Validation of Fetal Medicine Foundation competing-risks model for small-for-gestational-age neonate in early third trimester.

OBJECTIVE: To evaluate the new 36-week Fetal Medicine Foundation (FMF) competing-risks model for the prediction of small-for-gestational age (SGA) at an earlier gestation of 30 + 0 to 34 + 0 weeks. METHODS: This was a retrospective multicenter cohort study of prospectively collected data on 3012 women with a singleton pregnancy undergoing ultrasound examination at 30 + 0 to 34 + 0 weeks' gestation as part of a universal screening program. We used the default FMF competing-risks model for prediction of SGA at 36 weeks' gestation combining maternal factors (age, obstetric and medical history, weight, height, smoking status, race, mode of conception), estimated fetal weight (EFW) and uterine artery pulsatility index (UtA-PI) to calculate risks for different cut-offs of birth-weight percentile and gestational age at delivery. We examined the accuracy of the model by means of discrimination and calibration. RESULTS: The prediction of SGA < 3rd percentile improved with the addition of UtA-PI and with a shorter examination-to-delivery interval. For a 10% false-positive rate, maternal factors, EFW and UtA-PI predicted 88.0%, 74.4% and 72.8% of SGA < 3rd percentile delivered at < 37, < 40 and < 42 weeks' gestation, respectively. The respective values for SGA < 10th percentile were 86.1%, 69.3% and 66.2%. In terms of population stratification, if the biomarkers used are EFW and UtA-PI and the aim is to detect 90% of SGA < 10th percentile, then 10.8% of the population should be scanned within 2 weeks after the initial assessment, an additional 7.2% (total screen-positive rate (SPR), 18.0%) should be scanned within 2-4 weeks after the initial assessment and an additional 11.7% (total SPR, 29.7%) should be examined within 4-6 weeks after the initial assessment. The new model was well calibrated. CONCLUSIONS: The 36-week FMF competing-risks model for SGA is also applicable and accurate at 30 + 0 to 34 + 0 weeks and provides effective risk stratification, especially for cases leading to delivery < 37 weeks of gestation. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Is nuchal translucency measurement feasible in early pregnancy?

BACKGROUND: To investigate whether early nuchal translucency measurement at 7+0 to 9+0 weeks (NT7-9w) is feasible, obtain normal values for different crown-rump lengths (CRL) in the above weeks and create percentile tables. METHODS: A prospective study was conducted in the Obstetrics and Gynecology Department of the University Hospital of Ioannina, including data from women with singleton pregnancies, examined in the early pregnancy unit between November 2010 and May 2015 at a CRL of 10-27 mm. The early pregnancy scan was performed vaginally, and the NT7-9w, CRL, fetal heart rate, and mean yolk sac diameter were measured. Demographic data, including body mass index and smoking, were recorded. RESULTS: NT7-9w was measured successfully in 192 fetuses out of 210 (91.4 %), with a CRL ranging from 10-27 mm. The median maternal age was 31 (range 18-43) years, and the median CRL was 19.9 (range 10.0-27.0) mm. Considering the above measurements, we created normal values and percentiles tables of NT at 7+0 to 9+0 weeks in relation to the corresponding CRL measurement. CONCLUSION: According to the literature, this is the first attempt to measure NT in such weeks of pregnancy. NT measurement as early as 7+0 to 9+0 is feasible and normal values can be created and correlated with CRL measurements. HIPPOKRATIA 2021, 25 (4):151-155.

Heterogeneity in defining fetal corpus callosal pathology: systematic review.

OBJECTIVE: Fetal anomalies of the corpus callosum (CC) have been reported in the prenatal imaging literature since 1985, and, especially when isolated, pose challenges for both the patient and fetal medicine specialist. The purpose of this study was to review systematically the literature on prenatally diagnosed abnormalities of the CC, focusing on the terminology used to describe abnormalities other than complete agenesis of the CC, and to assess the heterogeneity of the nomenclature and definitions used. METHODS: This study was conducted in accordance with the PRISMA statement for reporting systematic reviews. A literature search was performed to identify prospective or retrospective case series or cohort studies, published in English, French, Italian, German or Spanish, reporting fetal imaging findings and describing anomalies of the CC. Quality and risk of bias of the studies were evaluated using the Newcastle-Ottawa scale and a modification of the scale developed by Conde-Agudelo et al. for other fetal imaging studies. The data extracted included the number of patients, the number of different anomalies identified, the descriptive names of the anomalies, and, where applicable, the definitions of the anomalies, the number of cases of each type of anomaly and the biometric charts used. Secondary tests used to confirm the diagnosis, as well as the postnatal or post-termination tests used to ascertain the diagnosis, were also recorded. RESULTS: The search identified 998 records, and, after review of titles and abstracts and full review of 45 papers, 27 studies were included initially in the review, of which 24 were included in the final analysis. These 24 studies had a broad range of quality and risk of bias and represented 1135 cases of CC anomalies, of which 49% were complete agenesis and the remainder were described using the term partial agenesis or nine other terms, of which five had more than one definition. CONCLUSIONS: In comparison to the postnatal literature, in the prenatal literature there is much greater heterogeneity in the nomenclature and definition of CC anomalies other than complete agenesis. This heterogeneity and lack of standard definitions in the prenatal literature make it difficult to develop large multicenter pooled cohorts of patients who can be followed in order to develop a better understanding of the genetic associations and neurodevelopmental and psychological outcomes of patients with CC anomalies. As this information is important to improve counseling of these patients, a good first step towards this goal would be to develop a simpler categorization of prenatal CC anomalies that matches better the postnatal literature. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Pregnant women with SARS-CoV-2 infection are at higher risk of death and pneumonia: propensity score matched analysis of a nationwide prospective cohort (COV19Mx).

OBJECTIVE: There are limited, unmatched data reporting low complication rates in pregnant women with coronavirus disease 2019 (COVID-19). The aim of this study was to compare COVID-19-related outcomes between pregnant and non-pregnant women after adjusting for potential risk factors for severe outcomes. METHODS: Data were obtained from the COVID-19 National Data Registry of Mexico, which is an ongoing prospective cohort of people of any age with clinically suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and admitted to 475 monitoring hospitals. This study included pregnant and non-pregnant women of reproductive age (15-45 years) with COVID-19 confirmed by reverse transcription polymerase chain reaction. To adjust for underlying risk factors, propensity score matching was conducted for chronic obstructive pulmonary disease, asthma, smoking, hypertension, cardiovascular disease, obesity, diabetes, chronic renal disease, immunosuppression, age, language, nationality and level of health insurance. The primary outcome was death. Secondary outcomes were pneumonia, intubation and intensive care unit (ICU) admission. RESULTS: The cohort comprised 5183 pregnant and 175 905 non-pregnant women with COVID-19. The crude (unmatched) rates of death, pneumonia, intubation and ICU admission in pregnant compared with non-pregnant women were 1.5% vs 1.5%, 9.9% vs 6.5%, 8.1% vs 9.9% and 13.0% vs 6.9%, respectively. After propensity score matching (5183 pregnant and 5183 non-pregnant matched women), pregnant women had a higher odds of death (odds ratio (OR), 1.84; 95% CI, 1.26-2.69), pneumonia (OR, 1.86; 95% CI, 1.60-2.16) and ICU admission (OR, 1.86; 95% CI, 1.41-2.45) than non-pregnant women, but similar odds of intubation (OR, 0.93; 95% CI, 0.70-1.25). CONCLUSION: After adjusting for background demographic and medical factors, pregnancy is a risk factor for death, pneumonia and ICU admission in SARS-CoV-2-infected women of reproductive age. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Risk of miscarriage following amniocentesis or chorionic villus sampling: systematic review of literature and updated meta-analysis.

OBJECTIVE: To estimate the procedure-related risk of miscarriage after amniocentesis and chorionic villus sampling (CVS) based on a systematic review of the literature and an updated meta-analysis. METHODS: A search of MEDLINE, EMBASE and The Cochrane Library was carried out to identify studies reporting complications following CVS or amniocentesis. Eligible for inclusion were large controlled studies reporting data for pregnancy loss prior to 24 weeks' gestation. Study authors were contacted when required to identify additional necessary data. Data for cases that had an invasive procedure and controls were inputted into contingency tables and the risk of miscarriage was estimated for each study. Summary statistics based on a random-effects model were calculated after taking into account the weighting for each study included in the systematic review. Procedure-related risk of miscarriage was estimated as a weighted risk difference from the summary statistics for cases and controls. Subgroup analyses were performed according to the similarity in risk levels for chromosomal abnormality between the invasive-testing and control groups. Heterogeneity was assessed using the I2 statistic. Egger's bias was estimated to assess reporting bias in published studies. RESULTS: The electronic search yielded 2943 potential citations, from which 12 controlled studies for amniocentesis and seven for CVS were selected for inclusion in the systematic review. A total of 580 miscarriages occurred following 63 723 amniocentesis procedures, resulting in a weighted risk of pregnancy loss of 0.91% (95% CI, 0.73-1.09%). In the control group, there were 1726 miscarriages in 330 469 pregnancies with a loss rate of 0.58% (95% CI, 0.47-0.70%). The weighted procedure-related risk of miscarriage following amniocentesis was 0.30% (95% CI, 0.11-0.49%; I2 = 70.1%). A total of 163 miscarriages occurred following 13 011 CVS procedures, resulting in a risk of pregnancy loss of 1.39% (95% CI, 0.76-2.02%). In the control group, there were 1946 miscarriages in 232 680 pregnancies with a loss rate of 1.23% (95% CI, 0.86-1.59%). The weighted procedure-related risk of miscarriage following CVS was 0.20% (95% CI, -0.13 to 0.52%; I2 = 52.7%). However, when studies including only women with similar risk profiles for chromosomal abnormality in the intervention and control groups were considered, the procedure-related risk for amniocentesis was 0.12% (95% CI, -0.05 to 0.30%; I2 = 44.1%) and for CVS it was -0.11% (95% CI, -0.29 to 0.08%; I2 = 0%). CONCLUSIONS: The procedure-related risks of miscarriage following amniocentesis and CVS are lower than currently quoted to women. The risk appears to be negligible when these interventions were compared to control groups of the same risk profile. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Riesgo de aborto después de una amniocentesis o una biopsia de vellosidades coriónicas: revisión sistemática de bibliografía y metaanálisis actualizado OBJETIVO: Estimar el riesgo de aborto relacionado con el procedimiento de la amniocentesis o la biopsia de vellosidades coriónicas (BVC) mediante una revisión sistemática de bibliografía y un metaanálisis actualizado. MÉTODOS: Se realizó una búsqueda en MEDLINE, EMBASE y The Cochrane Library para identificar estudios que reportaron sobre complicaciones después de una BVC o amniocentesis. Se consideraron elegibles para su inclusión los estudios controlados de gran tamaño que reportaron datos sobre la pérdida del embarazo antes de las 24 semanas de gestación. Se estableció contacto con los autores de los estudios cuando fue necesario para identificar datos adicionales necesarios. Se introdujeron en tablas de contingencia los datos de los casos que se sometieron a un procedimiento invasivo y controles y se estimó el riesgo de aborto para cada estudio. Las estadísticas resumen basadas en un modelo de efectos aleatorios se calcularon después de tener en cuenta la ponderación para cada estudio incluido en la revisión sistemática. El riesgo de aborto relacionado con cada procedimiento se estimó como una diferencia de riesgo ponderada de las estadísticas resumen para los casos y controles. Los análisis de subgrupos se realizaron de acuerdo con la similitud en los niveles de riesgo de anomalías cromosómicas entre los grupos de prueba invasiva y de control. La heterogeneidad se evaluó mediante el test estadístico I2 . Se estimó el sesgo de Egger para evaluar el sesgo de información reportada en los estudios publicados. RESULTADOS: La búsqueda electrónica arrojó 2943 citas potenciales, de las cuales se seleccionaron para su inclusión en la revisión sistemática 12 estudios controlados para la amniocentesis y siete para la BVC. Después de los 63723 procedimientos de amniocentesis sucedieron un total de 580 abortos, lo que resultó en un riesgo ponderado de pérdida de embarazo del 0,91% (IC 95%, 0,73-1,09%). En el grupo de control hubo 1726 abortos en 330469 embarazos, con una tasa de pérdida del 0,58% (IC 95%, 0,47-0,70%). El riesgo ponderado de aborto relacionado con el procedimiento de amniocentesis fue del 0,30% (IC 95%, 0,11-0,49%; I2  = 70,1%). Después de 13011 procedimientos de BVC se produjeron un total de 163 abortos, lo que resultó en un riesgo de pérdida de embarazo del 1,39% (IC 95%, 0,76-2,02%). En el grupo de control hubo 1946 abortos en 232680 embarazos, lo que supuso una tasa de pérdida del 1,23% (IC 95%, 0,86-1,59%). El riesgo ponderado de aborto relacionado con el procedimiento de BVC fue de 0,20% (IC 95%, -0,13-0,52%; I2  = 52,7%). Sin embargo, cuando se consideraron los estudios que incluyeron sólo mujeres con perfiles de riesgo similares para la anomalía cromosómica en los grupos de intervención y control, el riesgo relacionado con el procedimiento de la amniocentesis fue de 0,12% (IC 95%, -0,05-0,30%; I2  = 44.1%) y para el MVC fue de -0,11% (IC 95%, -0,29-0,08%; I2  = 0%). CONCLUSIONES: Los riesgos de aborto relacionados con el procedimiento de la amniocentesis y la BVC son menores que los actualmente mencionados a las mujeres. El riesgo parece ser insignificante cuando estas intervenciones se compararon con grupos de control del mismo perfil de riesgo.

First-trimester and combined first- and second-trimester prediction of small-for-gestational age and late fetal growth restriction.

OBJECTIVE: To develop a first-trimester or combined first- and second-trimester screening algorithm for the prediction of small-for-gestational age (SGA) and late fetal growth restriction (FGR). METHODS: This was a retrospective study of women with singleton pregnancy, who underwent routine first-, second- and third-trimester ultrasound assessment. Late FGR was defined, at ≥ 32 weeks' gestation in the absence of congenital anomalies, as either (i) estimated fetal weight (EFW) or birth weight (BW) < 3rd centile, or (ii) EFW < 10th centile and either uterine artery mean pulsatility index (UtA-PI) > 95th centile or cerebroplacental ratio (CPR) < 5th centile. Neonates with BW < 10th centile, regardless of prenatal parameters, were defined as SGA. The predictive effectiveness of maternal and first- and second-trimester factors was tested using logistic regression and receiver-operating characteristics curve analyses. RESULTS: A total of 3520 fetuses were included (late FGR, n = 109 (3.1%); SGA, n = 292 (8.3%)). Of the late FGR cases, 56 (1.6%) fulfilled the antenatal criteria (EFW < 3rd centile or EFW < 10th centile plus abnormal UtA-PI or CPR) and were defined as prenatally detected late FGR. A first-trimester screening model (comprising conception method, smoking status, maternal height, pregnancy-associated plasma protein-A (PAPP-A) and UtA-PI) could predict 50.0% of the prenatally diagnosed and 36.7% of the overall late FGR fetuses for a 10% false-positive rate (FPR). A model combining first- and second-trimester screening parameters (conception method, smoking status, PAPP-A, second- trimester EFW, head circumference/abdominal circumference ratio and UtA-PI) could predict 78.6% of the prenatally detected, and 59.6% of the overall late FGR fetuses, for a 10% FPR (area under the curve 0.901 (95% CI, 0.856-0.947) and 0.855 (95% CI, 0.818-0.891), respectively). The prediction of SGA was suboptimal for both first-trimester and combined screening. CONCLUSIONS: A simple model combining maternal and first- and second-trimester predictors can detect 60% of fetuses that will develop late FGR, and 79% of those fetuses that will be classified prenatally as late FGR, for a 10% FPR. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Breast self-examination in Greek midwives and midwifery students.

The aim of this study is to assess breast self-examination (BSE) practice in a representative sample of Greek midwives and midwifery students. Breast self-examination (BSE) is infrequent in healthcare professionals, including physicians and nurses. All midwives (n=245) and graduating midwifery students (n=165) who attended a congress of midwives were eligible to participate in the study, and a self-administered, anonymous questionnaire was developed to assess BSE practice. Midwives performed BSE more frequently than students (p<0.001). In addition, 27.0% of students performed BSE less frequently than every year whereas the midwives' rate is 14.0% (p<0.001). The proportion of subjects searching for specific signs of breast cancer during BSE and the BSE technique did not differ between midwives and students. In midwifery students, higher perceived knowledge of breast cancer-related issues was associated with more frequent BSE. Only a minority of Greek midwives and midwifery students practice BSE every month, and therefore implications for nursing management in BSE education should be included in midwifery school curricula to ensure increased BSE frequency, improved BSE accuracy and the promotion of BSE teaching to patients.

High miscarriage rate in women treated with Essure® for hydrosalpinx before embryo transfer: a systematic review and meta-analysis.

OBJECTIVES: Essure® has been tested as an alternative treatment for hydrosalpinx before embryo transfer (ET) in women undergoing assisted reproduction techniques. However, the persistence of a foreign body inside the uterine cavity might have a negative impact on the outcome of pregnancy. The present systematic review aimed at identifying, appraising and summarizing the available evidence regarding the effectiveness and safety of using Essure prior to ET for women with hydrosalpinx. METHODS: We searched for studies in PubMed, Scopus, CENTRAL, Web of Science and ClinicalTrials.gov and the reference lists of eligible studies. All studies including at least 10 women with hydrosalpinx who received Essure, any other intervention or no treatment prior to ET were considered eligible. Study selection, data extraction and evaluation of the risk of bias were performed independently by two authors. Study outcomes were miscarriage per clinical pregnancy, singleton preterm birth per singleton live birth and live birth/ongoing pregnancy and clinical pregnancy per ET. The pooled results for each outcome and intervention were summarized as proportions with their respective 95% CIs, using a random-effects model. RESULTS: Our electronic search of databases was performed on 7 November 2015, and 26 studies with 43 study arms were considered eligible: eight study arms evaluating Essure; seven assessing tubal aspiration; seven appraising effects of no treatment; 12 evaluating salpingectomy; two assessing tubal division; and seven evaluating tubal occlusion. When compared with women who had no intervention, women with Essure had a higher clinical pregnancy rate per ET (36% (95% CI, 0-43%) vs 13% (95% CI, 9-17%)). When compared with women who had other interventions, women with Essure had a higher miscarriage rate per clinical pregnancy (38% (95% CI, 27-49%) vs 15% (95% CI, 10-19%)). CONCLUSIONS: The available evidence suggests that, although Essure prior to ET in women with hydrosalpinx improves the chance of achieving a clinical pregnancy compared with no intervention, it is associated with a higher rate of miscarriage when compared with the other interventions. Although this evidence is based on observational studies, we believe that salpingectomy should be the first option for women who are eligible for videolaparoscopy. However, it is still premature to make recommendations for women who are not eligible for surgery, and randomized controlled trials are needed to clarify which is the best treatment alternative in such a scenario. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Neonatal acute kidney injury following Valsartan exposure in utero: report of two cases.

BACKGROUND: Maternal sartan intake during pregnancy has been associated with several fetal/neonatal complications related to disturbed renal development. Description of cases: We present two cases of neonatal acute kidney injury (AKI) following valsartan administration during pregnancy and provide evidence for the use of novel AKI biomarkers in these neonates. The first case was a female neonate, delivered at 32+4 weeks of gestation after maternal valsartan intake from 24 to 32 gestational weeks. In the second case, ultrasound examination revealed a growth-restricted fetus with severe oligohydramnios following maternal valsartan intake during the first 29 gestational weeks. In the absence of any improvement in amniotic fluid, the neonate was born at 31+5 weeks. In both cases, AKI was documented after birth, but renal function progressively recovered. Urine cystatin-C and neutrophil gelatinase-associated lipocalin were found abnormally increased during the first week of life. CONCLUSION: Sartan use during pregnancy is associated with the development of neonatal AKI. Novel urine biomarkers may be used to document renal injury. Hippokratia 2016, 20(1): 73-75.

Effect of mode of delivery on vertical human papillomavirus transmission - A meta-analysis.

A systematic review of the literature has been conducted (last update March 2014) for clinical studies reporting the prevalence of human papillomavirus (HPV) in the offspring of HPV-infected women in association to their mode of delivery. A meta-analysis was carried out according to the identification of concordant neonatal to maternal HPV types. Overall eight studies were included in the meta-analysis. Our pooled results, showed that caesarean section is associated with significantly lower rates of HPV transmission than vaginal birth (14.9% vs. 28.2%, risk ratio or RR: 0.515, 95% confidence interval or CI: 0.34-0.78). The number of caesarean sections needed to prevent one case of perinatal infection (number needed to treat or NNT) would be 7.5. As a conclusion it should be noted that caesarean section decreases the risk for perinatal HPV transmission by approximately 46%. Perinatal transmission still occurs in approximately 15% of the children born by caesarean section.

Perinatal outcome in women treated with progesterone for the prevention of preterm birth: a meta-analysis.

OBJECTIVE: To quantify the effect on perinatal outcome in women treated with progesterone for the prevention of preterm birth. METHODS: MEDLINE and SCOPUS searches, including references of the retrieved articles and additional automated search using the 'search for related articles' PubMed function, were used. Randomized controlled trials assigning women at risk for preterm birth to progesterone or placebo were included (both singleton and multiple pregnancies). Outcomes were neonatal and perinatal death, respiratory distress syndrome (RDS), retinopathy, necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH) Grade 3-4, sepsis, admission to the neonatal intensive care unit (NICU) and composite adverse outcome. RESULTS: Sixteen studies (singletons, n = 7; twins, n = 7; triplets, n = 2) were included in the meta-analysis. For singleton pregnancies, progesterone reduced the rates of neonatal death (risk ratio (RR) 0.487 (95% CI, 0.290-0.818)), RDS (RR 0.677 (95% CI, 0.490-0.935)), NICU admission (RR 0.410 (95% CI, 0.204-0.823)) and composite adverse outcome (RR 0.576 (95% CI, 0.373-0.891)). No favorable effect was observed in twins; in fact, progesterone was associated with increased rates of perinatal death (RR 1.551 (95% CI, 1.014-2.372)), RDS (RR 1.218 (95% CI, 1.038-1.428)) and composite adverse outcome (RR 1.211 (95% CI, 1.029-1.425)). No significant effect was observed in triplet pregnancies. CONCLUSION: Progesterone administration in singleton pregnancies at risk for preterm birth improves perinatal outcomes, but may actually have adverse effects in multiple pregnancies.

Large luteinized follicular cyst of pregnancy.

A large (165 × 235 × 250 mm) solitary, unilocular cyst with a thin, smooth wall and homogeneous anechoic content was detected during a routine ultrasound scan at 24 weeks of gestation in an asymptomatic 39-year-old woman with a singleton pregnancy. The cyst was aseptate, lacked mural blood flow and was not associated with ascites. It was located in the central abdominal area above and anterior to the uterus. Gradually increasing abdominal discomfort developed, and a laparotomy was performed at 27 weeks; the cyst was removed after aspiration of 6.3 L of serous fluid and the ipsilateral ovary was preserved. Pathological examination indicated a large luteinized follicular cyst of pregnancy. A healthy male infant was delivered vaginally at term. A rapidly enlarging ovarian mass in pregnancy poses significant diagnostic problems. Large luteinized cysts of pregnancy are uncommon and thought to involve stimulation by human chorionic gonadotropin (hCG), or increased tissue sensitivity to hCG. A literature search identified four previous cases that had been detected prenatally. With one exception, the cysts appeared to enlarge during pregnancy, eventually becoming symptomatic, and two previous cases also required removal of the cyst before birth. Adverse pregnancy outcome was only reported in one of the previous cases. In summary, large luteinized cysts of pregnancy are an uncommon type of cystic mass particular to pregnancy, characterized by the combination of a benign appearance and a tendency to enlarge rapidly, eventually becoming symptomatic and most often necessitating surgery.

Discordance in nuchal translucency thickness in the prediction of severe twin-to-twin transfusion syndrome.

OBJECTIVE: To examine in monochorionic pregnancies the possible value of intertwin discordance in nuchal translucency (NT) thickness in the prediction of early fetal death or severe twin-twin transfusion syndrome (TTTS). METHODS: In 512 monochorionic twin pregnancies NT was measured at 11 to 13 + 6 weeks' gestation and regression analysis was used to determine the significance of the association between the intertwin discordance in NT and subsequent early fetal death or development of severe TTTS requiring endoscopic laser surgery. RESULTS: In 412 (80.5%) pregnancies there was a normal outcome, in 58 (11.3%) there was severe TTTS requiring endoscopic laser surgery at 18-24 weeks, in 19 (3.7%) there was death of one or both fetuses at 13-18 weeks and in 23 (4.5%) there was fetal death at 21-38 weeks. In the four outcome groups the median discordance in NT was 11%, 22%, 35% and 7%, respectively. Significant prediction of early fetal death and severe TTTS was provided by the discordance in fetal NT, which was not significantly improved by including the discordance in crown-rump length. If the discordance in NT was 20% or more, the false positive rate was 20%, the detection rate of early fetal death was 63% and the detection rate of severe TTTS was 52%. CONCLUSIONS: Discordance in NT of 20% or more is found in about 25% of monochorionic twins and in this group the risk of early fetal death or development of severe TTTS is more than 30%. If the discordance is less than 20% the risk of complications is less than 10%.

Ectopic missed abortion after laparoscopic sterilization with the harmonic scalpel.

A case of a patient who presented with ectopic pregnancy and subsequent missed abortion one year after laparoscopic sterilization with the harmonic scalpel is reported. According to our knowledge of the relevant literature, this is the first time that a case of ectopic pregnancy after sterilization with a harmonic scalpel has been reported.

The current status of HPV DNA testing.

Infection with high-risk types of HPV underlies most cases of high-grade cervical intraepithelial neoplasia (CIN) and practically all cases of invasive cervical cancer. Currently, cervical HPV DNA is detected by means of PCR and sandwich capture molecular hybridization methods. Research has focused on the potential role of HPV testing in three conditions: screening for cervical neoplasia, triage of women with low-grade lesions and follow-up after conservative surgical treatment for CIN. Concerning the first condition, HPV testing does not seem to offer an obvious advantage over traditional cytology screening, mainly due to false positive results in younger women with transient HPV infection. A possible exemption to this is the case of middle-aged women and low-resource settings, where the excellent sensitivity of a HPV test is desirable. Although data are controversial regarding low grade lesions, results from randomized studies indicate that HPV testing could be useful in a triage of women with an initial cytological diagnosis of ASCUS, where detection of DNA of a high-risk type should lead to colposcopy. Although there is a lack of randomized controlled trials in this field, data from observational studies indicate that HPV DNA testing after conservative surgical treatment for CIN may be very sensitive and detect early residual and recurrent disease.

Clear cell ovarian carcinoma in a pregnant woman with a history of infertility, endometriosis and unsuccessful IVF treatment.

Ovarian cancer in pregnancy is a very rare event. We present here the case of a 37-year-old woman in whom a clear cell ovarian carcinoma was diagnosed in the first trimester of pregnancy. This patient had a history of infertility, endometriosis and two previous unsuccessful attempts of in vitro fertilization. Transvaginal sonography at six gestational weeks revealed a 6 x 4 cm ovarian cyst with an internal papillary excrescence. The cyst persisted throughout the first trimester, whereas the initial CA 125 value of 226 U/ml dropped to 61 U/ml at 12 gestational weeks. Exploratory laparotomy and cystectomy was performed at 14 weeks and the disease was classified as Stage Ic, arising in endometriosis. The couple decided to continue with pregnancy and the woman was followed by serial sonographic, MRI and CA 125 examinations. A cesarean section, hysterectomy, bilateral salpingo-oophorectomy and omentectomy was performed at 34 weeks. Histology and cytology were negative for recurrence. Four months later the woman and baby are doing well. We review cases of ovarian clear cell carcinoma diagnosed during pregnancy and discuss the association of endometriosis, infertility, infertility drugs and ovarian cancer.

Successful myomectomy during pregnancy.

BACKGROUND: Although leiomyomas usually remain asymptomatic during pregnancy, they may complicate its course. In this study, pregnancy outcome observed when myomectomy was performed during pregnancy in carefully selected patients is presented. METHODS: A prospective cohort study of 13 women who underwent myomectomy during pregnancy between January 1994 and December 2001. Surgical management of leiomyoma was required on the basis of characteristics of the myoma and symptoms. RESULTS: Among a total of 15,579 women registered at the authors' prenatal clinic, 622 consecutive pregnant women had sonographically identified myoma; hence, the incidence was 3.9% (95% CI 3.6-4.3%). The vast majority of these women was asymptomatic during pregnancy or managed conservatively (97.4%; 95% CI 96-98%). Among 622 pregnant patients with leiomyoma, 13 presented with complications during pregnancy that required surgical intervention (2.1%; 95% CI 0.9-3.2%), due to increase in lesion size causing discomfort and/or severe abdominal pain not responding to conservative management with analgesic and non-steroidal anti-inflammatory drug medication. In 92% of these cases, successful myomectomy was performed and the pregnancy progressed to term without further complications. CONCLUSIONS: These data provide reassurance for pregnant women with uterine myoma. Surgical management of uterine leiomyoma during pregnancy may be successfully performed in carefully selected patients.