Twin-to-twin transfusion syndrome complicated with in utero limb ischemia of the donor twin - a case report.

BACKGROUND: In utero limb ischemia is a rare complication of the monochorionic twin pregnancies complicated with twin to twin transfusion syndrome (TTTS). The condition is more often seen in recipient twins. There are few theories of the pathogenesis including in utero venous thromboembolism, but the cause remains unclear. However, limb ischemia is thought to be unrelated with any prenatal intervention. CASE PRESENTATION: We present a case of a monochorionic twin pregnancy complicated with TTTS admitted to the Clinic for selective fetoscopic laser photocoagulation. The invasive procedure failed due to poor visibility. In the following weeks of pregnancy, amnioreduction procedures were performed. At 28 weeks of gestation due to twin anemia-polycythemia sequence diagnosis the patient was qualified for cesarean section. Postnatally, the donor twin was diagnosed with lower right limb ischemic necrosis. The extremity was amputated 2 days later with an uncomplicated recovery. After speculations of the potential pathogeneses it was suggested that the ischemic limb occurred as a complication of the main condition - TTTS. CONCLUSIONS: In literature, there have been no cases reported of TTTS stage I complicated with donor twin limb ischemia. The actual cause of the in utero limb ischemic necrosis in monochorionic twins remains unknown. Nevertheless, increased attention to the potential complication after failed invasive procedures or conservative treatment should be required.

Vascular anastomoses in intrauterine growth in monochorionic twins.

Objectives To evaluate the impact of placental anastomoses on the intrauterine growth of monochorionic (MC) twins. Methods A prospective study was conducted in a group of 53 MC twins. Intrapartally umbilical cords were clamped to identify placental sides corresponding to each twin. The postnatal dye injection technique was administered to evaluate vascular anastomoses, their number and type and visualize placental territory sharing patterns. Data from digital analysis were correlated with obstetrical follow-up. Results Vascular anastomoses were revealed in 88.7% of cases. Arteriovenous (AV) anastomoses occurred in 75.4% and arterioarterial (AA) in 71.1% while venovenous (VV) in 26.4%. In the subgroup of MC twins without placental anastomoses, significantly higher birthweight difference and discordance were revealed when compared to MC twins without anastomoses (382.0 vs. 22 g; P = 0.03 and 49.14% vs. 16.02%; P = 0.03). On the other hand, in subgroups of MC twins with at least one AA anastomosis, twins' birthweights were similar (p = ns) despite significantly higher placental territory sharing discordance (30.44% vs. 15.81%; P = 0.31). Conclusions Vascular anastomoses have a major impact on the intrauterine growth of MC twins. In certain cases, they may cause specific complications; however, in general, they regulate intertwin blood exchange and may compensate unequal placental territory.

Maternal Nutritional and Water Homeostasis as a Presage of Fetal Birth Weight.

Birth weight is a key determinant of perinatal outcomes which affect physical development and metabolic function. In this study, we evaluated the potential role of maternal body composition and nutritional status in programing fetal birth weight. This was a longitudinal study that included 29 pregnant women and their full-term newborns. Maternal dietary energy and fluid intake and body adipose tissue were assessed. In addition, we measured the serum content of copeptin, aldosterone, and angiotensin II in maternal and umbilical cord blood. The measurements were done across the three trimesters of pregnancy, on average, at 11.6 weeks, 18.3 weeks, and 30.2 weeks. Each newborn's birth weight was determined at the percentile line, using the World Health Organization (WHO) standards based on the gestational age, gender, and weight. We found no appreciable relation of fetal birth weight to the maternal dietary and fluid intakes, and the content of angiotensin II, aldosterone, or copeptin. However, birth weight correlated with increases in body adipose tissue in early pregnancy stages. Further, birth weight correlated positively with copeptin and adversely with angiotensin II in cord blood. We conclude that the present findings may be helpful in the assessment of a critical level of body adipose tissue in women of child-bearing age, above which the potential risk of macrosomia appears. The female population of child-bearing age needs a continual update on the nutritional knowledge to prevent modifiable maternal and fetal perinatal complications.

Multi-center results on the clinical use of KANET.

An extensive review of the literature on the diagnostic and clinical accuracy of Kurjak's antenatal neurodevelopmental test (KANET) and the summarized results of the multi-center study involving 10 centers revealed that four-dimensional ultrasonography (4D US) has become a powerful tool and KANET a valuable test that empowers the clinicians worldwide to evaluate the fetal behavior in a systematic way and contribute to the detection of fetuses that might be at high risk for neurological impairments and in particular cerebral palsy (CP). After 10 years of clinical use, many published papers and multi-center studies, hundreds of trained physicians and numerous tests performed all over the world, KANET has proven its value and has been showing encouraging results so far. The aim of this paper is to show the results from the studies done so far and to reveal the clinical value of the KANET. We expect that data from the larger ongoing collaborative study, the short- and long-term postnatal follow-up will continue to improve our knowledge. Ultimately, we all strive to prevent the CP disorders, autism spectrum disorder (ASD) and other neurological impairments and we are convinced that KANET might be helpful in the realization of this important aim.

Cervical Measurement and Pessary Application in Relation to Gestational Age at Delivery in Patients Treated with Fetoscopic Endotracheal Occlusion.

OBJECTIVE: To evaluate the impact of cervical length and cervical pessary application in congenital diaphragmatic hernia (CDH) treated by the fetoscopic endotracheal occlusion (FETO) procedure. METHODS: The study group consisted of 80 patients with severe CDH treated by FETO. Cervical length measurement was performed by transvaginal ultrasound in all patients within the 24 h prior to the FETO procedure. The study group (n = 44) had cervical pessaries applied routinely within the 24 h following the FETO procedure, whereas the control group (n = 36) were not offered pessaries and only had cervical length measurement performed. RESULTS: The median cervical length was 31 (range 22-45) mm. The median gestational age at delivery was 34.7 (range 27.8-39.2) weeks. Gestational age at delivery correlated significantly with gestational age at balloon removal (r = 0.768; p < 0.0001) and premature rupture of membranes (r = 0.501; p = 0.003). There was no significant correlation between gestational age at delivery and cervical length before the procedure (r = 0.141; p = 0.26) or pessary application (r = 0.081; p = 0.51). In the multivariate linear regression model, the only factor independently associated with gestational age at delivery was gestational age at fetoscopic balloon removal (ß = 0.713; p < 0.0001). CONCLUSION: In cases of severe CDH treated by the FETO procedure, neither cervical length before the procedure nor cervical pessary application was associated with gestational age at delivery.

Sudden Fetal Hematologic Changes as a Complication of Amnioreduction in Twin-Twin Transfusion Syndrome.

We present the first case of a monochorionic twin pregnancy in which sudden hematologic changes occurred as a complication of the amnioreduction procedure for twin-twin transfusion syndrome (TTTS). At 33 weeks of gestation, 4 days after the amnioreduction, the recipient developed severe anemia while the donor developed severe polycythemia. Postnatal placental examination revealed several arteriovenous and venoarterial anastomoses, a pale placental mass of the recipient and a congested and plethoric placental mass of the donor. We speculate on the pathophysiologic changes and potential deleterious effects provoked by the decompressive amnioreduction. Decompression of the placenta and anastomoses after the amnioreduction may have led to an acute blood shift from recipient to donor (thus also a reversal of feto-fetal transfusion), resulting in anemia in the recipient and polycythemia in the donor twin. In the past 15 years, 13 TTTS cases with late presentation were treated with amnioreduction. This is the first time we encountered this severe complication, yielding an incidence of 8%. Although the optimal treatment in TTTS with late presentation is not known, perinatologists should be aware that treatment with amnioreduction can lead to sudden hematologic changes.

Rapid cervical phIGFBP-1 test in asymptomatic twin pregnancies is inefficient in predicting preterm delivery prior to 34 gestational weeks.

OBJECTIVES: To assess the effectiveness of a rapid second trimester test for cervical phIGFBP-1 in the prediction of sponta-neous preterm delivery prior to 34 weeks in asymptomatic twin pregnancies. MATERIAL AND METHODS: A prospective observational study conducted on 232 twin pregnancies tested for phIGFBP-1 at 20-24 weeks of gestation. 151 patients assessed as asymptomatic, with cervical length > 25 mm at 20-24 weeks were analysed. The primary outcome was the delivery < 34 weeks of gestation. RESULTS: The spontaneous preterm delivery before completing 34 weeks occurred in 23 patients (15.2%), including 9 in dichorionic and 14 in monochorionic pregnancies. The sensitivity of phIGFBP-1 test was 0.39 and specificity 0.63 in predicting delivery before 34 gestational weeks. phIGFBP-1 had a low positive predictive value of 0.16 and high negative predictive value (0.85). Both positive and negative predictive values of delivery < 34 weeks were close to 1. CONCLUSIONS: A test for phIGFBP1 presence is not an effective additional tool for predicting preterm delivery before 34 weeks in twin gestation.

Dietary macronutrients and fluid intakes in a sample of pregnant women with either gestational diabetes or type 1 diabetes mellitus, assessed in comparison with Polish nutritional guidelines.

OBJECTIVES: Pregnancy is a critical period during which environmental factors such as nutrition can affect development. Maintaining proper nutrition becomes even more significant when pregnant women have diabetes. The aim of this study was to measure changes in energy and macronutrient intakes among pregnant women and patients diagnosed either with gestational diabetes mellitus (GDM) during pregnancy, or, type 1 diabetes mellitus (T1DM) before pregnancy, and to assess the pregnant women's dietary intakes in comparison with Polish Institute of Food and Nutrition nutritional guidelines. MATERIAL AND METHODS: The analysis was conducted among 83 pregnant women (29 GDM patients, 26 T1DM patients and 28 normal pregnancy patients - the control group) from whom we gathered nutritional data during the second part of their pregnancies. Data on each woman's diet during pregnancy was collected is self-completed dietary records during seven consecutive 24-hour periods. RESULTS: The mean macronutrient intake of the GDM patients was 32.1% fat, 19.5% protein, and 48.3% carbohydrates; in the T1DM group the results were 34.2%, 19.4% and 46.4% respectively; and in control group they were 31.8%, 17.6% and 50.5% respectively. This study showed that many of the pregnant women did not reach the recommended level of energy intake during pregnancy. Moreover, most of the women exceeded their fat requirements, and fat intake as a proportion of energy intakes also exceeded the guidelines in more than 60% of the women across all groups. CONCLUSIONS: The implications and possible causes of excessive fat intake during pregnancy and pregnancies complicated by diabetes are underestimated and undertreated by obstetricians and warrant further investigation, especially in association with gestational weight gain, maternal and fetal perinatal complications, and post-gestational diabetes.

Dietary vitamin and mineral intakes in a sample of pregnant women with either gestational diabetes or type 1 diabetes mellitus, assessed in comparison with Polish nutritional guidelines.

OBJECTIVES: Maintaining proper nutrition during pregnancy is crucial for pregnant women and especially for who have been diagnosed with type 1 diabetes mellitus (T1DM) or who develop gestational diabetes mellitus (GDM). MATERIAL AND METHODS: To measure differences in vitamin and mineral intakes among women with normal pregnancies, pregnant women with GDM, and pregnant women with pre-gestational T1DM; and to assess the women's dietary intakes in comparison with Polish nutritional guidelines. The analysis was conducted among 83 pregnant women (29 GDM patients, 26 T1DM patients and 28 normal pregnancy participants) from whom we collected seven-day 24-hour dietary records during the second part of their pregnancies. RESULTS: There were no statistically significant differences observed for most of the vitamin and mineral intakes across the three groups. However, we did observe a significant difference in the vitamin C and calcium intakes between groups. The mean vitamin C and calcium intakes were significantly higher in the control group than among the diabetic patients. Insufficient dietary calcium intakes were found among 52.3% of the GDM patients and 61.6% of the T1DM participants, while only 28.6% of the normal pregnancy patients experienced a calcium deficiency. The highest incidence of inadequate intake in each of the GDM, T1DM and control groups was observed for vitamin D (100%, 100%, 100%), folate (97.7%, 100%, 100%), iron (97.7%, 100%, 100%), and iodine (97.7%, 92.4%, 85.7%), respectively. CONCLUSIONS: Diet alone may not be enough to provide adequate levels of vitamins and minerals for most micronutrients. Supplement use reduces the risk of inadequate intake for many micronutrients, but diet-related issues during pregnancy and pregnancy diagnosed with diabetes remain, and they deserve to be addressed during public health interventions.

Venous thromboembolism in obese pregnant women: approach to diagnosis and management.

Venous thromboembolism (VTE) remains among the leading causes of maternal mortality in the developed world, presenting variably as deep vein thrombosis (DVT), pulmonary embolism (PE) or cerebral vein thrombosis (CVT), among others. Obesity in particular has been recognized as the principal contributing factor to the risk of VTE in pregnancy and with the global increase in the rates of obesity affecting reproductive age women, heightened awareness of the risk and consequences of VTE in this population are vital. Thus, prophylaxis, diagnosis and treatment of VTE in the obese gravida are discussed.

Polish Gynecological Society Recommendations for Labor Induction.

Labor induction involves artificial stimulation of childbirth before the natural, spontaneous onset of labor. It is one of the most common procedures in modern obstetrics. The frequency of labor induction has doubled in recent decades due to the development of perinatology and methods of monitoring fetal well-being in particular. Currently, one in five pregnant women and 30-40% of women delivering vaginally undergo this procedure. Reasons for induction include reduction of the perinatal mortality and morbidity of the fetus and newborn, as well as the reduction of maternal complications. However, as every medical intervention, labor induction is associated with a risk of complications.

Favourable pregnancy outcome in a woman with secondary pulmonary hypertension complicating mitral stenosis.

Pulmonary hypertension (PH) is a rare condition with a high incidence of maternal and perinatal mortality (30-56% and 10-13%, respectively). Pulmonary hypertension is a contraindication to pregnancy because of high risk of maternal death, therefore the World Health Organisation (WHO) advises to discuss a termination in the event of pregnancy with women suffering from PH.

Labour in women with gestational diabetes mellitus.

OBJECTIVES: Gestational diabetes mellitus (GDM) constitutes one of the most common pregnancy complications and affects 3-5% of all pregnancies, with its incidence still growing. Due to possible maternal and fetal complications, the peripartum management of GDM patients continues to be a debatable issue. The aim of the study was to analyse the course and final way of delivery in women with gestational diabetes mellitus. The effectiveness of induction of labour (IOL) was also assessed and factors predisposing to cesarean section were identified. MATERIAL AND METHODS: The study group consisted of 204 women with GDM who delivered in the Academic Centre for Woman's and Neonate's Health in Warsaw over the years 2013 and 2014. The indications and ratios of elective and intrapartum cesarean sections were analysed. Patients qualified for induction of labour were compared depending on their final way of delivery. RESULTS: Over a half of all deliveries in the study group (53%) were cesarean sections. Elective surgeries accounted for 70% of all cesarean sections, predominantly due to a history of previous operational deliveries. Only 12% of the study group developed spontaneous uterine contractions and delivered vaginally. A comparison of the vaginal delivery group (n = 96) with cesarean section group (n = 108) pointed to high pregestational BMI value and advanced maternal age as factors increasing the patient's risk for surgical delivery (p = 0.0000 and p = 0.048 accordingly). The comparison of women undergo-ing IOL vs. omen with spontaneous uterine contractions showed no increase in the ratio of intrapartum cesarean sections in the IOL group - in both subgroups vaginal delivery was achieved in 75% of cases. CONCLUSIONS: Patients with GDM are more likely to undergo cesarean section, but the implementation of induction of labour at term does not further aggravate this risk. Major risk factors for operational delivery in GDM population included: advanced maternal age, high pregestational BMI value and undergoing insulin therapy.

Pregnancy in the liver transplant recipient.

During gestation, the woman's body undergoes various changes, and the line between physiology and pathology is very thin even in healthy women. Today, many of the liver transplant recipients are young women, who at one point in their lives may consider the possibility of pregnancy. Clinicians have to counsel them about the time of conception, the risk of miscarriage, the deterioration of the mother's health status, and the risk of birth defects. This review, based on our 20 years of clinical experience and up-to-date literature, provides comprehensive guidelines on pregnancy management in liver transplant recipients. Pregnancy in liver transplant recipients is possible but never physiological. Proper management and pharmacotherapy lowers the incidence of complications and birth defects. Critical factors for perinatal success include stable graft function before pregnancy, proper preparation for pregnancy, and cautious observation during its course. Liver Transplantation 22 1408-1417 2016 AASLD.

First trimester erythropoietin (EPO) serum concentration as a potential marker for abnormal placentation disorders. Reference values for erythropoietin (EPO) concentration at 11-13⁺6 weeks of gestation.

OBJECTIVES: To investigate the possible effect of abnormal placentation disorders such as preeclampsia (PE), pregnancy induced hypertension (PIH) and intrauterine growth restriction (IUGR) on erythropoietin (EPO) serum concentration in women in the first trimester of pregnancy. MATERIAL AND METHODS: A prospective study was performed in a group of pregnant women between 11 and 13⁺6 weeks' gestation. Serum concentration of EPO, beta HCG, PAPP-A and PlGF was measured. Mean arterial pressure (MAP) and uterine artery pulsatility index was calculated. RESULTS: A group of 198 analyzed patients was divided into three groups depending on pregnancy outcome: abnormal placentation group (n=30), macrosomia (n=13) and control group (n=155). EPO concentrations between the three groups of patients revealed that they differ significantly (F=15.172, P<0.001). EPO concentration is significantly higher in abnormal placentation patients compared to the control group (P<0.001) and macrosomia group (P=0.004). The most significant increase in EPO concentration was detected within patients with PIH. Also the uterine artery pulsatility index was positively correlated with EPO concentration (P<0.01). CONCLUSIONS: First-trimester maternal EPO concentration might be considered as a possible marker of abnormal placentation disorders and should be given more attention in future prospective studies.

First and third trimester serum concentrations of adropin and copeptin in gestational diabetes mellitus and normal pregnancy.

OBJECTIVES: Gestational diabetes mellitus (GDM) is a metabolic disease diagnosed in 1.7% up to 11.6% pregnancies. The prevalence of adverse pregnancy outcome is significantly higher in the case of early onset of diabetes mellitus. Adropin is a hormone promoting carbohydrate oxidation over fat oxidation, and influence nitric oxide synthase. Copeptin is a cleavage product of the vasopressin precursor recently correlated with diabetes mellitus. The aim of the study was to determine maternal serum adropin and copeptin concentrations in women with early and late manifestation of GDM and to discuss their potential role as biochemical markers of insulin resistance. MATERIAL AND METHODS: Case-control study on 58 pregnant Caucasian women. Serum levels of adropin and copeptin were assessed in patients with early onset (GDM1) and classical gestational diabetes mellitus (GDM2). Complications such as macrosomia and hypotrophy were evaluated. RESULTS: There was no significant difference between the study and the control group (age, BMI, parity). Fetal growth disturbance rate was 37.5% in GDM1, 11% in GDM2 and 6% in controls. Adropin concentration in GDM patients was significantly higher than in control group (p < 0.001), but there was no difference between GDM1 and GDM2 group. High serum concentration of adropin positively correlated with elevated HbA1c (p < 0.05). The groups did not differ in terms of copeptin serum concentration. CONCLUSIONS: High adropin serum concentration in GDM patients is associated with increased risk of fetal growth disturbances, possibly due to improper placentation. According to our prospective study, neither copeptin nor adropin serum concentration are useful to discriminate between early and late onset of gestational diabetes mellitus.

Placental examination with dye injections in post-delivery chorionicity assessment in dichorionic triplet pregnancy.

The incidence of spontaneous triplet pregnancy is approximately 1 in 7000 deliveries. Due to the fact that every presentation of a triplet and higher order pregnancy is associated with high rate of morbidity and preterm delivery, chorionicity and amnionicity remain significant predictive factors which determine specific management throughout the pregnancy. Ultrasound chorionicity assessment in triplet pregnancies is more complex than in twins, and in many cases it remains unknown. We present a case report of a 24-year-old primipara in a spontaneous dichorionic triplet pregnancy, qualified for a cesarean section at 33 weeks of gestation, with subsequent placental examination with dye injections and post-delivery chorionicity assessment.

Perinatal outcome according to chorionicity in twins - a Polish multicenter study.

OBJECTIVES: The aim of the study was to analyze the perinatal outcome of twin gestations and estimate the influence of chorionicity on the outcome in a large cohort of twin pregnancies in Poland. MATERIAL AND METHODS: A retrospective analysis of 465 twin deliveries in 6 Polish centers in 2012 was conducted. Baseline characteristics, the course of pregnancy and labor, as well as the neonatal outcome were analyzed in the study group and according to chorionicity. RESULTS: A total of 356 twin pregnancies were dichorionic (DC group) (76.6%), and 109 were monochorionic (MC group) (23.4%). There were no differences in the occurrence of pregnancy complications according to chorionicity, except for IUGR of at least one fetus (MC 43.1% vs. DC 34.6%; p = 0.003). 66.5% of the women delivered preterm, significantly more in the MC group (78% vs. 62.9%; p = 0.004). Cesarean delivery was performed in 432 patients (92.9%). Mean neonatal birthweight was statistically lower in the MC group (2074 g vs. 2370 g; p < 0.001). Perinatal mortality of at least one twin was 4.3% (2.8% in the DC group vs. 9.2% in the MC group; p = 0.004). Neonatal complications, including NICU admission, respiratory disorders, and infections requiring antibiotic therapy, were significantly more often observed among the MC twins. CONCLUSIONS: The overall perinatal outcome in the presented subpopulation of Polish twins and its dependence on cho-rionicity is similar to the reports in the literature. Nevertheless, the rates of preterm and cesarean deliveries remain higher. It seems that proper counselling of pregnant women and education of obstetricians may result in reduction of these rates.

Phosphorylated IGFBP-1 in predicting successful vaginal delivery in post-term pregnancy.

PURPOSE: To estimate whether phosphorylated IGFBP-1 (phIGFBP-1) in cervical secretion in term and post-term pregnancies can predict spontaneous onset of labor or vaginal delivery. METHODS: A prospective cohort study of 167 women in singleton term and post-term pregnancies, was conducted at 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, between 2013 and 2014. phIGFBP-1 test (Actim Partus Medix Biochemica), ultrasound cervix assessment and Bishop score were analyzed in the study group. Spontaneous onset of labor was the primary and vaginal delivery was the secondary outcome. RESULTS: In 32.5 % of patients, spontaneous uterine contractions appeared. 67.5 % of women delivered vaginally, 32.5 % had cesarean section. phIGFBP-1 test predicted spontaneous onset of labor (sensitivity 0.69, specificity of 0.42) and successful vaginal delivery (0.67, 0.48). In the prediction of spontaneous delivery onset ultrasound cervical assessment and phIBFBP-1 had comparable sensitivity and in the prediction of successful vaginal birth all three tests had comparable sensitivity. The time from preinduction to spontaneous onset of delivery was significantly shorter in women with positive phIGFBP-1 test (13.65 ± 6.7 vs 20.75 ± 2.6 h; p = 0.006). CONCLUSION: A test for phIGFBP1 presence might be an additional tool for predicting both spontaneous onset of labor and successful vaginal delivery in post-term pregnancies.

Placental pathologic changes in gestational diabetes mellitus.

Nowadays, the continuous rise of maternal obesity is followed by increased gestational diabetes mellitus incidence. GDM is associated with adverse fetal and neonatal outcome that often presents with macrosomia, birth trauma, neonatal hypoglycemia, and respiratory distress syndrome. Inclusion of GDM into 'the great obstetrical syndromes' emphasizes the role of the placenta in interactions of the maternal and fetal unit. The placenta acts as a natural selective barrier between maternal and fetal blood circulations. Placenta is sensitive to the hyperglycemic milieu and responses with adaptive changes of the structure and function. Alteration of the placental development and subsequent vascular dysfunction are presented in 6 out of 7 women with all ranges of diabetic severity. Most placentas from GDM pregnancies present typical histological findings such as villous immaturity, villous fibrinoid necrosis, chorangiosis, and increased angiogenesis. The type of dysfunction depends on how early in pregnancy glycaemia disorders occurred. Generally, if impaired glucose metabolism is diagnosed in the early pregnancy, mainly structural dysfunctions are observed. GDM that is detected in late gestation affects placental function to a greater extent. Moreover many studies suggest that diabetic placental changes are associated with inflammation and oxidative stress that can lead to the chronic fetal hypoxia. This article aims to review particular changes of the development, anatomy and function of the placenta in the environment of abnormal glucose metabolism which can establish the maternal-placental-fetal interface dysfunction as a potential source of adverse pregnancy outcomes. A detailed sequence of events that leads from hyperglycemia to placental dysfunction and subsequent pregnancy complications may become an important issue for further studies.