Sonographic evaluation of retained products of conception within 48 h following delivery: a retrospective cohort study.

OBJECTIVE: Early diagnosis of retained products of conception (RPOC) is critical for directing clinical management and for preventing associated complications. This study aimed to evaluate the utility of post-delivery ultrasound in patients with risk factors for RPOC. STUDY DESIGN: A retrospective cohort-study was conducted in a single tertiary university-affiliated hospital (January 2016-September 2022). Sonographic evaluation, including endometrium thickness measurement and color Doppler, were reviewed of women with risk factors for RPOC: postpartum hemorrhage, a hemoglobin drop > 4 g/dl, manual removal of the placenta, and suspicious placenta. Results of early postpartum ultrasound (within 48 h), misoprostol administration and hysteroscopies were evaluated. RESULTS: Of the 591 women included, RPOC was suspected in 141 (24%). Endometrial thickness > 5 mm was associated with sonographic RPOC diagnosis in 58%. Suspected sonographic RPOC was concluded for 100%, 92% and 7% of the women with marked, moderate, and undetectable vascularity, respectively, p < 0.001. Misoprostol 1000 mcg per rectum (PR) was administered to 86% of those with suspected RPOC; only 11% of them needed an operative hysteroscopy for removal of the RPOC. RPOC on a pathology report was confirmed for 71% of those who underwent hysteroscopy. CONCLUSIONS: Postpartum transabdominal ultrasonography within 48 h of delivery was effective for assessing RPOC. For appropriate triage, color Doppler grading increased the accuracy of RPOC diagnosis. Misoprostol treatment was successful in 88% of women with suspected sonographic RPOC. The combination of sonographic evaluation and misoprostol treatment for suspected RPOC might lower the rate of unnecessary invasive procedures.

The role of the cerebroplacental ratio in predicting pregnancy outcomes at 40-42 gestational weeks: a prospective observational trial.

PURPOSE: The cerebroplacental ratio is a sonographic tool used to predict poor pregnancy outcomes. Data are insufficient regarding its use in postdate pregnancy. We evaluated the cerebroplacental ratio's prediction of unfavorable pregnancy outcomes in women at 40-42 weeks gestation with normal amniotic fluid index. METHODS: This prospective observational study included 101 women with low-risk singleton pregnancy and gestational age > 40 weeks who delivered in a university affiliated hospital during 2020-2021. The middle cerebral artery pulsatility index, the umbilical artery pulsatility index, and the cerebroplacental ratio, which is their quotient, were compared between women with favorable and unfavorable pregnancy outcomes. The latter included: meconium-stained amniotic fluid, cesarean or vacuum-assisted delivery due to pathological cardiotocography (category 2 or 3), 5-min Apgar score < 7, umbilical cord pH < 7.1, neonatal intensive care unit admission, and neonatal death. RESULTS: Fetal Doppler, performed at a median gestational age of 40.3 (40.0-41.6), did not differ between 75 (74.3%) women with favorable obstetrical outcomes and 26 (25.7%) with unfavorable outcomes. In multivariate analysis, advanced maternal age and a history of a cesarean section were correlated with unfavorable outcomes, while Doppler indices were not found to be predictive. Among women at 41-42 weeks' gestation, for those with intrapartum fetal monitor category 2-3 vs. category 1, the mean umbilical artery pulsatility index was higher: 0.92 ± 0.34 vs. 0.71 ± 0.11 (p = 0.044). CONCLUSION: According to the study results, fetal Doppler indices, including the cerebroplacental ratio, are not predictive of unfavorable outcome in women with pregnancies exceeding 40 weeks. Larger prospective studies are needed.

Perinatal outcomes of pregnancies with borderline oligohydramnios at term.

Introduction Limited evidence exists on borderline oligohydramnios. Our objective was to determine perinatal outcomes in uncomplicated term pregnancies with borderline oligohydramnios. Methods This retrospective analysis compared adverse perinatal outcomes among pregnancies during 2018-2022, between those with borderline oligohydramnios defined as amniotic fluid index (AFI) 5.1-8.0 cm, those with oligohydramnios (AFI ≤5 cm) and those with normal AFI (8.1-25 cm). The latter, matched one-to-one to the borderline oligohydramnios group, served as the control group. The outcomes compared included birthweight, cesarean delivery due to fetal distress, the presence of meconium-stained amniotic fluid, Apgar scores, neonatal intensive care unit admission and the occurrence of small-for-gestational-age (SGA) neonates. Results During the study period, 140 women had borderline oligohydramnios and 345 had oligohydramnios; the control group included 140 women. Borderline oligohydramnios was associated with increased rates of delivering SGA neonates (adjusted odds ratio (aOR) = 3.6, 95% confidence interval (CI) 1.1-11.6, p=0.034) and cesarean delivery due to fetal distress (aOR = 3.0, 95% CI 1.1-8.3, p=0.032). Rates of composite neonatal outcome (including at least one of the following: cesarean delivery due to fetal distress, meconium-stained amniotic fluid, 5-minute Apgar score <7, umbilical artery pH <7.15 or neonatal intensive care unit admission) were higher in both the borderline oligohydramnios (20.7%) and oligohydramnios (18.6%) groups compared to the control group (9.3%) (p=0.019). Conclusions Pregnancies with borderline oligohydramnios were associated with increased risks of delivering SGA neonates and requiring cesarean delivery due to fetal distress. These findings support considering closer antepartum surveillance for these pregnancies, especially for identifying abnormal fetal growth.

Volume Measurement of the Cavum Septi Pellucidi: Normative Values Between 20 and 40 Weeks of Gestation.

BACKGROUND: The cavum septi pellucidi (CSP) is a brain-enclosed cavity located on the midline between the two leaflets of the septum pellucidum that separates the lateral ventricles. This structure develops in the fetus from week 18 and can be seen up to week 37 in almost all cases and then begins to disappear. OBJECTIVES: To measure and determine the normative values of the CSP volume in fetuses between 20 to 40 weeks of gestation. METHODS: The study comprised 161 consecutive pregnant women between 20 to 40 weeks of gestation with single viable fetuses. All patients had normal, disease-free pregnancies. Transvaginal or transabdominal ultrasound was used according to the fetal presentation. The fetal head was assessed in mid-sagittal sections. Once the CSP was visualized, its volume was measured using three-dimensional ultrasound with Virtual Organ Computer-aided Analysis software. The width of the CSP was also measured at the biparietal diameter (BPD) plane. RESULTS: Of the 161 fetuses, the CSP volume was measured in 158. In three patients the CSP was not identified. The CSP volume correlated poorly with gestational age (r=0.229) and with the BPD (r=0.295). The mean CSP volume was 0.508 ± 0.372 ml (range: 0.03-1.78 ml). The simple measurement of the CSP width correlated better with gestational age (r=0.535) and the BPD (r=0.484). CONCLUSIONS: The CSP volume had a poor correlation with gestational age; however, the volume did not exceed 2 ml regardless of gestational age. This information can be used to assess pathologies involving the CSP.

Antenatal ultrasound findings in choanal atresia: A case report and review of the literature.

Choanal atresia occurs in about 1 in 5000 births and is associated with other structural and genetic abnormalities. Choanal atresia is usually diagnosed postnatally due to respiratory distress, and rarely diagnosed antenatally. Here, a woman with severe polyhydramnios is described, whose fetus was diagnosed antenatally with isolated bilateral choanal atresia, as evident by persistent absence of flow through the nostrils on ultrasound. A literature review is presented of the antenatal findings of choanal atresia, using ultrasound and other imaging modalities. An association of choanal atresia with polyhydramnios should be considered. Examining flow through the fetal nose, using color Doppler, might aid in diagnosing choanal atresia. If this condition is suspected, a detailed ultrasound scan should be done to rule out other anomalies. Fetal magnetic resonance imaging has been suggested as an additional imaging tool in selected patients. Genetic counselling and invasive prenatal testing should be offered.

Interstitial heterotopic pregnancy after bilateral total salpingectomy in IVF patients: a case report and literature review.

OBJECTIVES: Heterotopic pregnancy of an intrauterine pregnancy and an interstitial or stump pregnancy after bilateral salpingectomy is a rare complication of in vitro fertilization (IVF) that can lead to severe hemorrhage; prompt identification and management are important. The aim of this paper was to present a case report and an updated literature review of women who had had combined interstitial/stump and intrauterine pregnancies during an in an IVF cycle after total bilateral salpingectomy. MATERIAL AND METHODS: We conducted a search in PubMed for reported heterotopic pregnancy, of a combined intrauterine pregnancy with an interstitial or stump pregnancy, in women who underwent IVF after bilateral salpingectomy. RESULTS: Our search yielded 13 heterotopic pregnancies in women who underwent IVF after bilateral salpingectomy. Forty-six percent of the women had more than two embryos transferred, and all the women had a history of ectopic pregnancies or tubal infertility. Most of the women presented at 6-7 weeks of pregnancy with vaginal bleeding and/or abdominal pain. A ruptured ectopic pregnancy was presented in 42%. Ultrasound was the main diagnostic tool in most cases. Only two women had been medically treated with local KCL or methotrexate, while 83% underwent surgical treatment. Five women had uncomplicated cesarean sections near or at term. CONCLUSIONS: Women with bilateral total salpingectomy remain at risk of heterotopic pregnancy, which poses a diagnostic and treatment challenge. This risk may be reduced by the reduction in the number of transferred embryos in IVF. For those who wish to preserve intrauterine pregnancy, cornual resection can be performed with good prognosis.

The accuracy of sonographic fetal weight in very preterm infants (≤32 weeks).

OBJECTIVE: To examine the accuracy of sonographic fetal weight to predict birthweight in very preterm infants (<32 weeks), and to compare the accuracy of estimated fetal weight (EFW) between those small for gestational age (SGA) and those appropriate for gestational age (AGA). STUDY DESIGN: A retrospective study was conducted of data recorded between January 2010 and March 2023. Included were women with singleton livebirths at 23+0-31+6 weeks who had an EFW within one week from delivery. Mean percentage error, mean absolute percentage error, and underestimation and overestimation rates were calculated. We compared the accuracy of EFW between SGA and AGA infants. RESULTS: In total, 360 women were included. The mean absolute percentage error was 7.8 % (range 0 %-68.9 %); for 207 (57.5 %) infants the percentage error was within ±10 %. Overestimation error >10 % was observed in 102 (28.3 %) infants and errors >20 % in 34 (9.4 %). Among infants born in the periviable period (23+0 - 25+6 weeks; N = 56), the mean absolute percentage error was 9.8 % (range: 0 %-40.3 %); the value was within ±10 % for only 28 periviable infants (50 %) and exceeded 20 % for 16.1 %. Among SGA compared to AGA infants, the mean absolute percentage error was higher (11.1% vs. 6.6 %, p = 0.035). Overestimation error >10 % was more frequent among SGA than AGA infants (55 (49.1 %) vs. 47 (19.0 %), p < 0.001). In a multivariate logistic regression analysis, SGA status was independently associated with a higher mean percentage error (beta = 0.260, p < 0.001) and an increased risk of an error >10 % (odds ratio = 2.1, 95 % confidence interval 1.2-3.5, p = 0.008). CONCLUSIONS: Sonographic EFW is limited in assessing very preterm infants, particularly those who are SGA or born during the periviable period. These limitations should be considered regarding impending very preterm births and concerns about abnormal fetal growth.

Diagnostic accuracy and characteristics of symptomatic versus asymptomatic retained products of conception: A retrospective cohort study.

OBJECTIVE: To assess the accuracy of diagnosing retained products of conception (RPOC) in symptomatic versus asymptomatic women, and to identify potential divergent ultrasound features between these groups. METHODS: This retrospective study included women aged 17-50 years who underwent hysteroscopy for suspected RPOC during 2018-2021. Clinical and sonographic data were analyzed, and multivariable linear regression models employed, to examine correlations between RPOC and sonographic findings, and to compare diagnostic accuracy between symptomatic and asymptomatic women. RESULTS: Of the 225 women included, 123 (54.7 %) were symptomatic and 102 (45.3 %) were asymptomatic. Hysteroscopy complications were more frequent in asymptomatic women. Regarding sonography, statistically significant differences were not found between the groups in endometrial thickness or uterine fluid presence, but positive Doppler flow was more common in asymptomatic than symptomatic women. Endometrial thickness >1.49 cm demonstrated diagnostic utility, with similar sensitivity and specificity in the two groups. Multivariable models revealed significant associations of RPOC presence with endometrial thickness and Doppler flow in symptomatic women. In both groups, hysteroscopy enhanced diagnostic accuracy, with higher positive predictive values and lower false-positive rates compared to ultrasound alone. CONCLUSION: An endometrial thickness cutoff of 1.49 cm aids diagnosing RPOC. Doppler flow enhances diagnostic value in symptomatic women. Integration of hysteroscopy improves diagnostic accuracy compared to ultrasound alone. Regular sonographic assessment for women with identifiable risk factors assists in RPOC detection irrespective of symptoms.

Epidemiological and Clinical Characteristics of Mpox in Cisgender and Transgender Women and Non-Binary Individuals Assigned to the Female Sex at Birth: A Comprehensive, Critical Global Perspective.

The 2022-2023 Mpox multi-country outbreak, identified in over 110 WHO Member States, revealed a predominant impact on cisgender men, particularly those engaging in sex with men, while less frequently affecting women. This disparity prompted a focused investigation into the gender-specific characteristics of Mpox infections, particularly among women, to address a notable knowledge gap. This review systematically gathers and analyzes the scientific literature and case reports concerning Mpox infections in women, covering a broad geographical spectrum including regions such as Argentina, Brazil, Colombia, Nigeria, Europe, Vietnam, and the United States. The analysis delves into various aspects of Mpox in women, including clinical features, epidemiology, psychological impacts, preparedness strategies, and case studies, with particular attention to pregnant women and those with underlying health conditions. Empirical data from multiple studies underscore the unique epidemiological and clinical patterns of Mpox in women. In the United States, a small percentage of Mpox cases were reported among cisgender women, with a notable portion involving non-Hispanic Black or African American, non-Hispanic White, and Hispanic or Latino ethnicities. The primary transmission route was identified as sexual or close intimate contact, with the virus predominantly manifesting on the legs, arms, and genital areas. Further, a study in Spain highlighted significant disparities in diagnosis delays, transmission modes, and clinical manifestations between genders, indicating a different risk profile and disease progression in women. Additionally, a case from Vietnam, linked to a new Mpox sub-lineage in women, emphasized the role of women in the transmission dynamics and the importance of genomic monitoring. This review emphasizes the necessity for inclusive surveillance and research to fully understand Mpox dynamics across diverse population groups, including women. Highlighting gender and sexual orientation in public health responses is crucial for an effective approach to managing the spread and impact of this disease. The findings advocate for a gender-diverse assessment in health services and further research to explore the nuances of Mpox transmission, behavior, and progression among different groups, thereby enhancing the global response to Mpox and similar public health challenges.

Novel fetal phenotype of TAF8 deficiency.

TAF8 is part of the transcription factor TFIID complex. TFIID is crucial for recruiting the transcription factor complex containing RNA polymerase II. TAF8 deficiency was recently reported as causing a severe neurodevelopmental disorder in eight patients. We have ascertained three Muslim Arab couples with fetal brain malformations. Clinical, imaging, pathological, biochemical, and molecular analyses were performed. Pre-natal ultrasound performed in four pregnancies revealed massive cerebellar atrophy, microcephaly, cerebral and corpus callosum (CC) anomalies. Pre-natal MRI studies of two of the affected fetuses confirmed microcephaly, small vermis, abnormal sulcation pattern with malformation, and shortening of CC. The fetuses were found to carry a novel likely pathogenic homozygous variant (c.45 + 5 G > A) of TAF8, predicted to affect splicing and presenting autosomal recessive inheritance. Post-mortem examinations confirmed the imaging studies in one fetus. Dysmorphic features including hypertelorism, wide nasal bridge, clinodactyly, and hirsutism were present. Western blotting analysis in fibroblasts of an affected fetus demonstrated a significant reduction of TAF8 protein. We determined high expression levels of TAF8 which progressively diminish in fetal brains of WT mice. We report for the first time the fetal presentation of TAF8 deficiency due to a novel genetic variant, and study TAF8 presence during fetal and neonatal periods in mouse brains. Our study may contribute to understanding the role of TAF8 in the developing human brain.

Spontaneous Rupture of the Unscarred Uterus: A Review of the Literature.

Importance: Uterine rupture is defined as a nonsurgical disruption of all layers of the uterus. Most ruptures occur in the presence of a scar, usually secondary to a previous cesarean delivery. Rupture of an unscarred uterus is rare and is associated with severe maternal and neonatal outcomes. Objective: To outline the literature on potential predisposing factors, clinical findings, and maternal and fetal outcomes of a rupture of an unscarred uterus. Evidence Acquisition: PubMed was searched for the phrases "uterine rupture," "unscarred," and "spontaneous." Individual case reports, retrospective case series, and review articles in English between 1983 and 2020 were included. Results: We found 84 case reports in 79 articles. The mean maternal age was 29.3 (SD, 5.7) years; 38 women (45.2%) were nulliparous. Uterine rupture occurred in 37% of the women at term; in 9.9%, the gestational age was ≤12 weeks. The most common clinical presentations were abdominal pain (77.4%), signs of hypovolemic shock (36.9%), fetal distress (31%), and vaginal bleeding (22.6%). The most common risk factors were the use of uterotonic drugs for induction or augmentation of labor and a prior curettage procedure. The most frequently ruptured site was the body of the uterus. Hysterectomy managed 36.9% of the ruptures. Four women died (4.8%). Perinatal mortality was 50.6%. Perinatal death was higher in developing than developed countries. Conclusions and relevance: Although rare, spontaneous rupture of the unscarred uterus has serious consequences to the mother and the fetus and should be included in the differential diagnosis of acute abdomen in pregnancy.

Pregnancy of unknown location: the value of frozen section analysis and its relation to Beta-hCG levels and endometrial thickness

Abstract Objective Frozen section examination is a rapid method for identifying products of conception in endometrial curetting, yet its accuracy is inconclusive. The purposes of this study is to determine the accuracy of frozen section analysis of endometrial curetting in pregnancies of unknown location, and to verify the relation of β-human chorionic gonadotrophin (hCG) level and endometrial thickness to the assessed accuracy. Methods We reviewed data from January 2009 to December 2014 of diagnostic curettages from women with suspected ectopic pregnancies sent for frozen section examination at a medical center. A frozen section diagnosis was considered accurate if it concurred with the final pathologic diagnosis. Results Of 106 frozen section studies, the diagnosis was accurate in 94 (88.7%). Of 79 specimens interpreted as negative on frozen sections (no products of conception noted), 9 (11.4%) were positive on final pathologic review. Three of the 27 (11.1%) specimens interpreted as positive by a frozen section failed to demonstrate products of conception on a final pathologic section. The sensitivity of frozen sections in the diagnosis of ectopic pregnancy was 72.7%, specificity 95.9%, positive predictive value 88.9%, negative predictive value 88.6%, and accuracy 88.6%. A statically significant correlation was found between β-hCG level and high accuracy of the frozen section technique (p< 0.001). No correlation was found between endometrial thickness and the accuracy of the frozen section technique. Conclusion The accuracy of frozen section examination was high and was found to correlate with β-hCG level, but not with endometrial thickness.