Relation between types of yolk sac abnormalities and early embryonic morphology in first-trimester missed miscarriage.

AIM: The aim of this study was to identify yolk sac (YS) abnormalities and analyze their relation with different embryonic morphologies detected by ultrasonography in first-trimester missed miscarriage. MATERIAL AND METHODS: This descriptive study was carried out on 204 women with established first-trimester missed miscarriage. Ultrasonography depicted the YS's diameter, shape, and echogenicity, as well as the embryonic morphologic findings, including normal shape, isolated defects, and growth disorganization types 1 to 4. The findings were qualified and analyzed. RESULTS: Abnormalities in YS diameter were much more common than those in YS shape or echogenicity. YS with normal diameter constituted 30.9% of the cases, as opposed to a vast majority with normal shape and normal echogenicity (93.5% and 94.7%, respectively). YS of normal diameter, shape and echogenicity were most commonly (47.5%) associated with normal embryonic morphology. Absent YS was most commonly (75%) associated with growth disorganization type 1. Too-small YS were most prevalent among normal embryos (44.8%) and type 1 growth disorganization embryos (27.6%). Cystic YS were mostly associated with isolated embryonic anomalies (36.8%). CONCLUSIONS: This study found a significant relation between YS abnormalities and embryonic morphology in missed miscarriage cases. This was most evident with abnormalities in YS diameter rather than the YS shape or appearance. The commonest combinations met in our cases were growth disorganized 1 embryos with an absent YS, normal embryonic morphology with normal or small YS, and isolated embryonic defects with cystic YS.

Fetal mid-thigh soft-tissue thickness: a novel method for fetal weight estimation.

PURPOSE: To derive a novel formula for fetal weight estimation utilizing the linear measurement of mid-thigh soft-tissue thickness (STT). METHODS: 300 women, with singleton uncomplicated pregnancy, were included in a prospective cross-sectional study. The study included four consecutive phases: phase (1) validated the original Scioscia's formula, phase (2) derived a novel modified formula for fetal weight estimation, phase (3) validated the novel modified formula, and phase (4) evaluated the agreement between the modified and original formulae. RESULTS: A statistically significant correlation was found between actual fetal weight (AFW) and various sonographic biometric measurements including mid-thigh STT (r (2) = 0.656, p < 0.001), femur length (FL) (r (2) = 0.573, p < 0.001), bi-parietal diameter (BPD) (r (2) = 0.250, p < 0.001), abdominal circumference (AC) (r (2) = 0.310, p < 0.001), and estimated fetal weight (EFW) using the original Scioscia's formula (r (2) = 0.644, p < 0.001). The modified formula showed a better signed % difference (median = -0.41 %, IQR -1.88 to 2.03) than the original formula (median = -0.51 %, IQR -2.33 to 2.00). It was noted that, using the original formula, 88.7 % of the sample had absolute error below 5 and 98.3 % of the sample had absolute error below 10 %. On the other hand, using the modified formula, 87.3 % of the sample had absolute error below 5 %, while 97.3 % had absolute error below 10 %. The agreement between the two formulae was moderate as 134 patients out of 150 had similar ranking (κ = 0.57). CONCLUSION: Fetal mid-thigh SST is a simple, useful, and easily applicable parameter for fetal weight estimation.

Can a smaller than expected crown-rump length reliably predict the occurrence of subsequent miscarriage in a viable first trimester pregnancy?

AIM: To elicit the diagnostic value of smaller than expected crown-rump length (CRL) to predict the occurrence of subsequent miscarriage in women with a viable first trimester pregnancy. METHODS: A cohort study was conducted in the fetal special care unit of a tertiary care maternity hospital. The recruited participants were young pregnant women at 6-13 weeks of gestation. Transvaginal ultrasonography was performed to determine pregnancy viability and measure the embryonic CRL. To compare the differences in CRL between those pregnancies that remained viable and those that subsequently miscarried, the deviation of observed and expected CRL was calculated and expressed in standard deviations (SD) as Z score. The primary outcome measure was the percentage of pregnancies with antecedent growth delay that miscarried by the end of the first trimester. RESULTS: Of the pregnancies that subsequently miscarried, 79.3% (42/53) had smaller than expected CRL, and in 56.6% (30/53) the CRL was 2 SD or less from that expected for gestational age (GA). The mean Z score for CRL was significantly lower in pregnancies that subsequently miscarried compared to pregnancies that remained viable (-2.9 ± 2.6 vs -0.8 ± 2.1, respectively, P < 0.001). A CRL of 2 SD or less from that expected for GA as a cut-off point had a sensitivity of 56.6, specificity of 81.9, positive predictive value of 36.6, negative predictive value of 91.1, likelihood ratio positive of 3.1 and likelihood ratio negative of 0.5 in predicting subsequent miscarriage. CONCLUSION: Viable first trimester pregnancies with small for GA CRL were associated with a higher probability of a subsequent miscarriage.

Prediction of spontaneous preterm birth: salivary progesterone assay and transvaginal cervical length assessment after 24 weeks of gestation, another critical window of opportunity.

Objectives: Measurement of salivary progesterone (SP4) levels and cervical length (CL) after 24 weeks to assess their potential predictive value among asymptomatic women at high risk of spontaneous preterm birth (PTB). Methods: This prospective observational (noninterventional) study consecutively recruited asymptomatic women at high risk of spontaneous PTB. SP4 and CL were measured at recruitment (24-28 weeks of gestation) then repeated after 3-4 weeks. All recruited women were followed up regularly till delivery. The primary outcome measure was the occurrence of spontaneous PTB. Results: One hundred and thirty four women completed the study, 22 (16.4%) and 32 (23.9%) women had early (<34 weeks) and late (≥34 weeks) PTB, respectively. Initially, the mean CL was 3.2 ± 0.6 cm and the mean SP4 was 4062.8 ± 814.6 pg/ml; with follow up, the mean CL became 3.0 ± 0.6 cm and the mean SP4 became 3871.6 ± 1136.9. Women with early PTB had significantly lower initial and follow up CL and SP4 measures when compared to women with late PTB and those who had birth at term. The rate of drop in SP4 and CL measurements between the two visits was also significantly higher among women with early PTB than those with late PTB and term birth. Receiver-operating characteristic (ROC) curves showed that, CL was a good predictor but SP4 was a better predictor of PTB as the area under the curve (AUC) for CL was less than that for SP4 at both visits (i.e. 0.858 and 0.868 versus 0.986 and 0.990 at the initial and follow up visits, respectively). There was a statistically significant correlation between CL and SP4 measurements. Multivariable binary logistic regression analysis revealed that follow up SP4 measurement was the only independent predictor of spontaneous PTB, and neither BMI, maternal age, SP4 nor CL were independent predictors of early spontaneous PTB. Conclusions: After 24 gestational weeks, SP4 assessment is a simple and reliable promising tool to predict spontaneous PTB among asymptomatic high-risk women, with a little superior performance than CL measurement.

Women with clomiphene citrate resistant polycystic ovarian disease: predictors of spontaneous ovulation after laparoscopic ovarian drilling.

OBJECTIVE: To evaluate the role of different clinical, biochemical and sonographic factors as predictors of spontaneous ovulation after laparoscopic ovarian drilling (LOD) in women with clomiphene citrate resistant polycystic ovarian disease (CCR-PCOD). STUDY DESIGN: This prospective study recruited 251 infertile women with CCR-PCOD. Several clinical, biochemical and sonographic criteria were tested as possible predictors of spontaneous ovulation after LOD using multivariate analysis. RESULTS: Women with higher preoperative levels of LH, FSH and/or androstenedione had significantly higher rates of spontaneous ovulation within the first eight weeks after LOD, but only FSH and androstenedione were found to be independent predictors. Other factors including age, BMI, type of infertility, duration of infertility, menstrual pattern, testosterone level, ovarian volume and SHBG were insignificant predictors. Receiver-operating characteristic (ROC) curves derived from FSH, LH, androstenedione, and a logistic regression model showed that the best cut-off values were 4.1IU/l, 7.8IU/l, 1.2ng/ml, and 0.4897, respectively, with sensitivity of 91.18%, 100%, 73.53%, and 88.24% and specificity of 69.57%, 69.57%, 65.22%, and 73.91% for FSH, LH, androstenedione, and logistic regression model respectively. An extended follow up (9 months after LOD) was conducted for the anovulatory and the non-pregnant ovulatory women, who were treated individually according to their clinical situation. Of these women, 53.5% (69/129) got pregnant, resulting in a cumulative pregnancy rate of 48% (82/171). Of these pregnancies, 16/82 (19.5%) were spontaneous while 35.4% (29/82) and 45.1% (37/82) occurred after ovulation induction by CC and gonadotropins, respectively. CONCLUSION: This study supports the use of androstenedione, LH and FSH as a simple reliable tool in triaging patients with CCR-PCOD to select the ideal candidates for LOD.

Caesarean deliveries by Pfannenstiel versus Joel-Cohen incision: A randomised controlled trial.

OBJECTIVE: This study was designed to compare the Pfannenstiel versus Joel-Cohen incisions during caesarean deliveries. MATERIAL AND METHODS: Women undergoing caesarean deliveries (n=153) were randomly assigned to the conventional Pfannenstiel or the Joel-Cohen incision. The outcome measures included postoperative pain, requirement for analgesics, operative time and other postoperative data. RESULTS: Maternal age, parity, gestational age and indications for caesarean delivery were similar across groups. Total operative time, postoperative recovery duration, time to get out of bed, to walk straight without support, to detect audible intestinal sounds and to pass gases or stools were shorter in the Joel-Cohen group. Postoperative haematocrit decreases and estimated intraoperative blood loss were similar between the two techniques. Moderate and severe pain at 6, 12 and 18 hours postoperatively was less frequent after the Joel-Cohen technique. CONCLUSION: Joel-Cohen incision in the non-scarred abdomen may provide a faster technique for caesarean section with less postoperative pain and probably early postoperative recovery in our circumstances.