.

Background: Arteriovenous malformation of umbilical cord is an extremely rare congenital malformation. Causes of this condition are unknown. AVM of umbilical cord can cause significant complications in the developing fetus. Methods: We report our management of the case with accurate ultrasound study that could improve and facilitate the approach to this pathology due to the lack of literature and with an overview of the available literature. Results: There are only two cases of umbilical AVM diagnosed in the prenatal period with associated pathology. The mainstay of prenatal detection is the accurate study of umbilical cord also even if it is not requested from the actual guide lines in a way to improve the perinatal morbidity and mortality.

Total laparoscopic hysterectomy four-handed ergonomic technique: description of an original surgical procedure for the reduction of learning curve.

The aim of this study was to propose the four-handed technique for total laparoscopic hysterectomy (TLH), with or without adnexectomy. From our point of view this is a more ergonomic, efficient, and effective technique that can contribute to the training of specialists in obstetrics/gynecology. In fact, teacher and learner have both an active role on the surgical field using two laparoscopic instruments each. They are alternately, mutually, and symmetrically first operator and assistant, reducing number of attempts needed for laparoscopic hysterectomy learning curve. The detailed description of all the surgical steps of TLH, "four-handed technique" (FHT), with or without adnexectomy, make sure that it can be effectively reproduced step by step safely, by transposing "FHT" surgical steps of laparotomic approach. This may allow easy access to anatomical spaces inserting trocars in different ways. By clearly knowing the steps of TLH, "FHT" it is possible to favor minimally invasive routes so that patients benefit from its multiple proven benefits. Operating this way, operative time, blood loss, use of analgesics and hospitalization can be significantly reduced. In conclusion benefits of TLH have already been widely demonstrated in literature. It is a real opportunity that young specialists become confident with this innovative "FHT," a procedure that allows them to be surgeon first assistant, and in which they can learn faster real intraoperative stereotaxis and surgical steps sequence, familiarizing with the anatomy of retroperitoneal space.

Five-vessel umbilical cord and fetal outcome: an obstetric overview.

PURPOSE: The birth of a child with an increased number of blood vessels in the umbilical cord (UC) is a rare event and has been previously reported to be associated with a higher incidence of congenital anomalies. METHODS: A case of a healthy female infant with an intra-uterine growth restriction (IUGR), born from a bicornuate uterus at 37 weeks of gestation and weighing 2500 g with a diagnosis of five-vessel UC made post-natally, on gross examination of the UC and confirmed by histopathological examination is documented. In particular, sections from the UC showed four umbilical arteries (UA) and one umbilical vein (UV). A review of literature was performed. RESULT: The physical examination of the baby after birth was normal. To the best of our knowledge, this is the first case to document the association of five-vessel UC with IUGR and the Mullerian anomaly of bicornuate uterus. CONCLUSION: The detection of supernumerary blood vessels in the UC mandates comprehensive workup for associated congenital anomalies but this case suggests that such finding might not always serve as an ominous sign for an adverse perinatal outcome.

The association between the regular use of early-term labor induction and improved birth outcomes: new evidence from an Italian hospital.

BACKGROUND: Associations have been recently reported between the frequent use of early-term preventive labor induction and improvements in multiple parameters of birth health. We sought to replicate these findings in an Italian hospital. METHODS: The outcomes of 120 consecutively delivered women who were exposed to the alternative method of care were compared to the outcomes of 159 women who received standard management. The primary and secondary outcomes were group cesarean delivery rate and group adverse outcome index score. RESULTS: Exposed women had a higher induction rate, a lower cesarean delivery rate (1.7% vs. 43.4%), and a lower group AOI Score (0.2 vs.5.8). CONCLUSIONS: Exposure to high levels of early term preventive labor induction was associated with a lower group cesarean delivery rate and improvement in several other major birth outcomes. An adequately powered randomized controlled trial is needed to further explore this alternative method of care.

Risk assessment for Down syndrome with genetic sonogram in women at risk.

OBJECTIVE: To evaluate the algorithms of risk assessment for Down syndrome (DS). METHODS: Cohort study conducted in women at risk undergoing midtrimester genetic sonogram. Univariate and logistic regression analysis were used to relate findings to the occurrence of DS. The resulting model was validated in an independent population of patients. RESULTS: In a multivariable model adjusted for gestational age and maternal age, nuchal fold thickness (NFT) >or= 5 mm (OR = 4.6, 95% CI 0.9-23.9), presence of renal pelvic dilation (OR = 18.0, 95% CI 2.9-110.5), absent mid-phalanx of the 5th finger (OR = 29.9, 95% CI 6.1-145.8), presence of noncardiac malformations (OR = 20.1, 95% CI 2.6-154.7) or isolated heart defects (OR = 60.2, 95% CI 9.5-382.8), the interactions of gestational age with NFT >or= 5 mm (P = 0.04) and malformations with heart defects (P = 0.03) were significantly associated with DS. Utilizing this model and a risk cutoff point of 1/270, the sensitivity was 83.3% (5/6) with a false positive rate (FPR) of 28.5% (159/558). CONCLUSION: Genetic sonogram has adequate accuracy to be incorporated into management algorithms for risk assessment of DS in women at risk.

Risks of induction of labour in women with a uterine scar from previous low transverse caesarean section.

OBJECTIVE: Recent studies have shown that among women with uterine scars from previous caesarean section of any type, induction of labour is associated with increased risk of uterine rupture compared with spontaneous labour. We have assessed the risk of uterine rupture in a cohort of women with a previous low transverse caesarean section in whom induction and management of labour were performed according to a strict protocol. DESIGN: Cohort study. SETTING: University Hospital. POPULATION: All women with a singleton pregnancy and a previous low transverse caesarean section requiring induction of labour from 1/1/1992 to 12/30/2001 (n = 310) were compared with a control cohort during the same study period constituted of women with a previous low transverse caesarean section in spontaneous labour (n = 1011). METHODS: Clinical characteristics and rate of uterine rupture of women with previous caesarean section undergoing induction of labour were compared with those of women with previous caesarean section in spontaneous labour. MAIN OUTCOME MEASURE: Incidence of uterine rupture. RESULTS: Uterine rupture occurred in 0.3% in the previous caesarean section--induction group versus 0.3% in the previous caesarean section--spontaneous labour group (P = 0.9). Logistic regression analysis showed no significant difference in the rate of uterine rupture between the induction and spontaneous labour group (P = 0.67) after controlling for maternal age, parity, duration of labour, gestational age at delivery and birthweight. CONCLUSION: Among women with a previous low transverse caesarean section, induction of labour is not associated with significantly higher rates of uterine rupture compared with spontaneous labour, provided a consistent protocol with strict criteria for intervention is adopted.

Caveats for the use of humerus length in the prediction of fetal Down syndrome.

OBJECTIVE: To assess the reliability and reproducibility of fetal humerus length in the diagnosis of trisomy 21. METHODS: Cohort study inclusive of 22 trisomy 21 fetuses, who underwent ultrasonographic examination between 14 and 22 weeks' gestation, and 457 euploid controls. Regression analysis was performed for humerus length as function of biparietal diameter. Based on the generated regression equation in euploid fetuses, expected values of humerus length for a given biparietal diameter were calculated. The ratios of observed to expected (O/E) humerus length values were compared between euploid and trisomy 21 fetuses using Student's t test. Receiver operating characteristic (ROC) curve analysis was used to detect optimal thresholds of O/E humerus length for diagnosis of trisomy 21. In addition, a MEDLINE search was conducted for articles published on humerus length as predictor of trisomy 21. RESULTS: No differences were present between the regression lines of trisomy 21 and euploid fetuses (mean +/- standard deviation O/E humerus length in euploid and aneuploid fetuses: 1.00 +/- 0.10 vs. 0.97 +/- 0.11, p = 0.21). The optimal threshold O/E humerus length <0.88 identified by ROC curve analysis had a sensitivity of 18% and a false-positive rate of 9% for the diagnosis of trisomy 21. From a review of the evidence provided by the 17 published series on humerus length as predictor of Down syndrome, the following caveats emerge: (1) with a median false-positive rate of 5% (range 1-12%), the median sensitivity of humerus length was only 28% (range 15-64%); (2) differences were present among centers in the regression lines of euploid fetuses and in the optimal diagnostic thresholds of humerus length, suggesting inter-center variability, and (3) most populations studied were at high genetic risk for trisomy 21, hence the diagnostic ability of humerus length in low risk populations has not been tested. CONCLUSIONS: The ability of humerus length to predict trisomy 21 is inconsistent. Only institutions with locally generated regression equations and documented predictive ability of this marker should utilize humerus length as a screening test for trisomy 21, alone or incorporated into diagnostic algorithms with serum or other sonographic markers of trisomy 21. The diagnostic ability of humerus length in low risk populations is currently unknown.

Factors affecting the decision regarding amniocentesis in women at genetic risk because of age 35 years or older.

OBJECTIVE: To evaluate the effects of anamnestic factors and sonographic findings on the patient's decision regarding amniocentesis in a cohort of women at genetic risk because of advanced age. METHODS: All women 35 years of age or older registered for prenatal care between January 1990 and December 1998 were asked about their attitude towards genetic amniocentesis during the course of individual genetic counseling and once again after ultrasound examination inclusive of markers of aneuploidies (nuchal fold thickness greater than 6 mm, renal pyelectasis, choroid plexus cysts, and hyperechogenic bowel). Their attitudes towards genetic amniocentesis before and after ultrasound examination were compared using chi-square, Fisher's exact test, Mann-Whitney U-test, and logistic regression analysis, with a two-tailed p < 0.05 or an odds ratio (OR) with 95% confidence interval (CI) not inclusive of the unity considered significant. RESULTS: Among the 1486 women in the cohort, 1368 (97%) expressed an opinion towards genetic testing at the time of counseling: 501 (37%) were in favor and 867 (63%) were against having the procedure. After ultrasonographic examination, 33% (446/1368) of women opted for amniocentesis, 36% (146/402) after abnormal findings and 31% (300/966) after normal ultrasound findings. Significantly more women with abnormal than normal ultrasound findings opted for diagnostic testing in both groups. Overall, only 8% (115/1368) of women changed their attitude towards diagnostic testing after ultrasonographic examination. Normal sonographic findings were three times more likely to change the attitude of women initially interested in amniocentesis than abnormal sonographic findings did in women a priori not interested in the procedure (20% versus 7%, p < 0.001, OR = 3.2, 95% CI 1.8; 5.8). CONCLUSIONS: In a cohort of women at genetic risk because of advanced age, the key determinant of the choice regarding genetic amniocentesis is the a priori opinion of the woman towards the procedure, which was expressed by 93% of women. Ultrasonography plays a secondary role in changing or confirming women's attitude towards invasive diagnostic testing. Normal sonographic findings affect women's decisions more powerfully than abnormal sonographic findings, suggesting that ultrasonography has an important reassuring function for the woman.