Pregnancy outcome in systemic lupus erythematosus patients: a monocentric cohort analysis.

OBJECTIVE: SLE is an autoimmune disease, mainly affecting women of childbearing age, with possible impact on pregnancy. In this study, we evaluated pregnancy outcomes in all pregnant patients affected by SLE, followed in the context of a rheumatology/gynaecology multi-disciplinary team. METHODS: Since 2008, we evaluated 70 consecutive pregnancies occurring in 50 SLE patients referring to the Lupus Clinic of Sapienza University of Rome; as controls we evaluated 100 consecutive pregnancies in 100 women without autoimmune diseases. RESULTS: By comparing SLE patients and controls, we did not find differences in terms of pregnancy outcomes, except for the occurrence of small for gestational age, which was significantly higher in the SLE group (22.8% vs 11%, P =0.003). Small for gestational age was associated with the positivity for anti-dsDNA, anti-Sm and anti-RNP (P =0.009, P =0.02, P =0.002, respectively). A disease flare was reported in 28 pregnancies (40%) and in 31 puerperium periods (44.3%). Flare during pregnancy was associated with anti-SSA (P =0.02), while puerperium relapse with previous MMF treatment (P =0.01) and haematological flare during pregnancy (P =0.03). CONCLUSION: The present study confirms how pre-gestational counselling and a multi-disciplinary approach could result in positive pregnancy outcomes for SLE patients. The high percentage of disease relapse justifies even more the need for multi-disciplinary management.

Breastfeeding in women affected by systemic lupus erythematosus: Rate, duration and associated factors.

OBJECTIVE: Breastfeeding is a crucial moment for both mothers and child, providing a beneficial effect on child survival, nutrition, development and on maternal health. Despite the prevalent involvement of childbearing women in systemic lupus erythematosus (SLE), breastfeeding is still a neglected topic. The objective of this study was to evaluate breastfeeding frequency, duration and associated factors in SLE women. METHODS: We consecutively enrolled SLE pregnant women reporting demographic, clinical, serological, gynaecological and obstetric data. Breastfeeding experience was evaluated by using a specific questionnaire. Disease activity was assessed before and during pregnancy as well as during postpartum. RESULTS: A total of 57 pregnancies in 43 SLE women were included in the present study. In almost all the pregnancies, mothers planned to breastfeed their child (96.5%) and forty-one (71.9%) actually did breastfeed. The median time of breastfeeding was 3 months (IQR 7). Non-breastfeeding women showed a more frequent caesarean section (p = 0.0001), IUGR occurrence (p = 0.004) and disease relapse (p = 0.0001) after pregnancy. When comparing patients according with breastfeeding duration (cut-off 6 months), we found a significant more frequent smoking habitus (p = 0.02), caesarean section (p = 0.009), and joint involvement during postpartum (p = 0.0001) in women breastfeeding for less than or equal to 6 months, together with higher median BMI (p = 0.0001). Moreover, breastfeeding duration was positively associated with disease duration and hydroxychloroquine (HCQ) treatment during disease history, pregnancy and postpartum. CONCLUSIONS: SLE women didn't show lower breastfeeding rate in comparison with general population but they presented higher prevalence of early discontinuation within three months. Early interruption was positively associated with smoking, BMI, joint involvement; meanwhile disease duration and HCQ treatment during postpartum were positively associated with a longer breastfeeding duration.

Premature ovarian failure in patients affected by systemic lupus erythematosus: a cross-sectional study.

OBJECTIVES: We evaluated age at natural menopause and the prevalence of premature ovarian failure (POF) in a monocentric Caucasian cohort of patients with systemic lupus erythematosus (SLE). METHODS: In this cross-sectional study, we enrolled women affected by SLE compared with healthy controls (HC) to investigate data about natural menopause (amenorrhoea for at least 12 months at ≥40 years) and POF (amenorrhoea for at least 12 months at <40 years). RESULTS: We enrolled 196 SLE (median age 47.0 years, IQR 16.7; median disease duration 132 months, IQR 180) and 90 HC (median age 49.9 years, IQR 15.0). Ninety-four SLE (48.0%) and 26 HC (23.4%) were menopausal: median age at onset was significantly lower in SLE than HC (47 years, IQR 8.0 vs. 50.5 years, IQR 4; p=0.0001). POF was registered in 17% of the SLE, and in none of the HC (p<0.0001). POF was significantly associated with anti-Sm (p=0.0004), anti-RNP (p=0.02), anti-cardiolipin (p=0.0008), lupus anticoagulant (p=0.0002), treatment with cyclophosphamide (p=0.0001), azathioprine (p=0.0001), mycophenolate mofetil (p=0.0001), cyclosporine A (p=0.007). CONCLUSIONS: SLE patients develop menopause at a younger age; moreover, a higher POF frequency was observed in SLE patients in comparison with HC. POF is associated with specific SLE-related autoantibodies and the use of immunosuppressant drugs, in particular cyclophosphamide.

Treatment with Gonadotropin Releasing Hormone Agonists in Systemic Lupus Erythematosus Patients Receiving Cyclophosphamide: A Long-term Follow-up Study.

BACKGROUND: Cyclophosphamide treatment has been associated with ovarian function impairment. Co-treatment with gonadotropin-releasing hormone-analogue (GnRH-a) seems to be able to prevent this complication. However, even though data are available on neoplastic patients, limited data have been published on systemic lupus erythematosus (SLE) women cohorts. OBJECTIVES: To evaluate GnRH-a efficacy on ovarian function preservation in SLE women receiving cyclophosphamide treatment. METHODS: The authors performed a retrospective study including SLE women requiring cyclophosphamide treatment and compared those treated with and without GnRH-a (case and controls, respectively). All patients were evaluated before cyclophosphamide treatment and every 3 months in the following years. Ovarian function was evaluated using hormonal profiles. RESULTS: The study comprised 33 SLE cyclophosphamide-treated women: 18 co-treated with triptorelin and 15 controls. The mean follow-up was 8.1 ± 5.1 years (range 4-11). Premature ovarian failure (POF) prevalence was significantly lower in SLE women treated by cyclophosphamide plus triptorelin compared to controls (11.1% vs. 33.3%, P = 0.0002). The occurrence of POF was significantly associated with higher age at the time of cyclophosphamide treatment (P = 0.008). Only patients in the GnRH-a treated group had successful pregnancies. CONCLUSIONS: The study provides information about the efficacy of co-treatment with GnRH-a in SLE women receiving cyclophosphamide, as demonstrated by the lower POF incidence compared to untreated subjects, based on long-term follow-up. These results reinforce the use of GnRH-a for fertility preservation in premenopausal SLE patients treated by cyclophosphamide.

New-onset ulcerative colitis in pregnancy associated to toxic megacolon and sudden fetal decompensation: Case report and literature review.

Ulcerative colitis (UC) is a chronic inflammatory disease rarely arising during gestation. Because the available information is based on case reports or small retrospective studies, diagnosis may be difficult and treatment is still controversial. A case of toxic megacolon developing in late pregnancy associated to a sudden fetal decompensation is described. Diagnostic and clinical topics of acute UC onset in pregnancy are debated.A primipara, 34 years old, 33/0 weeks of gestation, was admitted with a diagnosis of preterm labor, associated to acute bloody diarrhea (up to 10 daily motions) and cramping abdominal pain. A diagnosis of new-onset early-stage UC was made by sigmoidoscopy. An intensive care regimen including hydrocortisone, antibiotics and parenteral nutrition was immediately started. Magnetic resonance imaging of maternal abdomen, fostered by the worsening patient conditions, evidenced dilatation of the entire colon and a severely hampered of fetal muscular tone.Toxic megacolon complicated by superimposed Clostridium difficile infection was associated to a sudden fetal decompensation diagnosed by chance during maternal abdominal magnetic resonance imaging. An emergency cesarean section was mandatory. According to a senior surgeon's decision, total colectomy was not immediately performed following cesarean section with reference to the absence of colonic perforation. We obtained a good short-term maternal outcome and an uncomplicated neonatal course. Counseling of those patients must be focused on timely and multidisciplinary intervention in order to improve the course of maternal disease and to prevent fetal distress.

Are Second Trimester Apparent Diffusion Coefficient Values of the Short Uterine Cervix Associated with Impending Preterm Delivery?

Purpose To prospectively determine whether the apparent diffusion coefficient (ADC) of the cervix is associated with preterm delivery in asymptomatic patients with a sonographic cervical length of 15 mm or less and positive fetal fibronectin test results between 23 and 28 weeks of gestation. Materials and Methods The institutional review board approved this prospective hypotheses-generating study. A total of 30 pregnant women (mean gestational age, 26 weeks) with a sonographic short cervix (≤15 mm) underwent pelvic 1.5-T magnetic resonance (MR) imaging. Oblique sagittal diffusion-weighted images were obtained with b values of 0, 400, and 800 sec/mm(2). ADC values at MR imaging of the subglandular and stromal cervix and the difference between both were correlated to the interval to delivery. Receiver operating characteristic curve analysis was performed to obtain sensitivity and specificity of ADC values in association with delivery within 7 days. Results Eight (27%) of 30 patients delivered within 6 or 7 days after MR imaging (impending delivery group), and 22 (73%) of 30 patients delivered between 18 and 89 days after imaging (mean, 55 days) (late delivery group). Mean subglandular ADC and mean ADC difference were higher (P < .001) in patients with impending delivery than in those with late delivery ([2406.3 ± 166.0] × 10(-6) mm(2)/sec vs [1708.9 ± 108.1] × 10(-6) mm(2)/sec and [657.3 ± 129.9] × 10(-6) mm(2)/sec vs [69.2 ± 70.2] × 10(-6) mm(2)/sec, respectively). Subglandular ADC inversely correlated with the interval between MR imaging and delivery (r = -0.75). Receiver operating characteristic curve analysis of subglandular ADC revealed 100% sensitivity (95% confidence interval: 63.1, 100) and 100% specificity (95% confidence interval: 84.6, 100) in association with impending delivery with a 1921 × 10(-6) mm(2)/sec threshold. Stromal ADC and sonographic cervical length showed no difference between groups (P = .072 and P = .511, respectively). Conclusion Cervical subglandular ADC at MR imaging is associated with impending preterm birth in patients with a short sonographic cervix. (©) RSNA, 2016.

Hypertension and early menopause after the use of assisted reproductive technologies in women aged 43 years or older: Long-term follow-up study.

AIM: The aim of this study was to investigate the long-term consequences to women's health and the onset of menopause in healthy women of advanced reproductive age who conceived by assisted reproductive technologies (ART). METHODS: Healthy women who conceived by ART (72) and controls (80) were selected among 320 women ≥ 43 years, who delivered between January 2010 and December 2011 in the Department of Gynecological and Obstetrical Sciences and Urological Sciences of "Sapienza" University of Rome. Body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), and presence of hypertension and diabetes were analyzed at three days, six months, and three years after delivery. The onset of menopause was analyzed after three years. RESULTS: In the ART group, SBP, DBP and hypertension were higher at three days, six months, and three years after delivery. Menopausal age was significantly lower. CONCLUSION: The impact of ART in healthy women of advanced reproductive age in the years after delivery is not limited to the possible development of cardiovascular risk factors, such as hypertension, but can also influence the age of onset of menopause.

Epirubicin: a new entry in the list of fetal cardiotoxic drugs? Intrauterine death of one fetus in a twin pregnancy. Case report and review of literature.

BACKGROUND: Current knowledge indicate that epirubicin administration in late pregnancy is almost devoid of any fetal cardiotoxicity. We report a twin pregnancy complicated by breast cancer in which epirubicin administration was causatively linked to the death of one twin who was small for gestational age (SGA) and in a condition of oligohydramnios and determined the onset of a transient cardiotoxicity of the surviving fetus/newborn. CASE PRESENTATION: A 38-year-old caucasic woman with a dichorionic twin pregnancy was referred to our center at 20 and 1/7 weeks for a suspected breast cancer, later confirmed by the histopathology report. At 31 and 3/7 weeks, after the second chemotherapy cycle, ultrasound examination evidenced the demise of one twin while cardiac examination revealed a monophasic diastolic ventricular filling, i.e. a diastolic dysfunction of the surviving fetus who was delivered the following day due to the occurrence of grade II placental abruption. The role of epirubicin cardiotoxicity in the death of the first twin was supported by post-mortem cardiac and placental examination and by the absence of structural or genomic abnormalities that may indicate an alternative etiology of fetal demise. The occurrence of epirubicin cardiotoxicity in the surviving newborn was confirmed by the report of high levels of troponin and transient left ventricular septal hypokinesia. CONCLUSION: Based on our findings we suggest that epirubicin administration in pregnancy should be preceded by the screening of some fetal conditions like SGA and oligohydramnios that may increase its cardiotoxicity and that, during treatment, the diastolic function of the fetal right ventricle should be specifically monitored by a pediatric cardiologist; also, epirubicin and desamethasone for lung maturation should not be closely administered since placental effects of glucocorticoids may increase epirubicin toxicity.

Thrombotic thrombocytopenic purpura during pregnancy versus imitator of preeclampsia.

BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) is a severe disorder affecting the microcirculation of multiple organs due to a systemic endothelial cell injury secondary to a deficiency in ADAMTS13 (a disintegrin and metalloprotease with thrombospondin type 1 motif, member 13) activity. TTP is a rare complication of pregnancy with a poor prognosis and high fetal mortality, especially when it occurs during the first trimester. Recent data have supported that effective treatment of TTP is plasma therapy. Unfortunately a major problem remains in the delay in diagnosis due to confounding factors between other "imitators of preeclampsia." Rapid and readily available laboratory testing to quickly diagnose TTP is desperately needed to improve care and to save mother and future child life. CASE REPORT: We describe a rare case of successful pregnancy after TTP manifestations occurring in the first trimester; most importantly, our experience represents the first case of atypical manifestation due to neurologic and kidney manifestations preceding laboratory assay alterations. RESULTS: We treated a patient with plasma replacement of 30 mL/kg/day and daily plasmapheresis in combination with continuous infusion of fresh-frozen plasma 10 mL/kg/day. The response of clinical manifestation immediately improved. At 30 weeks, the patient had multiple episodes of high blood pressure and concomitant decrease of hemoglobin and platelet count, so a cesarean section was immediately performed. She delivered a healthy female baby. CONCLUSION: Early diagnosis by ADAMTS13 activity, occasionally occurring before clinical manifestations, aided us in promptly administering commended and life-saving treatments.

Autoimmune lymphoproliferative syndrome in pregnancy: a case of favorable mother-fetal outcome in a well-controlled disease.

The autoimmune lymphoproliferative syndrome (ALPS) is a disorder of abnormal lymphocyte survival caused by the dysregulation of the Fas apoptotic pathway. The Fas gene is expressed at the maternal-fetal interface and is involved in the regulation of immune response and implantation. Altered Fas expression may result in altered apoptosis and, ultimately, affect both the immune response and implantation; it is in fact associated with recurrent pregnancy loss, preterm premature rupture of membranes and pre-eclampsia. Currently, there are over 500 cases of ALPS reported worldwide from various racial and ethnic backgrounds. Up to date, the published work contains no specific reports on pregnancy outcome in women affected by ALPS. We present a case of full-term uneventful pregnancy in a patient affected by ALPS. A specific clinical follow-up in a pregnant woman with primary immunologic disease is suggested.

Menopausal symptoms after the discontinuation of long-term hormone replacement therapy in women under 60: a 3-year follow-up.

BACKGROUND: Prescriptions for hormone replacement therapy (HRT) declined following the publication of the Women's Health Initiative study. The number of women who experience recurrence of menopausal symptoms after discontinuation of long-term HRT (LT-HRT), the length of time these symptoms last and the preferred alternative treatments remain unknown. METHODS: This prospective 3-year follow-up study analyses the prevalence and intensity of menopausal symptoms that occur in young postmenopausal women who discontinued LT-HRT. Symptoms were evaluated using the Menopause Rating Scale. RESULTS: Women (254) who discontinued LT-HRT (mean use: 6.9 ± 2.3 years) were recruited. Mean age at menopause was 48.1 ± 3.4 years. Mean age at discontinuation was 56.8 ± 3.7 years. 23% of the women were lost to follow-up. Of the remaining 196 women, 93% experienced a recurrence of menopausal symptoms within the first year, 25% resumed low-dose HRT, 62% used vaginal estrogens, 54% used phytoestrogens, and 2% used alternative therapies. A decrease in symptom prevalence and intensity was observed during the 3-year follow-up. CONCLUSIONS: Symptoms re-appeared in a significant proportion of patients within the first year after discontinuation of LT-HRT. However, after 3 years, the majority of these women were asymptomatic. Patients who discontinue LT-HRT may require a more detailed follow-up immediately after the discontinuation of treatment.

Dysregulation of diurnal salivary cortisol production is associated with spontaneous preterm delivery: a pilot study.

OBJECTIVES: The purpose of this study was to evaluate whether the diurnal fluctuation of salivary cortisol and its overall diurnal secretion are associated with the length of gestation in patients who were admitted to the hospital with an assigned diagnosis of possible preterm labor (PL) at a gestational age of 28-33 weeks. METHODS: In 22 patients, maternal saliva samples were collected for a cortisol assay 4 times per day (8 AM, 12 AM, 4 PM and 8 PM) on day 4 and day 6 after antenatal corticosteroid prophylaxis to prevent neonatal respiratory distress syndrome. RESULTS: Eight patients who ultimately delivered before term (32.6 ± 1.7 gestation weeks) showed an inverted fluctuation of salivary cortisol on both days 4 and 6, morning cortisol levels being significantly lower than evening levels. In contrast, in 14 patients who delivered at term (39.5 ± 0.6 gestation weeks), the physiological diurnal fluctuation of salivary cortisol was maintained. In addition, a distinctive feature of women delivering before term was a significantly hampered salivary cortisol diurnal production measured on day 6. CONCLUSIONS: Corticoadrenal activity is dysregulated and anticipates very preterm delivery in women with an assigned diagnosis of possible PL.

Maternal C-reactive protein at hospital admission is a simple predictor of funisitis in preterm premature rupture of membranes.

AIM: To analyze the prognostic value of maternal serum C-reactive protein (CRP) in predicting funisitis in patients with preterm premature rupture of membranes (pPROM). METHODS: 66 patients (gestational age 24-33 weeks) hospitalized 1-12 h after pPROM were enrolled. White blood cell count (WBC), platelet count (PLT) and plasma concentration of CRP were assessed every 3 days. Histological evidence of chorioamnionitis and funisitis was obtained post-partum. Receiver operating characteristic (ROC) curves were employed to evaluate the role of maternal CRP in predicting funisitis. RESULTS: Funisitis was found in 24 patients (36.3%); 42 patients (63.7%) without funisitis were considered as controls. PLT and WBC at admission and before delivery did not show significant differences and were not statistically different between the two groups. Patients with funisitis had significantly higher CRP levels both at admission to hospital and 24- 48 h before delivery. ROC curve analysis showed that CRP at admission (area under the curve: 0.671, p = 0.021) and before delivery (area under the curve: 0.737, p = 0.001) are predictive of funisitis. CONCLUSIONS: High maternal serum CRP levels (>20,000 µg/l) in pPROM patients at admission to hospital may be an early marker which indicates, with a good diagnostic performance, the presence of funisitis.

Pregnancy and post-partum outcomes of obese women after bariatric surgery: A case-control study.

INTRODUCTION: Bariatric surgery (BS) is known to reduce several obesity-related complications during pregnancy, but there is concern that it may increase the risk of maternal-fetal morbidity because of the malabsorption. This study aimed to investigate the impact of restrictive BS on several pregnancy outcomes in comparison with different grades of obesity. MATERIALS AND METHODS: A single-center retrospective case-control study. All primiparous singleton pregnant women who underwent BS between the previous 1-5 years or with body mass index (BMI) ≥ 30 kg/m2 delivering in our center were included. Obstetric and perinatal outcomes were analyzed and compared between the two groups. RESULTS: Overall, 90 women were included: 30 underwent BS and 60 were obese. The mean pre-pregnancy BMI was 31.0 ± 4.2 kg/m2 in the BS group and 38.1 ± 4.3 kg/m2 in the control group (p < 0.001). The obese group experienced higher rate of fetal macrosomia (25% vs 6.7%; p = 0.049), gestational hypertension (23.3% vs 3.3%; p = 0.04), preeclampsia (23.3% vs 0%; p = 0.04), gestational diabetes (33.3% vs 6.7%; p = 0.01), and cesarean section (68.3% vs 20%; p < 0.0001). The BS group showed higher frequency of small for gestational age (SGA) (46.7% vs 18.3%; p = 0.006), late preterm delivery (PTD) (33.3% vs 10%; p = 0.009), cholestasis (13.3% vs 1.7%; p = 0.049). Breastfeeding ≥ 6 months was higher among BS mothers (36.7% vs 11.7%; p = 0.007). CONCLUSIONS: Our findings support the positive impact of BS on several obstetric outcomes, at the expense of a higher frequency of SGA and PTD. BS mothers more frequently achieved the recommended goal of breastfeeding for 6 months compared to obese women.

Stillbirth and fetal capillary infection by SARS-CoV-2.

We presented the case of stillbirth in a paucisymptomatic mother affected by SARS-CoV-2. At gross examination, the placenta showed a diffuse marble appearance and a focal hemorrhagic area. Multiple areas of hemorrhagic or ischemic necrosis with central and peripheral villous infarctions and thrombosis of several maternal and fetal vessels with luminal fibrin and platelet deposition were observed. All lesions seemed to be synchronous. Virus particles were identified within the cytoplasm of endothelial cells using electron microscopy, whereas SARS-CoV-2 RNA was detected in the placental tissue using real-time reverse transcription-polymerase chain reaction. Here, fetal vascular malperfusion was associated with infection; in fact, electron microscopy images showed that marked SARS-CoV-2 endotheliotropism involved the intravillous fetal capillaries. Furthermore, we confirmed that syncytiotrophoblast is the major target cell type for SARS-CoV-2 infection of the placenta. In conclusion, the possible consequences of the action of the placentotropic SARS-CoV-2 included the occurrence of vertical transmission, as reported in the literature, and/or stillbirth: the latter possibility may be triggered by a hampered maternal and/or fetal perfusion of the placenta. The diffuse thrombosis and subsequent ischemia of fetal capillaries induced by COVID-19 cannot be predicted by standard clinical surveillance.

Magnetic resonance imaging of clinically stable late pregnancy bleeding: beyond ultrasound.

OBJECTIVES: To compare the accuracy of magnetic resonance (MRI) and colour Doppler-ultrasound (US) in the diagnosis of late pregnancy bleeding and to assess the accuracy of the different MR sequences in visualizing the origin of haemorrhage. METHODS: 42 patients in the third trimester of pregnancy underwent to US and MRI for the evaluation of painless vaginal bleeding. Multiplanar HASTE, True Fisp, 3D T1 GRE and sagittal DWI sequences were acquired. Two radiologists, blinded to the results of US, reviewed each case, resolving by consensus any discrepancy. Reference standards were surgical and pathological findings. RESULTS: The reference standards identified 22 placenta previa, 11 placental abruptions (1 coincident with a placental chorioangioma), 1 thrombohaematoma and 1 fibroma with haemorrhagic degeneration. MRI identified correctly all these condition with an interobserver agreement of 0.955. DWI and T1 weighted sequences were statistically superior to Haste and True Fisp sequences in detecting the cause of bleeding (p < .001). US had 6 false negatives and 2 false positive results, its diagnostic accuracy resulting lower than MRI (p = .001). CONCLUSIONS: MRI accurately evaluates pregnancy bleeding with an excellent interobserver agreement and can grant new and additional data when US is negative.

Cabergoline as an adjuvant to standard heart failure treatment in peripartum cardiomyopathy: A case report and review of the literature.

INTRODUCTION: Peripartum cardiomyopathy (PPCM) is a rare and idiopathic form of dilated cardiomyopathy presenting late in pregnancy or early postpartum. Since the 16-kDa fragment of prolactin has been identified as a key factor in the pathophysiology of PPCM, prolactin inhibitors have been used as an adjuvant to standard heart failure treatment. Although bromocriptine is the current first choice, promising results have been reported with cabergoline, albeit scant. CASE PRESENTATION: We presented the case of a 41-year-old woman who received a diagnosis of PPCM one week after delivery and was successfully treated with cabergoline, finally experiencing a complete recovery. CONCLUSION: The case adds to the scant evidence supporting the use of cabergoline in PPCM patients. We argue that the favorable pharmacokinetic and metabolic profiles of this drug should prompt its consideration as a valid alternative prolactin inhibitor in these critical patients.

Non-compaction cardiomyopathy in pregnancy: a case report of spongy myocardium in both mother and foetus and systematic review of literature.

PURPOSE: Cardiovascular disease is the main nonobstetric cause of maternal death during pregnancy and is present in 0.5-4% of pregnancies in the western world. While hypertensive disorders remain the most frequent events, occurring in 6-8% of all pregnancies, cardiomyopathies are rare but encompass high complication rates. The aim of this systematic review is to report all data available up to date regarding pregnancies in patients with left ventricular noncompaction (LVNC) cardiomyopathy. METHODS: PubMed, Medline, Cochrane, Scopus and Embase were searched, up to January 2019, using combinations of these terms: left ventricular noncompaction, hypertrabeculation cardiomyopathy, spongy myocardium, spongiform cardiomyopathy and delivery, gestation, pregnancy, cesarean section (CS). After careful selection, 22 articles, reporting a total of 30 cases, including our own were included in the review. RESULTS: Fifteen out of 26 women (58%) were diagnosed with LVNC before pregnancy. Around 56% of women presented with symptoms during pregnancy while 44% were asymptomatic. Heart failure is by far the most common symptom occurring in almost half the cases. Uncommon clinical presentations included a heart attack, a stroke, and pulmonary hypertension. Timing of delivery was reported preterm in 58% of cases and at term in 42%. Eleven women gave birth through vaginal delivery, while 15 (58%) underwent a CS. Our reported case is the first case of a pregnancy where both mother and fetus are affected by LVNC and the fetus is diagnosed prenatally. CONCLUSIONS: LVNC is not a contraindication for pregnancy, but clearly increases the risk of preterm birth and the rate of cesarean section. On the other hand, pregnancy in a LVNC patient exposes her to increased risk of clinical deterioration. Further studies are needed to better characterize the management of pregnancies in women with cardiomyopathies.

Immigration and Adverse Pregnancy Outcomes in an Italian Free Care Hospital.

INTRODUCTION: The ever-increasing wave of immigration in Italy has posed demanding challenges in the management of the new multiethnic obstetric population. The aim of this study was to compare pregnancy and perinatal outcomes between immigrants and the native population in an Italian public hospital. MATERIALS AND METHODS: Singleton pregnant women (≥ 24 weeks of gestation) who delivered during a 3-year period in an Italian free care hospital were included. Long-term (≥ 2 years of residence) immigrant patients were divided into 4 groups according to their ethnic origin: Europeans, Asians, Latin Americans, and Africans. Perinatal indicators of obstetric outcomes were collected and compared between immigrants and Italians. RESULTS: Of the 3556 patients included, 1092 were immigrants and 2464 Italians. The immigrant cohort experienced a higher rate of macrosomia (1.8% vs 0.6%; p = 0.001), very low birth weight (1.3% vs 0.6%; p = 0.048), very early preterm delivery (1.4% vs 0.4%; p = 0.048), and gestational diabetes mellitus (1.8% vs 0.5%; p = 003) compared with the native population. The overall rate of cesarean sections was greater among Italians (56% vs 45.8%; p < 0.001). Among ethnic groups, Europeans and Latin Americans reported a higher rate of preterm delivery (20.2% and 19%, respectively; p < 0.001). Latin Americans carried also a greater risk of fetal macrosomia (3.6%; p < 0.008), while the rate of very low birth weight was higher among Europeans and Africans (2% and 1.8%, respectively; p < 0.04). CONCLUSION: Obstetricians should pay special attention to the potential disparities in pregnancy outcomes between immigrants and the native population. Future efforts should focus on reducing preterm delivery and glucose dysmetabolism among pregnant immigrants.

Caesarean Section on Maternal Request: An Italian Comparative Study on Patients' Characteristics, Pregnancy Outcomes and Guidelines Overview.

In recent years, the rate of caesarean sections has risen all over the world. Accordingly, efforts are being made worldwide to understand this trend and to counteract it effectively. Several factors have been identified as contributing to the selection of caesarean section (CS), especially an obstetricians' beliefs, attitudes and clinical practices. However, relatively few studies have been conducted to understand the mechanisms involved, to explore influencing factors and to clearly define the risks associated with the caesarean section on maternal request (CSMR). This comparative study was conducted to elucidate the factors influencing the choice of CSMR, as well as to compare the associated risks of CSMR to CS for breech presentation among Italian women. From 2015 to 2018, a total of 2348 women gave birth by caesarean section, of which 8.60% (202 women) chose a CSMR. We found that high educational attainment, use of assisted reproductive technology, previous operative deliveries and miscarriages within the obstetric history could be positively correlated with the choice of CSMR in a statistically significant way. This trend was not confirmed when the population was stratified based on patients' characteristics, obstetric complications and gestational age. Finally, no major complications were found in patients that underwent CSMR. We believe that it is essential to evaluate patients on a case-by-case basis. It is essential to understand the personal experience, to explain the knowledge available on the subject and to ensure a full understanding of the risks and benefits of the medical practice to guarantee the patients not only their best scientific preparation but also human understanding.