Expectant management in pregnant women with early and severe preeclampsia and concomitant risk factors.

AIM: The aim of this study was to demonstrate that women with severe early-onset preeclampsia and concomitant risk factors benefit from expectant management. METHODS: This retrospective study was conducted between January 2009 and December 2010. Stable women with severe preeclampsia between 23+6 and 33+6weeks of gestation were admitted to the IOCU for conservative management. They were classified into two groups: those with concomitant risk factors, i.e. associated medical conditions, HELLP syndrome, severe oligohydramnios, fetal growth restriction and multiple pregnancies (group A) and those without (group B). P values lesser than 0.05 were considered statistically significant. RESULTS: No significant differences were found in maternal and perinatal outcomes between groups. Neither were differences observed in pregnancy prolongation (mean: 8.42days (SD±7.462) in group A and 10.5days (SD±8.235) in group B (p=0.391)). At the start of expectant management, 31.8% of fetuses had an abnormal middle cerebral artery Doppler; prior to delivery, this percentage was 77.4%. CONCLUSION: Pregnant women with severe early-onset preeclampsia and associated risk factors benefited from expectant management. During expectant management using a continuous magnesium sulfate regimen, the majority of fetuses showed cerebral vasodilatation. The exact clinical value of this finding should be clarified in further studies.

Sonographic cervical length measurement in pregnant women with a cervical pessary.

OBJECTIVES: The aims of this study were to describe and assess the feasibility of measuring cervical length by standard transvaginal sonography (TVS) and transperineal sonography (TPS) in women with a cervical pessary and compare these measurements with those obtained with a new transvaginal technique. METHODS: Measurement of cervical length by TPS was attempted immediately before measurement using TVS in 48 women with a cervical pessary at between 22 and 23 weeks' gestation. The TVS procedure consisted of two types of measurement: in the first, the probe was placed on the anterior fornix (standard technique) and in the second, the probe was inserted into the pessary to touch the anterior cervical lip (new technique). Two physicians consecutively performed these procedures and compared the measurements obtained. Intraclass correlation coefficients (ICCs) with 95% CI were used to evaluate interobserver reliability, and Bland-Altman analysis was used to assess interobserver agreement. RESULTS: In total, 258 measurements (obtained from 43 women) were analyzed. Interobserver ICCs of the measurements obtained were 0.58 (95% CI, 0.34-0.75) for TPS, 0.65 (95% CI, 0.44-0.79) for the standard TVS technique and 0.97 (95% CI, 0.95-0.98) for the new TVS technique. Bland-Altman analysis showed small mean differences between measurements obtained by two physicians for the three methods, but with narrower limits of agreements (LOA) for the new TVS technique: TPS mean difference - 0.99 mm (95% LOA, - 13.23 to 11.25 mm), standard TVS technique mean difference - 0.23 mm (95% LOA, - 10.90 to 10.44 mm) and new TVS technique mean difference - 0.01 mm (95% LOA, - 2.57 to 2.55 mm). It was apparent from the images obtained that the external os was not visible in 89% of cases when either the TPS or standard TVS technique was used. However, the external os was visible in all cases when the new TVS method was used. CONCLUSIONS: We propose a new technique for measuring and monitoring cervical length in women with a cervical pessary that provides improved visualization of the cervix and increased reliability in comparison to established techniques.

Prevalence of neurological damage in monochorionic twins with selective intrauterine growth restriction and intermittent absent or reversed end-diastolic umbilical artery flow.

OBJECTIVE: To assess the incidence of parenchymal lesions on early and late neonatal brain scans and its association with the presence or absence of intermittent absent or reversed end-diastolic umbilical artery flow velocity (A/REDV) in monochorionic twins complicated by selective intrauterine growth restriction (IUGR), as compared to dichorionic twins and monochorionic twins without selective IUGR. METHODS: This was a prospective cohort study involving 42 monochorionic twins diagnosed with selective IUGR and managed expectantly. The presence or absence of intermittent A/REDV was recorded in all cases. This study group was compared to dichorionic twins (n = 29) and monochorionic twins without selective IUGR (n = 32) delivered at 26-34 weeks during the study period. All infants underwent an early neonatal brain scan (at or before the fourth day of postnatal life) and at least one follow-up scan during the first 28 days of postnatal life. Perinatal outcome and the incidence of neurological damage were compared between the study groups. RESULTS: The incidence of intrauterine fetal death (IUD) and periventricular leukomalacia was significantly increased in monochorionic twins complicated with selective IUGR, as compared with the other study groups. Intermittent A/REDV was observed in 22/42 (52.4%) twin pairs, and was always present in the growth-restricted twin. The incidence of IUD (overall 9/44 (20.5%) vs. 0/40, P < 0.001; smaller twin 6/22 (27.3%) vs. 0/20, P < 0.05) and parenchymal brain damage (overall 7/35 (20.0%) vs. 2/40 (5.0%), P = 0.07; larger twin 7/19 (36.8%) vs. 1/20 (5.0%), P < 0.05) was significantly higher in pregnancies with intermittent A/REDV than in those without intermittent A/REDV. Brain damage usually occurred in the larger twin, irrespective of whether the smaller twin was liveborn or not. CONCLUSIONS: The presence of intermittent A/REDV in monochorionic twins with selective IUGR identifies a subgroup with an elevated risk of intrauterine demise of the smaller twin and neurological damage in the larger twin; this latter finding is not restricted to cases with IUD of the cotwin.

Incidence and characteristics of umbilical artery intermittent absent and/or reversed end-diastolic flow in complicated and uncomplicated monochorionic twin pregnancies.

OBJECTIVE: To evaluate the incidence and clinical relevance of intermittent absent and/or reversed diastolic flow on umbilical artery Doppler in different groups of monochorionic twin pregnancies. METHODS: This was a prospective study involving three groups of monochorionic pregnancies: Group 1: controls followed fortnightly from the first trimester (n = 80); Group 2: cases with selective intrauterine growth restriction (n = 40); and Group 3: cases with severe twin-twin transfusion syndrome (n = 50). The presence and persistence over time of intermittent absent and/or reversed end-diastolic flow on umbilical artery Doppler was recorded. Placentas were examined and placental sharing and the presence of large arterioarterial anastomoses (AAA) was assessed. Perinatal outcome was recorded in all cases. RESULTS: Intermittent absent and/or reversed diastolic flow was present in 5% (4/80) of cases in Group 1, 45% (18/40) in Group 2 and 2% (1/50) in Group 3 (P < 0.0001, Group 2 vs. 1 and 3). Placental examination was performed in 76.4% (130/170) of cases and sharing was 58% for Group 1, 81% for Group 2 and 73% for Group 3 (P < 0.0001, Groups 2 and 3 vs. 1). Large AAA were identified in all examined cases with intermittent flow (18/18) and in 3.6% (4/112) of those without. The in-utero mortality rate was 0% in Group 1 and in Group 2 fetuses without intermittent flow. However, it was 19.4% in Group 2 cases with intermittent diastolic flow. CONCLUSIONS: Intermittent absent and/or reversed end-diastolic flow may be considered to be a characteristic sign of monochorionic pregnancy, and seems to result from the existence of large AAA. Its incidence is significantly increased in the context of selective intrauterine growth restriction, indicating a high risk for poor pregnancy outcome in these cases.