Correction of the Tuberous Breast with Fat Grafting and Implant: Techniques, Evaluation with BREAST-Q, and Preliminary Results.

BACKGROUND: The correction of tuberous breast deformity with fat grafting has gained popularity in recent years, but it remains unclear whether this new technique can produce patient satisfaction levels comparable to those achieved with implant-based correction. METHODS: This study aimed to compare patients' satisfaction and quality of life using the BREAST-Q questionnaire after correction of tuberous breast deformity with fat grafting and implants. Twenty-four patients (36 breasts) were included in our study. Thirteen patients (15 breasts) had a correction with lipofilling (mean 2.67 interventions) and 11 patients (21 breasts) had an implant-based correction (mean 1 intervention). RESULTS: Both fat and implant treatments showed statistically significant improvements in breast satisfaction (p value=0.001, 0.002, respectively), psychosocial (p value=0.003, 0.003, respectively), and sexual satisfaction (p value=0.008, 0.002, respectively) between the pre-treatment and post-treatment stages. However, the only statistically significant differences between the treatments were observed in the physical condition pre-treatment (p value=0.008) and sexual condition post-treatment (p value=0.030). The outcome of both treatments was not statistically different. Furthermore, the outcome exhibited a statistically significant positive linear relationship with breast satisfaction for both treatments. CONCLUSIONS: This study suggests that lipofilling can achieve breast and outcome satisfaction comparable to that of implants, although this parity in results comes at the cost of more interventions. These preliminary results lend support to the notion that, as surgeons have access to two equally effective techniques, it is crucial to provide appropriate guidance to patients to ensure their satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prenatal diagnosis of bilobate placenta: incidence, risk factors and impact on pregnancy outcomes.

OBJECTIVES: To investigate the incidence and risk factors of bilobate placenta, as well as to assess its impact on preeclampsia (PE), preterm delivery (PTD) and small-for-gestational age (SGA) neonates. METHODS: A prospective study of singleton pregnancies, undergoing routine anomaly scan at 20+0-23+6 gestational weeks, was conducted, between 2018 and 2022. The impact of prenatally diagnosed bilobate placenta on PE, PTD and SGA was assessed. Multivariate logistic regression models were employed to assess the independent association between bilobate placenta and the main pregnancy outcomes, using specific confounders. Additionally, a risk factor analysis was performed. RESULTS: The study population included 6,454 pregnancies; the incidence of prenatally diagnosed bilobate placenta was 2.0 % (n=129). Bilobate placenta was associated with PE (aOR: 1.721; 95 % CI: 1.014-2.922), while no statistically significant association was found between this anatomical variation and SGA (aOR: 1.059; 95 % CI: 0.665-1.686) or PTD (aOR: 1.317; 95 % CI: 0.773-2.246). Furthermore, pregnancies with prenatally diagnosed bilobate placenta had an increased prevalence of abnormal cord insertion (marginal or velamentous) (9.8 vs. 27.1 %; p<0.001) and increased mean UtA PI z-score (0.03 vs. 0.23; p=0.039). Conception via ART (aOR: 3.669; 95 % CI: 2.248-5.989), previous history of 1st trimester miscarriage (aOR: 1.814; 95 % CI: 1.218-2.700) and advancing maternal age (aOR: 1.069; 95 % CI: 1.031-1.110) were identified as major risk factors for bilobate placenta. CONCLUSIONS: Bilobate placenta, excluding cases of co-existing vasa previa, is associated with higher incidence of PE, increased mean UtA PI z-score and higher probability of abnormal cord insertion, but not with increased risk for SGA or PTD. It is more common in pregnancies following ART and in women with a previous 1st trimester miscarriage.

The impact of lateral placenta on preeclampsia and small for gestational age neonates: a systematic review and meta-analysis.

OBJECTIVES: We conducted a systematic review and meta-analysis to quantitatively summarize the present data on the association of prenatally identified lateral placenta in singleton pregnancies with small for gestational age (SGA) neonates, preeclampsia and other perinatal outcomes. METHODS: From inception to November 2021, we searched PubMed/Medline, Scopus and The Cochrane Library for papers comparing the risk of SGA and preeclampsia, as well as other perinatal outcomes in singleton pregnancies with a prenatally identified lateral placenta to those with non-lateral placentas. The revised Newcastle-Ottawa Scale was used to evaluate the quality of eligible papers. The I2 test was employed to evaluate the heterogeneity of outcomes among the studies. To investigate the possibility of publication bias, funnel plots were constructed. Prospero RN: CRD42021251590. RESULTS: The search yielded 5,420 articles, of which 16 were chosen, comprising of 15 cohort studies and one case control study with a total of 4,947 cases of lateral and 96,035 of non-lateral placenta (controls) reported. SGA neonates were more likely to be delivered in cases with a lateral placenta (OR: 1.74; 95% CI: 1.54-1.96; p<0.00001; I2=47%). Likewise, placental laterality was linked to a higher risk of fetal growth restriction (OR: 2.18; 95% CI: 1.54-3.06; p<0.00001; I2=0%), hypertensive disorders of pregnancy (OR: 2.39; 95% CI: 1.65-3.51; p=0.0001; I2=80%), preeclampsia (OR: 2.92; 95% CI: 1.92-4.44; p<0.0001; I2=82%) and preterm delivery (OR: 1.65; 95% CI: 1.46-1.87; p<0.00001; I2=0%). CONCLUSIONS: The prenatal diagnosis of a lateral placenta appears to be associated with a higher incidence of preeclampsia, fetal growth restriction, preterm delivery and SGA. This may prove useful in screening for these conditions at the second trimester anomaly scan.

The Effect of Resolution Level and Targeted Design in the Diagnostic Performance of Prenatal Chromosomal Microarray Analysis.

INTRODUCTION: This study was performed to assess the optimal resolution for prenatal testing by array comparative genomic hybridization (aCGH), aiming to balance between maximum diagnostic yield and minimal detection of variants of uncertain significance (VOUS). METHODS: This was a prospective study using data of 2,336 fetuses that underwent invasive prenatal diagnosis, and the samples were analyzed by aCGH. In total, six different aCGH platforms were studied; four different resolutions (0.18 Mb, 0.5 Mb, 1 Mb, and 2 Mb) and two platform designs (whole-genome [WG] and targeted). The results of these designs were compared based on their diagnostic yield and VOUS rate. The performance of the different designs was further analyzed according to indication for invasive testing. RESULTS: The diagnostic yield of copy number variants increased with increasing level of analysis. The detection rates of clinically significant chromosomal abnormalities were almost the same across our targeted array designs; 7.2% with 0.18 Mb backbone/0.05 Mb versus 7.1% with 0.5 Mb backbone/0.05 Mb (p >0.05). However, a significant difference in the rate of VOUS was observed; 9.4% with 0.18 Mb backbone/0.05 Mb versus 6% with 0.5 Mb backbone/0.05 Mb (p <0.001). After analyzing the results across different indications for testing, we found that the application of non-targeted platform designs and lower levels of resolution analysis (such as 1 Mb WG or 0.5 MbL/1 MbG WG) would offer similar diagnostic yield in most cases with major congenital anomalies, with lower VOUS rates. However, the sample size for many indication groups was too small to extract robust associations. CONCLUSION: It appears that the targeted array platform with 0.5 Mb backbone resolution and 0.05 Mb on targeted gene-rich regions is optimal for routine chromosomal microarray analysis use in prenatal diagnosis. It may be beneficial to individualize the minimum resolution in specific referral indications as the indications for invasive prenatal testing may be quite heterogeneous.

Cervical length screening for predicting preterm birth: A comparative review of guidelines.

A cervical length (CL) assessment may predict preterm birth (PTB). This study aimed to analyze and compare the recommendations of guidelines on the role of CL in the prediction of PTB. There is no consensus regarding universal screening of asymptomatic women without a history of prior spontaneous PTB (sPTB), using CL. On the other hand, CL assessment is recommended in cases with a history of sPTB due to the high recurrence rate. Finally, there is discrepancy regarding CL assessment in asymptomatic women with multiple pregnancy. Although far from perfect, CL measurement remains the best available method to predict PTB.

Prenatal Diagnosis of Isolated Single Umbilical Artery: Incidence, Risk Factors and Impact on Pregnancy Outcomes.

Objectives: To assess the incidence of prenatally diagnosed isolated single umbilical artery (iSUA) and its impact on major pregnancy outcomes, as well as to investigate potential risk factors. Materials and methods: A prospective study of singleton pregnancies, undergoing routine anomaly scans at 20+0-24+0 weeks of gestation, was carried out from 2018 to 2022. The effect of sonographically detected iSUA on small-for-gestational-age neonates (SGA) and preterm delivery (PTD) was evaluated using parameterized Student's t-test, nonparametric Mann-Whitney U test and the chi-square test. Multivariable logistic regression models were implemented to assess the independent association between iSUA and the main outcomes, as well as with potential risk factors, while adjusting for specific confounders. Results: The study population included 6528 singleton pregnancies and the incidence of prenatally diagnosed iSUA was 1.3%. Prenatally diagnosed iSUA had a statistically significant association with both SGA neonates (aOR: 1.909; 95% CI: 1.152-3.163) and PTD (aOR: 1.903; 95% CI: 1.035-3.498), while no association was identified between this sonographic finding and preeclampsia. With regard to risk factors, conception via assisted reproductive technology (ART) was associated with increased risk of iSUA (aOR: 2.234; 95% CI: 1.104-4.523), while no other independent predictor for the development of this anatomical variation was identified. Conclusions: Prenatally diagnosed iSUA seems to be associated with a higher incidence of SGA and PTD and is more common in pregnancies following ART, which constitutes a novel finding.

Incidence and Risk Factors for Postpartum Hemorrhage: A Case-Control Study in a Tertiary Hospital in Greece.

Background and Objectives: Postpartum hemorrhage (PPH) is an obstetrical emergency and although the mortality rate from PPH has decreased, it is still considered a challenge in obstetrics. This study aimed to estimate the rate of primary PPH, as well as to investigate the potential risk factors and management options. Material and methods: This was a retrospective case-control study of all cases with PPH (blood loss > 500 mL, irrespective of the mode of delivery) managed in the Third Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Greece, from 2015 to 2021. The ratio of cases to controls was estimated to be 1:1. The chi-squared test was used to examine if there was any relationship between several variables and PPH, while subgroup multivariate logistic regression analyses of certain causes of PPH were also conducted. Results: During the study period, from a total of 8545 births, 219 (2.5%) pregnancies were complicated with PPH. A maternal age > 35 years (OR: 2.172; 95% CI: 1.206-3.912; p = 0.010), preterm delivery (<37 weeks) (OR: 5.090; 95% CI: 2.869-9.030; p < 0.001) and parity (OR: 1.701; 95% CI: 1.164-2.487; p = 0.006) were identified as risk factors for PPH. Uterine atony was the main cause of PPH in 54.8% of the women, followed by placental retention in 30.5% of the sample. Regarding management, 57.9% (n = 127) of the women received uterotonic medication, while in 7.3% (n = 16), a cesarean hysterectomy was performed to control PPH. Preterm delivery (OR: 2.162; 95% CI: 1.138-4.106; p = 0.019) and delivery via a cesarean section (OR: 4.279; 95% CI: 1.921-9.531; p < 0.001) were associated with a higher need for multiple treatment modalities. Prematurity (OR: 8.695; 95% CI: 2.324-32.527; p = 0.001) was identified as an independent predictor for an obstetric hysterectomy. From the retrospective analysis of the births complicated by PPH, no maternal death was identified. Conclusions: Most of the cases complicated with PPH were managed with uterotonic medication. An advanced maternal age, prematurity and multiparity had a significant impact on the occurrence of PPH. More research is needed on the risk factors of PPH, while the establishment of validated predictive models would be of value.

Mode of Delivery and Neonatal Outcomes of Preterm Deliveries: A Retrospective Study in Greece.

Background and Objectives: Preterm birth is a significant concern in obstetrics and neonatology since preterm neonates are at higher risk of various health complications and may require specialized care. The optimal mode of delivery in preterm birth is a matter of debate. This study aimed to evaluate the mode of delivery in preterm neonates and the associated neonatal outcomes. Material and Methods: This was a retrospective cohort study including all preterm neonates born between January 2010 and December 2020 at the 3rd Department of Obstetrics & Gynecology of Aristotle University of Thessaloniki, Greece. The mode of delivery in relation to gestational age groups and the cause of preterm birth were analyzed. Neonatal outcomes were also evaluated according to gestational age, indication and mode of delivery. Results: A total of 1167 preterm neonates were included in the study; the majority of them were delivered via cesarean section (76.1%). Most of the preterm neonates (n = 715; 61.3%) were delivered at 32+0-36+6 weeks, while cesarean section was the most common mode of delivery after 28+0 weeks. Furthermore, spontaneous onset of labor (OR: 6.038; 95% CI: 3.163-11.527; p < 0.001), multiple gestation (OR: 1.782; 95% CI: 1.165-2.227; p = 0.008) and fetal distress (OR: 5.326; 95% CI: 2.796-10.144; p < 0.001) were the main causes of preterm delivery at 32+0-36+6 weeks. The overall mortality rate was 8.1% among premature neonates. Regarding morbidity, 919 (78.7%) neonates were diagnosed with respiratory disorders, 129 (11.1%) with intraventricular hemorrhage and 30 (2.6%) with necrotizing enterocolitis. Early gestational age at delivery was the main risk factor of neonatal morbidity and mortality. Notably, the mode of delivery did not have any impact on neonatal survival (OR: 1.317; 95% CI: 0.759-2.284; p = 0.328), but preterm neonates born via cesarean section were at higher risk of respiratory disorders, compared to those born via vaginal delivery (OR: 2.208; 95% CI: 1.574-3.097; p < 0.001). Conclusions: Most preterm deliveries occurred in the moderate-to-late preterm period via cesarean section. Early gestational age at delivery was the main prognostic factor of neonatal morbidity and mortality, while the mode of delivery did not have any impact on neonatal survival. Future research on the mode of delivery of the preterm neonates is warranted to establish definitive answers for each particular gestational age.

Impact of Marginal and Velamentous Cord Insertion on Uterine Artery Doppler Indices, Fetal Growth, and Preeclampsia.

OBJECTIVES: To assess the impact of marginal (MCI) or velamentous (VCI) cord insertion on uterine artery pulsatility index (UtA PI), preeclampsia (PE), and offspring's birthweight (BW). METHODS: A retrospective cohort study of singleton pregnancies, undergoing routine anomaly scan at 20+0 -23+6 gestational weeks, was conducted between 2016 and 2020. The effect of placental cord insertion on BW and UtA mean PI z-scores was assessed using the t test or analysis of variance and post-hoc tests; their association with PE was evaluated with the chi-square test. A multivariate logistic regression model was employed to assess the independent association of placental cord insertion and UtA PI z-score with PE, BW <10th, <5th centile, and intrauterine death (IUD), using specific confounders. RESULTS: The study population included 4453 pregnancies. Conception via assisted reproductive technology (ART) was associated with increased risk of abnormal cord insertion (odds ratio [OR]: 2.237; 95% confidence interval [CI]: 1.561-3.206; P < .001). Women with MCI/VCI had higher mean UtA PI z-score than those with central/eccentric (0.29 vs 0.01; mean difference: -0.28; 95% CI: -0.399 to -0.165; P < .001). MCI/VCI were associated with higher rates of BW <10th centile (central/eccentric: 16.2% vs MCI: 21.9% vs VCI: 35.7%; P < .001) and BW <5th centile (9.8 vs 15.1 vs 23.2%, respectively; P < .001). No association was identified between MCI/VCI and PE (P = .968). Finally, VCI (aOR: 13.717; 95% CI: 1.576-119.379; P = .018) and increased BMI (aOR: 1.167; 95% CI: 1.071-1.271; P < .001) significantly correlated with IUD. CONCLUSIONS: Abnormal cord insertion is more common in ART pregnancies. MCI/VCI are associated with higher mean UtA PI and lower BW centile, but not with increased risk of PE.

Maternal perception of fetal movements: onset and associated factors.

OBJECTIVES: The purpose of this study was to determine the onset of fetal movements' perception and to identify parameters that affect this timing. METHODS: This was a prospective cohort study including singleton pregnancies that attended routine prenatal care, in a tertiary care center, in northern Greece, between January 2020 and July 2021. We collected data on medical and obstetric history, and invited women to record the time that they perceived the fetal movements for the first time, that being the primary outcome of the study. Furthermore, we studied the associations between this timing and several obstetric and sociodemographic parameters. RESULTS: In total, 2,009 women participated in the study. The mean gestational age at first perception of fetal movements was 19 weeks (±1.5). This ranged from as early as 14+0-14+6 weeks (0.1%) to 24+0-24+6 weeks (0.1%). The majority of women (73.3%) reported initial perception of fetal movements between 18+0 and 20+6 weeks. Following multivariate logistic regression analysis, we found that nulliparity (OR: 2.607; 95% CI: 1.876-3.622; p<0.001), anterior placental position (OR: 1.918; 95% CI: 1.575-2.336; p<0.001), increasing body mass index (OR: 1.063; 95% CI: 1.040-1.088; p=0.001) and advancing maternal age (OR: 1.062; 95% CI: 1.040-1.084; p<0.001) were associated with a delayed perception of fetal movements. Multiparous women reported the onset of fetal movements almost one week earlier on average (18.6±1.4 weeks) compared to nulliparous (19.4±1.4 weeks; MD: 0.843; 95% CI: 0.718-0.968; p<0.001). CONCLUSIONS: The onset of maternal perception of fetal movements is around 19 weeks and this timing may be delayed by higher maternal age, higher body mass index, nulliparity and anterior placental position.

Investigation and management of stillbirth: a descriptive review of major guidelines.

Stillbirth is a common and devastating pregnancy complication. The aim of this study was to review and compare the recommendations of the most recently published guidelines on the investigation and management of this adverse outcome. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), the Perinatal Society of Australia and New Zealand (PSANZ), the Society of Obstetricians and Gynecologists of Canada (SOGC) on stillbirth was carried out. Regarding investigation, there is consensus that medical history and postmortem examination are crucial and that determining the etiology may improve care in a subsequent pregnancy. All guidelines recommend histopathological examination of the placenta, genetic analysis and microbiology of fetal and placental tissues, offering less invasive techniques when autopsy is declined and a Kleihauer test to detect large feto-maternal hemorrhage, whereas they discourage routine screening for inherited thrombophilias. RCOG and SOGC also recommend a complete blood count, coagulopathies' testing, anti-Ro and anti-La antibodies' measurement in cases of hydrops and parental karyotyping. Discrepancies exist among the reviewed guidelines on the definition of stillbirth and the usefulness of thyroid function tests and maternal viral screening. Moreover, only ACOG and RCOG discuss the management of stillbirth. They agree that, in the absence of coagulopathies, expectant management should be considered and encourage vaginal birth, but they suggest different labor induction protocols and different management in subsequent pregnancies. It is important to develop consistent international practice protocols, in order to allow effective determination of the underlying causes and optimal management of stillbirths, while identifying the gaps in the current literature may highlight the need for future research.

Adverse perinatal outcomes following the prenatal diagnosis of isolated single umbilical artery in singleton pregnancies: a systematic review and meta-analysis.

OBJECTIVES: A systematic review and meta-analysis was conducted to quantitatively synthesize the current evidence on the association of prenatally diagnosed isolated single umbilical artery (iSUA) in singleton pregnancies with small for gestational age (SGA) neonates and other perinatal outcomes. METHODS: A search of PubMed/Medline, Scopus and The Cochrane Library was conducted, from inception to February 2021, in order to identify studies comparing the risk of SGA and other perinatal adverse outcomes in prenatally diagnosed iSUA singleton pregnancies vs. those with a 3-vessel cord (3VC). The quality of eligible studies was assessed according to the improved Newcastle-Ottawa Scale (NOS). The heterogeneity of results across the studies was tested using the I2 test. Funnel plots and Egger's test were used to assess the possibility of publication bias. Prospero RN: CRD42020182586. RESULTS: The electronic search identified 7,605 studies, of which 11 were selected, including three retrospective cohort and eight retrospective case control studies, overall reporting on 1,533 iSUA cases. The risk of delivering SGA neonates was increased in cases with iSUA (OR: 2.90; 95% CI: 2.02-4.18; p<0.00001; I2=71%). Similarly, iSUA was associated with an increased risk of pregnancy-induced hypertension (PIH) (OR: 2.23; 95% CI: 1.41-3.54; p<0.000; I2=1%), intrauterine death (IUD) (OR: 2.62; 95% CI: 1.43-4.79; p=0.002; I2=0%), preterm birth (PTB) (OR: 2.48; 95% CI: 1.73-3.56; p<0.00001; I2=56%), cesarean section (CS) (OR: 1.64; 95% CI: 1.11-2.41; p=0.01; I2=78%) and admission to neonatal intensive care unit (NICU) (OR: 2.28; 95% CI: 1.52-3.44; p<0.000001; I2=73%). CONCLUSIONS: In prenatally diagnosed iSUA there is a higher risk of SGA, PIH, IUD, PTB, CS and NICU admission. These findings support the value of prenatal diagnosis of iSUA, which may subsequently intensify surveillance for the detection of specific pregnancy complications.

Investigation and management of abnormal uterine bleeding in reproductive-aged women: a descriptive review of national and international recommendations.

PURPOSE: To review and compare the most recently published recommendations on the investigation and management of abnormal uterine bleeding (AUB). MATERIALS AND METHODS: A descriptive review of recommendations from the American College of Obstetricians and Gynaecologists (ACOG), the National Institute for Health and Care Excellence (NICE), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the International Federation of Gynaecology and Obstetrics (FIGO) on AUB in reproductive-aged women was carried out. RESULTS: There is a consensus that detailed personal and family history along with physical examination are essential in the investigation of menstrual, intermenstrual or postcoital AUB. All the medical societies recommend transvaginal ultrasound as the first-line imaging modality to determine the AUB cause. Moreover, they agree (except for RANZCOG) that, in women with AUB, endometrial biopsy should only be performed if additional risk factors for endometrial cancer are present. Laboratory tests may be helpful in the AUB investigation; however, there are several discrepancies among the recommendations. Regarding AUB management, NICE, ACOG and SOGC agree that the administration of hormonal or non-hormonal medications should be the first-line treatment modality in bleeding disorders and absent or minor structural pelvic pathology. Surgical management should be preferred in cases of identified polyps, large fibroids or unsuccessful pharmacological treatment. CONCLUSIONS: Since AUB affects a significant proportion of reproductive-aged women, the main objective is to improve the quality of life of these patients without missing cases of malignancy.

Invasive Prenatal Diagnostic Testing for Aneuploidies in Singleton Pregnancies: A Comparative Review of Major Guidelines.

Sophisticated screening protocols for genetic abnormalities constitute an important component of current prenatal care, aiming to identify high-risk pregnancies and offer appropriate counseling to parents regarding their options. Definite prenatal diagnosis is only possible by invasive prenatal diagnostic testing (IPDT), mainly including amniocentesis and chorionic villous sampling (CVS). The aim of this comparative review was to summarize and compare the existing recommendations on IPDT from the most influential guidelines. All the reviewed guidelines highlight that IPDT is indicated based on a positive screening test rather than maternal age alone. Other indications arise from medical history and sonography, with significant variations identified between the guidelines. The earlier time for amniocentesis is unequivocally set at ≥15 gestational weeks, whereas for CVS, the earlier limit varies from ≥10 to ≥11 weeks. Certain technical aspects and the overall approach demonstrate significant differences. Periprocedural management regarding Rhesus alloimmunization, virologic status and use of anesthesia or antibiotics are either inconsistent or insufficiently addressed. The synthesis of an evidence-based algorithm for IPDT is of crucial importance to healthcare professionals implicated in prenatal care to avoid unnecessary interventions without compromising optimal prenatal care.

Antenatal depression and anxiety during the COVID-19 pandemic: a cross-sectional study in pregnant women from routine health care contact in Greece.

OBJECTIVES: The impact of the COVID-19 pandemic and the public health measures introduced to control it, on mental health, is largely unknown. Research conducted during past epidemics found that pregnant women are more vulnerable psychologically. The aim of this study was to investigate antenatal depressive and anxiety symptoms during this pandemic in Greece. METHODS: All women receiving routine antenatal care, during a three-month period, starting one week after the total lockdown in Greece, in a University department, were asked to fill in two questionnaires, the Edinburg Postnatal Depression Scale (EPDS) and the State-Trait Anxiety Inventory (STAI). RESULTS: Overall, 505 women (93.3% of the eligible population) agreed to participate. The prevalence of antenatal depression (EPDS score≥13) in the population of the study was 13.5%. Unplanned pregnancy (OR: 2.447; 95% CI: 1.235-4.846), smoking (OR: 2.268; 95% CI: 1.166-4.411) and antenatal anxiety (OR: 5.074; 95% CI: 2.898-8.883) increased the risk of antenatal depression during the COVID-19 pandemic. State (current)-anxiety affected 34.1% of the participants, whereas Trait (lifetime)-anxiety affected 15.8%. The State-anxiety score (median) was significantly higher than the Trait-anxiety (median) (41 vs. 36; p<0.001), revealing an increase in the levels of anxiety in the pandemic, while there was also a positive linear correlation between the two scales (rho=0.592; p<0.001). CONCLUSIONS: The unprecedented situation of the COVID-19 pandemic has increased anxiety, but not depression levels of pregnant women in Greece. Population level interventions to address adverse effects on anxiety status in the initial phases of similar situations may be helpful in the future.

Chronic hypertension in pregnancy: synthesis of influential guidelines.

Chronic hypertension in pregnancy accounts for a substantial proportion of maternal morbidity and mortality and is associated with adverse perinatal outcomes, most of which can be mitigated by appropriate surveillance and management protocols. The aim of this study was to review and compare recommendations of published guidelines on this condition. Thus, a descriptive review of influential guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada and the American College of Obstetricians and Gynecologists on chronic hypertension in pregnancy was conducted. All guidelines agree on the definition and medical management, the need for more frequent antenatal care and fetal surveillance and the re-evaluation at 6-8 weeks postpartum. There is also a consensus that the administration of low-dose aspirin is required to prevent preeclampsia, although the optimal dosage remains controversial. No universal agreement has been spotted regarding optimal treatment blood pressure (BP) targets, need for treating mild-to-moderate hypertension and postnatal BP measurements. Additionally, while the necessity of antenatal corticosteroids and magnesium sulfate for preterm delivery is universally recommended, the appropriate timing of delivery is not clearly outlined. Hence, there is a need to adopt consistent practice protocols to optimally manage these pregnancies; i.e. timely detect and treat any potential complications and subsequently reduce the associated morbidity and mortality.

Comparison of the efficacy and safety of two combined misoprostol regimens for second trimester medical abortion.

OBJECTIVE: The aim of the study was to compare the efficacy and safety of two combined misoprostol regimens for second trimester medical abortion. METHODS: This was a retrospective cohort study examining data on singleton pregnancies that underwent second trimester medical abortion between November 2011 and November 2019 in a tertiary care centre in northern Greece. In the first study period (November 2011 to August 2015), the management protocol (protocol 1) consisted of 800 µg vaginal misoprostol followed by 400 µg oral misoprostol, every 3 h, for up to five doses. In the second study period (September 2015 to November 2019), a new protocol (protocol 2) was introduced, where the oral route was changed to sublingual, using the same dosage. The two routes were compared in terms of efficacy and safety. RESULTS: The study comprised 85 women: 43 (50.6%) received the protocol 1 regimen (vaginal-oral), while 42 (49.4%) received the protocol 2 regimen (vaginal-sublingual). The groups did not differ in terms of maternal age, gestational age and parity. Sublingual misoprostol was more effective than oral misoprostol, both in terms of dose needed (median 1600 µg vs 2000 µg; p = 0.031) and induction-to-abortion interval (8 h vs 11 h; p = 0.001). Surgical evacuation due to incomplete abortion was necessary in 11.9% of women in the sublingual group vs 18.6% in the oral group (p = 0.394). Women in the sublingual group reported a higher rate of severe pain (odds ratio [OR] 6.061; 95% confidence interval [95% CI] 1.240, 29.619) and shivering (OR 4.632; 95% CI 1.788, 11.995). CONCLUSION: The administration of vaginal-sublingual misoprostol, when compared with the vaginal-oral regimen, was associated with a shorter induction-to-abortion interval but a higher incidence of severe pain and shivering.

Operative vaginal delivery: a review of four national guidelines.

There is a broad range in the rates of operative vaginal deliveries (OVD) worldwide, which reflects the variety of local practice patterns, the number of trained clinicians and the lack of international evidence-based guidelines. The aim of this study was to review and compare the recommendations from published guidelines on OVD. Thus, a descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the American College of Obstetricians and Gynecologists (ACOG) on instrumental vaginal birth was conducted. All the guidelines point out that the use of any instrument should be based on the clinical circumstances and the experience of the operator. The indications, the contraindications, the prerequisites and the classification for OVD are overall very similar in the reviewed guidelines. Further, they all agree that episiotomy should not be performed routinely. The RCOG, the RANZCOG and the SOGC describe some interventions which may promote spontaneous vaginal birth and therefore reduce the need for OVD. They also highlight the importance of adequate postnatal care and counseling. There is no consensus on the actual technique that should be used, including the type of forceps or vacuum cup, the force and duration of traction or the number of detachments allowed. Hence, there is need for international practice protocols, so as to encourage the clinicians to use OVD when indicated, minimize the complications and reduce rates of cesarean delivery.

Modifiable risk factors for spontaneous preterm birth in nulliparous women: a prospective study.

Background Spontaneous preterm birth (sPTB) has a detrimental impact on perinatal outcome, as well as on the resources of health systems in high-income countries. Thus, the objective of the current study was to determine the incidence of modifiable risk factors in pregnancy and their impact on the rate of sPTB. Methods All nulliparous pregnant women, in singleton pregnancies, with free medical and obstetric history, were eligible to participate in this study. The primary outcome of interest was the incidence of specific modifiable risk factors for sPTB. The correlations between these risk factors and sPTB were also investigated. Results Overall, 2027 women were eligible for the study and agreed to participate. The incidence of sPTB was 4.9%; 25.5% (n = 518) of the participants were in extreme maternal age (<20 or >35 years), 34.5% (n = 701) had an abnormal body mass index (BMI) (<18.5 or ≥25 kg/m2), 4.4% (n = 89) reported use of assisted reproductive technology (ART) and 10.9% (n = 220) reported themselves as smokers in pregnancy. In the multivariate analysis, sPTB was significantly correlated with ART conception [odds ratio (OR): 2.494, 95% confidence interval (CI): 1.196-5.199]. Conclusion Approximately one in 20 primiparous pregnant women in the study had a sPTB. The study population included a high percentage of women of advanced maternal age, with abnormal BMI and smokers, but these characteristics did not affect the incidence of sPTB. On the other hand, conception following ART increased two-fold the risk of sPTB.

Management of Breech Presentation: A Comparison of Four National Evidence-Based Guidelines.

OBJECTIVE: The management of breech presentation may improve perinatal outcomes. The aim of this study was to synthesize and compare published evidence of four national guidelines on breech presentation. STUDY DESIGN: A descriptive review of four recently published national guidelines on breech presentation and external cephalic version (ECV) was conducted: Royal College of Obstetricians and Gynaecologists guideline on "External Cephalic Version and Reducing the Incidence of Term Breech Presentation" and "Management of Breech Presentation", American College of Obstetricians and Gynecologists guideline on "External Cephalic Version" and "Mode of Term Singleton Breech Delivery," Society of Obstetricians and Gynaecologists of Canada guideline on "Vaginal Delivery of Breech Presentation" and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists guideline on "Management of breech presentation at term." RESULTS: Regarding ECV, there is no recommendation by the SOGC, whereas all other national guidelines recommend this technique. Regarding breech vaginal delivery, there are limited recommendations by the ACOG, whereas all other guidelines provide similar recommendations. The RANZCOG makes no special recommendations on the intrapartum period. CONCLUSION: The differences among national guidelines point out the need for the adoption of an international consensus on the management of breech presentation.