Selective feticide reverses intrahepatic cholestasis of pregnancy in twins discordant for growth: A case report.

Twin gestations are associated with an increased risk of intrahepatic cholestasis in pregnancy (ICP), probably attributed to the elevated pregnancy hormones. We report a case of a dichorionic diamniotic twin pregnancy, at the third trimester, complicated with ICP and severe, selective fetal growth restriction (sFGR). A 32-year-old primiparous woman with a dichorionic, diamniotic twin gestation conceived via in vitro fertilization (IVF) presented with pruritus at the maternity care unit at 26+4 weeks of pregnancy. Following a detailed assessment, she was diagnosed with severe sFGR and ICP. During her hospitalization, selective feticide of the FGR fetus was decided and a remarkable improvement in the symptoms and the laboratory findings of ICP was noticed. The incidence of ICP is reported to be higher in twin pregnancies, especially those conceived via IVF, compared with singletons. The optimal timing of delivery and management of twin pregnancies complicated with ICP remain unclear. In our case, selective reduction of the FGR fetus led to the resolution of ICP.

The effect of placental laterality at 20-24 gestational weeks on uterine artery doppler indices, fetal growth and preeclampsia.

BACKGROUND: This study aimed (i) to assess the potential effect of placental location on uterine artery (UtA) pulsatility index (PI) and offspring birthweight (BW), and (ii) to examine the potential association of unilaterally increased UtA PI with preeclampsia (PE) or low BW. MATERIALS AND METHODS: This was an asynchronous cohort study of singleton pregnancies between 20+0 and 23+6 gestational weeks resulting in live birth, for whom the placental site (posterior, anterior, fundal, previa, right lateral, or left lateral) and bilateral UtA PI measurements were recorded. The effect of placental location on mean BW and UtA mean PI z-scores was assessed using t-test or ANOVA and post-hoc tests, as appropriate. The UtA PI measurements were then grouped into three categories (normal mean PI; unilaterally increased PI with normal mean; increased mean PI) and we calculated the odds ratios (ORs) of unilaterally increased or increased mean PI vs. normal mean PI for PE, BW <10th centile and BW <5th centile. The independent association of placental location, UtA PI category (normal mean, unilateral increase with normal mean, increased mean PI) and UtA PI z-score with PE, BW <10th centile and BW <5th centile was then assessed using logistic regression. RESULTS: The analysis included 5506 pregnancies. A lateral placenta was associated with higher mean PI z-score (p = .0001) and lower BW (p = .003) than non-lateral placenta. Compared with normal mean UtA PI, a unilaterally increased PI with a normal mean was associated with increased risk for PE (OR 4.3, 95%CI 1.9-9.7), BW <10th centile (OR 1.7, 95%CI 1.3-2.4) and BW <5th centile (OR 1.8, 95%CI 1.1-2.9). Similarly, increased mean UtA PI was also associated with increased risk for PE, BW <10th and BW <5th centile (OR 9.1, 95%CI 4.8-17.3; OR 4.4, 95%CI 3.5-5.7; OR 7.0, 95%CI 5.1-9.6, respectively). When assessing the independent association of placental location and UtA PI with PE and low BW, only mean UtA PI remains a significant predictor. CONCLUSIONS: A lateral placenta is associated with a higher mean UtA PI and lower BW. Unilaterally increased UtA PI still carries a greater risk of PE and low BW than bilaterally normal PI, however this effect appears to be eventually mediated through mean UtA PI z-score, which is relatively increased in these cases.

Early delivery or expectant management for late preterm preeclampsia: A meta-analysis of randomized controlled trials.

INTRODUCTION: Currently, there is no consensus regarding the timing of delivery in women with non-severe preeclampsia at the late preterm period. The aim of the present meta-analysis is to compare expectant management with immediate delivery in pregnant women with preeclampsia between 34+0 and 36+6 gestational weeks, in terms of maternal and neonatal outcomes. MATERIAL AND METHODS: A search was conducted until October 1, 2020 and eligible studies were identified in MEDLINE, Scopus, Cochrane Central Register of Controlled Trials (Central), the US Registry of clinical trials (www.clinicaltrials.gov), and sources of gray literature without limitations concerning the publication dates and languages. Randomized controlled trials, comparing planned delivery vs expectant management in women with preeclampsia at 34-37 weeks were included. The primary outcomes were neonatal intensive care unit (NICU) admission and progression to eclampsia. Secondary outcomes were HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, severe preeclampsia, composite adverse maternal outcome (defined by the presence of any of the potential preeclampsia-related complications, ranging from severe hypertension to maternal death), neonatal respiratory disease, and respiratory distress syndrome. Relative risks (RRs) and mean differences with 95% CI were used for the estimation of the effect sizes; the quality of the evidence was assessed per GRADE guidelines. RESULTS: The electronic search yielded 10 721 potential studies, of which six were fully reviewed and three (1773 participants) were included in the meta-analysis. Immediate delivery increased the risk for NICU admission, (RR 1.23, 95% CI 1.05-1.45) and decreased the risk for the composite adverse maternal outcome (RR 0.86, 95% CI 0.78-0.93). There were no differences for eclampsia (RR 0.55, 95% CI 0.16-1.85), HELLP syndrome (RR 0.58, 95% CI 0.25-1.33), severe preeclampsia (RR 0.27, 95% CI 0.02-3.52), respiratory disease of neonate (RR 1.04, 95% CI 0.75-1.44), and respiratory distress syndrome (RR 2.3, 95% CI 0.73-7.25). CONCLUSIONS: Immediate delivery of women with non-severe preeclampsia at the period of late prematurity decreases the risk of a composite adverse maternal outcome by 14%, at the cost of an increase in NICU admissions by 23%. The overall quality of the evidence for these outcomes is high, indicating a high degree of certainty for the results.

Timing of primary maternal cytomegalovirus infection and rates of vertical transmission and fetal consequences.

OBJECTIVE: Cytomegalovirus infection is the most frequent congenital infection and a major cause of long-term neurologic morbidity. The aim of this meta-analysis was to calculate the pooled rates of vertical transmission and fetal impairments according to the timing of primary maternal infection. DATA SOURCES: From inception to January 2020, MEDLINE, Scopus, Cochrane Library, and gray literature sources were used to search for related studies. STUDY ELIGIBILITY CRITERIA: Cohort and observational studies reporting the timing of maternal cytomegalovirus infections and rate of vertical transmission or fetal impairments were included. The primary outcomes were vertical transmission and fetal insult, defined as either prenatal findings from the central nervous system leading to termination of pregnancy or the presence of neurologic symptoms at birth. The secondary outcomes included sensorineural hearing loss or neurodevelopmental delay at follow-up and prenatal central nervous system ultrasonography findings. STUDY APPRAISAL AND SYNTHESIS METHODS: The pooled rates of the outcomes of interest with their 95% confidence intervals (CI) were calculated for primary maternal infection at the preconception period, periconception period, first trimester, second trimester, and third trimester. RESULTS: A total of 17 studies were included. The pooled rates of vertical transmission (10 studies, 2942 fetuses) at the preconception period, periconception period, first trimester, second trimester, and third trimester were 5.5% (95% CI, 0.1-10.8), 21.0% (95% CI, 8.4-33.6), 36.8% (95% CI, 31.9-41.6), 40.3% (95% CI, 35.5-45.1), and 66.2% (95% CI, 58.2-74.1), respectively. The pooled rates of fetal insult in case of transmission (10 studies, 796 fetuses) were 28.8% (95% CI, 2.4-55.1), 19.3% (95% CI, 12.2-26.4), 0.9% (95% CI, 0-2.4%), and 0.4% (95% CI, 0-1.5), for maternal infection at the periconception period, first trimester, second trimester, and third trimester, respectively. The pooled rates of sensorineural hearing loss for maternal infection at the first, second, and third trimester were 22.8% (95% CI, 15.4-30.2), 0.1% (95% CI, 0-0.8), and 0% (95% CI, 0-0.1), respectively. CONCLUSION: Vertical transmission after maternal primary cytomegalovirus infection increases with advancing pregnancy, starting from the preconception period. However, severe fetal impairments are rare after infection in the first trimester of pregnancy.

A novel familial mutation associated with Treacher Collins syndrome: A case report.

Treacher Collins syndrome (TCS) is a type of mandibulofacial dysostosis with incomplete penetrance and high intra- and interfamilial clinical heterogeneity, and it is associated with mutations of treacle ribosome biogenesis factor 1 (TCOF1), and RNA polymerase I and III subunit (POLR1)C and POLR1D genes. In the present case report, a patient with TCS with auricle dysplasia and hearing loss accompanied with intellectual disability is described. Sequence analysis was performed on blood samples from the patient and his father via oligonucleotide-based target capture, followed by next-generation sequencing. Alignment and variant calls were generated using the Burrows-Wheeler Aligner and Genome Analysis Toolkit, followed by bioinformatics analysis of the detected variants. A novel heterozygous mutation, c.911C>T (p.Ser304Leu), was detected in the TCOF1 gene, which was inherited from the father. The father of the patient only suffered from hearing loss. The present report is the first to identify an association between phenotypic variability and TCOF1 gene mutations and thus contributes to our understanding of the association between the genotype and phenotype in patients with TCS and offers clinically relevant information for diagnosis of the syndrome.

Prevention of gestational diabetes mellitus in overweight or obese pregnant women: A network meta-analysis.

AIMS: Several interventions have been implemented to prevent the development of gestational diabetes mellitus (GDM) in obese pregnant women, including physical exercise programs, and administration of metformin, vitamin D and probiotics. The aim of this network meta-analysis was to compare the efficiency of these interventions and identify the optimal. MATERIALS: A network meta-analysis of randomized trials was performed comparing the different interventions for the development of GDM in overweight or obese women, either to each other or placebo/no intervention. A search was conducted in four electronic databases and grey literature sources. The primary outcome was the development of GDM; secondary outcomes were other complications of pregnancy. RESULTS: The meta-analysis included 23 studies (4237 participants). None of the interventions was superior compared with placebo/no intervention for the prevention of GDM. Metformin and physical exercise were superior to placebo/no intervention for gestational weight gain (MD -1.21, 95% CI -2.14 to -0.28 and MD -0.96, 95% CI -1.69 to -0.22, respectively). Metformin was superior to placebo/no intervention for caesarean sections and admission to NICU. CONCLUSIONS: Interventions aiming to prevent the development of GDM in overweight/obese women are not effective, when applied during pregnancy.