Comparison of databases useful for the analysis of vaginal microbiota in Japanese women using next-generation sequencing data (QIIME 2 software).

AIMS: Approximately 10% of children are born prematurely, and bacterial vaginosis during pregnancy is associated with preterm delivery. Highly accurate species-level vaginal microflora analysis helps control bacteria-induced preterm birth. Therefore, we aimed to conduct a bioinformatic analysis of gene sequences using 16S databases and compare their efficacy in comprehensively identifying potentially pathogenic vaginal microbiota in Japanese women. METHODS AND RESULTS: The 16 s rRNA databases, Silva, Greengenes, and the basic local alignment search tool (BLAST) were compared to determine whether the classification quality could be improved using the V3-V4 region next-generation sequencing (NGS) sequences. It was found that NGS data were aligned using the BLAST database with the QIIME 2 platform, whose classification quality was higher than that of Silva, and the combined Silva and Greengenes databases based on the mutual complementarity of the two databases. CONCLUSIONS: The reference database selected during the bioinformatic processing influenced the recognized sequence percentage, taxonomic rankings, and accuracy. This study showed that the BLAST database was the best choice for NGS data analysis of Japanese women's vaginal microbiota.

The management of women of childbearing age with rheumatoid arthritis: an expert report.

INTRODUCTION: The introduction of biologic therapies and a treat-to-target approach has transformed the management of rheumatoid arthritis (RA), which has led to improved outcomes for women with RA who wish to become pregnant. However, guidelines for the management of reproductive health in female patients with RA are still lacking. AREAS COVERED: A task force (Women of Childbearing Age [WoCBA]-Rheumatoid Arthritis in Japan) comprising 10 experts in the fields of rheumatology, obstetrics and orthopedic surgery developed 10 clinical questions (CQ) related to the management of WoCBA with RA. For each CQ, a systematic literature review was conducted to identify relevant evidence. Based on this evidence, a set of recommendations for each CQ were drafted and evaluated using the modified Delphi method. This article describes the agreed recommendations along with the supporting evidence. EXPERT OPINION: There are many ongoing challenges associated with the provision of reproductive healthcare in WoCBA with RA. It is hoped that the consensus-based recommendations provided here can be implemented in clinical practice in order to increase collaboration between rheumatologists and obstetricians/gynecologists and to improve reproductive health outcomes for WoCBA with RA.

Efficacy of discontinuing the use of low-dose aspirin at 28 weeks of gestation for preventing preeclampsia.

AIM: Low-dose aspirin (LDA) has been shown to reduce the incidence of preeclampsia (PE). Previous studies have focused on the timing of LDA initiation, but no study to date has assessed the timing of LDA discontinuation. This study aimed to evaluate the effect of LDA when LDA is initiated between 12 and 16 weeks of gestation and continued until 28 weeks of gestation. METHODS: This prospective cohort study with historical controls investigated singleton pregnancies that were at a high risk for PE. High-risk factors were defined as a history of hypertensive disorders of pregnancy, chronic hypertension, diabetes mellitus, autoimmune disease, obesity, and high normal blood pressure in the first trimester. We performed adjustments using propensity score matching (PSM) for each indication of LDA, maternal age, primiparity, and assisted reproductive technology. The primary outcome was the incidence of PE. Secondary outcomes were the incidence of preterm PE, fetal growth restriction (FGR), preterm birth, fetal malformation, and maternal postpartum hemorrhage (PPH). RESULTS: A total of 203 and 543 participants were assigned to the LDA and control group, respectively. After PSM, there was no significant difference in the incidence of PE (22.0% vs. 16.8%; p = 0.20), preterm PE (12.0% vs. 13.1%; p = 0.76), FGR (7.9% vs. 12.0%; p = 0.17), or preterm birth (17.3% vs. 15.7%; p = 0.68). There was also no significant increase in maternal PPH or in the incidence of fetal malformations. CONCLUSION: Discontinuing the use of LDA at 28 weeks of gestation did not result in a lower incidence of PE and FGR.

Fiducial marker position affects target volume in stereotactic lung irradiation.

PURPOSE: Real-time tracking systems of moving respiratory targets such as CyberKnife, Radixact, or Vero4DRT are an advanced robotic radiotherapy device used to deliver stereotactic body radiotherapy (SBRT). The internal target volume (ITV) of lung tumors is assessed through a fiducial marker fusion using four-dimensional computed tomography (CT). It is important to minimize the ITV to protect normal lung tissue from exposure to radiation and the associated side effects post SBRT. However, the ITV may alter if there is a change in the position of the fiducial marker with respect to the tumor. This study investigated the relationship between fiducial marker position and the ITV in order to prevent radiation exposure of normal lung tissue, and correct target coverage. MATERIALS AND METHODS: This study retrospectively reviewed 230 lung cancer patients who received a fiducial marker for SBRT between April 2015 and September 2021. The distance of the fiducial marker to the gross tumor volume (GTV) in the expiratory (dex ) and inspiratory (din ) CT, and the ratio of the ITV/V(GTVex ), were investigated. RESULTS: Upon comparing each lobe, although there was no significant difference in the ddiff and the ITV/V(GTVex ) between all lobes for dex  < 10 mm, there was significant difference in the ddiff and the ITV/V(GTVex ) between the lower and upper lobes for dex ≥ 10 mm (p < 0.05). Moreover, there was significant difference in the ddiff and the ITV/V(GTVex ) between dex ≥10 mm and dex  < 10 mm in all lung regions (p < 0.05). CONCLUSION: The ITV that had no margin from GTVs increased when dex was ≥10 mm for all lung regions (p < 0.05). Furthermore, the increase in ITV tended to be greater in the lower lung lobe. These findings can help decrease the possibility of adverse events post SBRT, and correct target coverage.

Six-month survival of a monochorionic monoamniotic twin with sirenomelia.

BACKGROUND: Sirenomelia is a congenital malformation of the lower body characterized by a single midline lower limb and severe urogenital and gastrointestinal malformations. Sirenomelia is rare (estimated incidence of approximately 1/100,000) and usually lethal in the perinatal period. CASE: A 2,042 g Japanese male infant, one of monochorionic monoamniotic twins, was born at 34 weeks of gestation by elective caesarean section. Sirenomelia was prenatally diagnosed. Single midline lower limb, bilateral dysplastic kidneys, an omphalomesenteric fistula, colon atresia, imperforate anus, indiscernible genital structures, and myelomeningocele were detected at birth. The amniotic fluid volume was normal throughout the pregnancy course, which led to appropriate lung maturation of the twin with sirenomelia. Although renal replacement therapy was initiated soon after birth, stable peritoneal dialysis was difficult because of the limited intraperitoneal space, and the infant frequently developed peritonitis. He died of sudden cardiorespiratory arrest at 6 months of age. Postmortem examination showed bilateral dysplastic kidneys, agenesis of the ureters and urinary bladder, abnormal branching and agenesis of the distal colon, bilateral inguinal hernias, and small testes. CONCLUSION: Infants with sirenomelia, even those with end-stage kidney disease at birth, may survive if they have a stable cardiorespiratory status at birth and renal replacement therapy is appropriately initiated.

Incidence of chest X-ray abnormalities early in the third trimester of twin pregnancy and its relationship with the subsequent development of preeclampsia.

AIM: To clarify the incidence of abnormal findings on chest X-ray (CXR) early in the third trimester of twin pregnancy and its relationship with the development of preeclampsia and preeclampsia-related diseases. METHODS: This was a retrospective cohort study conducted among women with twin pregnancies who underwent chest radiography for preoperative screening early in the third trimester and delivered at our center at >34 weeks' gestation from 2013 to 2017. The primary outcome was the incidence of positive CXR findings, defined either as cardiomegaly or blunting of the costophrenic angle. The secondary outcome was the incidence of maternal complications, including preeclampsia; hemolytic, elevated liver enzymes, and low platelet syndrome; eclampsia; cerebrovascular disease; and placental abruption. We evaluated the significance of positive CXR findings, in addition to confounding factors, in the subsequent development of preeclampsia. RESULTS: During the study period, 358 twin pregnancies were identified, and 330 were finally enrolled. The incidence of positive CXR findings was 18.2%. The incidence of preeclampsia in the CXR-positive group was 36.7% (22/60), which was significantly higher than that in the CXR-negative group (7.0% [19/270]) (p < 0.01). Moreover, positive CXR findings were independently associated with subsequent preeclampsia (adjusted odds ratio: 9.15, 95% confidence interval: 4.13-20.3). CONCLUSION: In twin pregnancies, the incidence of CXR abnormalities early in the third trimester was 18.2%, even without the development of hypertension. This should be considered a significant risk factor for subsequent preeclampsia.

Developing an obstetric care screening tool to improve social support access for pregnant women: A prospective cohort study.

Background: This study aimed to develop an efficient interview sheet during pregnancy and screening tool to identify pregnant women needing social support at obstetric institutions. Moreover, we investigate the perinatal factors associated with the Edinburgh postnatal depression scale (EPDS). Methods: This prospective cohort study was conducted at three medical institutions that commonly encounter cases with social issues. Pregnant women were assessed using an interview sheet at the first visit (n = 678), at approximately 28 weeks gestation (n = 495), 36 weeks gestation (n = 296), and the postpartum period (n = 822). We investigated the important items identified on the new screening questionnaire (NEW interview sheets) for women needing social support. The items on the interview sheet were scored by multiple linear regression analysis, and the cutoff values were calculated using the receiver operating characteristic curve. The association between perinatal factors and EPDS was assessed using multiple logistic regression analyses. Results: The study included 166 cases for which all NEW interview sheets for all periods were available. NEW interview sheets and stepwise screening tools during the first and second trimester were developed in which 2.5% of pregnant women were identified as requiring social support, respectively. The factors associated with EPDS ≧ 9 were "Women who felt confused/troubled or did not feel anything to be pregnant" (adjusted odds ratio [aOR]: 6.51, 95% confidence interval [CI]: 1.62-26.15), "Maternal mental disorder" (aOR 4.38; CI 1.06-18.10), "Consultation request at first visit" (aOR 3.22; CI 1.09-9.45), and "Women who have difficulty or anxiety about pregnancy during the second trimester" (aOR 3.14; CI 1.29-7.67). Conclusions: We created the NEW interview sheets and screening tools during the first and the second trimester. Future studies are needed to validate these screening tools.

Re-evaluation of the predictive value of Quintero staging of twin-twin transfusion syndrome for fetal death after fetoscopic laser photocoagulation.

OBJECTIVE: To elucidate the significance of sonographic indices, including Doppler waveforms, that constitute the Quintero classification for predicting death of the recipient or donor after fetoscopic laser photocoagulation (FLP) for twin-twin transfusion syndrome (TTTS). METHODS: Prospectively collected data of twins who underwent FLP for TTTS were reviewed. Among the abnormal indices of ultrasound performed just before FLP, factors that were significantly associated with fetal and neonatal deaths in the log-rank test, including fetal demise of co-twins and preterm birth before 28 weeks of gestation, were introduced into the Cox proportional-hazards model to calculate risk ratio (RR). RESULTS: We included 235 cases with a prevalence of recipient and donor deaths of 7% and 14%, respectively. In the proportional-hazards model, absent or reversed umbilical artery end-diastolic velocity (UA AREDV) of recipients (n = 7) was independently associated with recipient death (RR = 6.97). In recipients without UA AREDV, reversed ductus venosus (DV) a-wave of recipients (RR = 3.55) was independently associated with recipient death. In donors, UA AREDV with a visible bladder (stage III atypical donor) was independently associated with donor death (RR = 4.24). CONCLUSION: Some individual components of the Quintero stage are associated with death of either recipient or donor twins following FLP.

Prevalence of umbilical artery Doppler waveform abnormality during the early second trimester and the subsequent variation of waveforms in monochorionic diamniotic twin pregnancies: A prospective cohort study.

AIM: To investigate the prevalence of qualitative abnormal umbilical artery Doppler waveforms (Abnormal UA) during the early second trimester and the subsequent variation of waveforms in monochorionic diamniotic (MCDA) twin pregnancies. METHODS: This prospective cohort study included 153 MCDA twin pregnancies. Pulsed Doppler examinations for UA were performed at four points, including the free-loop (FL) and near the placental cord insertion site (CI) of each UA, between 16 and 17 weeks' gestation. Cases were classified into positive diastolic waveforms (Type I), persistent Abnormal UA (Type II), and intermittent Abnormal UA (Type III). When the diastolic velocity in UA Doppler was positive twice after different sequential recordings, the cases were determined to have achieved normalization. Follow-up Doppler examinations of the UA were performed at 24, 28, and 32 weeks' gestation. RESULTS: Of all 153 cases, 38 (25%; 19 Type II and 19 Type III cases) showed Abnormal UA at the first examination. Abnormal UA was detectable at FL in all selective intrauterine growth restriction (sIUGR) cases, whereas it was noted only at CI site in some non-sIUGR cases. Abnormal UA normalized in 12 (63%) Type II and 15 (79%) Type III cases. CONCLUSIONS: A quarter of MCDA twin pregnancies in the early second trimester demonstrated Abnormal UA. In MCDA twins with Abnormal UA between 16 and 17 weeks' gestation, it is preferable to follow them up to consider the possibility of normalization of Abnormal UA as well as features of UA waveforms specific to FL and CI.

Pregnancy Outcomes in 2 Women Born with Complex Anorectal Malformations: Challenges and Considerations.

BACKGROUND: Complex anorectal malformations (ARMs) are a group of rare congenital malformations involving numerous anomalies that require reconstruction and can affect sexuality, fertility, and pregnancy outcomes. Few cases of pregnancy in complex ARM patients have been reported. CASES: We report on 2 patients with ARMs who delivered 3 term infants, all by cesarean section with successful collaboration between pediatric urologists and obstetricians. Both patients fully recovered with no long-term consequences after experiencing maternal morbidities including urinary infections, clitoral abscesses, vaginal lacerations, extensive adhesive disease, bladder injury, and maternal hemorrhage. SUMMARY AND CONCLUSION: In managing pregnancies and deliveries in women with complex ARMs, coordination between obstetricians, pediatric urologists, and pediatric surgeons is crucial.

Prevalence of Extraplacental Anastomoses in Monochorionic Twin Pregnancies.

OBJECTIVES: To evaluate the prevalence of extraplacental anastomoses (EPA) and the factors associated. METHODS: A retrospective study including 144 placentas from monochorionic diamniotic (MCDA) twins delivering at one institution was performed. EPA were defined as any intertwin anastomosis located outside the chorionic plate on macroscopic inspection. The association with perinatal factors and with umbilical cord insertion site was analyzed. RESULTS: The prevalence of EPA was 4.9% (7/144). Velamentous cord insertion of both twins was significantly associated with the presence of EPA in the multivariate logistic regression model (p = 0.045). DISCUSSION: EPA was found in ≈5% of MCDA twin pregnancies.

Placental histopathological features of fetoscopic laser photocoagulation for monoaminotic diamniotic twin pregnancies.

INTRODUCTION: This study aimed to compare the histopathological placental features of monochorionic diamniotic (MCDA) twins who did and did not undergo fetoscopic laser photocoagulation (FLP). METHODS: This was a retrospective single-institution cohort study on MCDA twins who underwent FLP between October 2010 and December 2018. The control group included MCDA twins who did not undergo FLP and were delivered during the same period in the institute. The incidence of chorioamnionitis (CAM), funisitis, and other pathological findings was compared between the FLP and control groups after matching by gestational age at delivery. RESULTS: In total, 292 MCDA pregnant women who underwent FLP and 356 controls gave birth during the study period. After matching the two groups in the ratio 1:1 by gestational age at delivery, each group comprised 194 subjects. The incidence of histological CAM with Blanc association (stage I, 6.2% vs. 3.1%, crude odds ratio (cOR) = 3.1, P = 0.052; stage II, 7.2% vs. 5.7%, cOR = 1.6, P = 0.30; stage III, 2.1% vs. 2.6%, cOR = 0.66, P = 0.52) and funisitis (artery, 5.2% vs. 3.6%, cOR = 1.3, P = 0.63; vein 7.2% vs. 4.1%, cOR = 1.6, P = 0.29) was not statistically significant difference between the FLP and control groups. The FLP group demonstrated a higher incidence of partial placental infarction than the control group (10.3% vs. 3.1%, cOR = 4.3, P = 0.004, adjusted OR = 2.8, P = 0.031). DISCUSSION: FLP did not appear to increase the incidence of histological CAM or funisitis in subjects matched by gestational age at delivery. The FLP group demonstrated a higher incidence of partial placental infarction than the control group.

Perinatal outcomes of intrauterine transfusion for the surviving twin in monochorionic twin gestation involving a single fetal demise.

AIM: This study aimed to evaluate the feasibility and outcome of intrauterine transfusion (IUT) for the surviving co-twin in monochorionic diamniotic (MCDA) twin gestations involving single intrauterine fetal death (sIUFD). METHODS: Cases of MCDA twin gestations involving emergent IUT for co-twins experiencing acute feto-fetal hemorrhage (AFFH) subsequent to sIUFD during the second trimester were reviewed. Fetal anemia was confirmed via fetal blood sampling, and perinatal data were retrieved from medical charts to determine the outcomes of surviving co-twins. A poor outcome at 28 days of age was defined as fetal death, neonatal death or neurological impairment such as severe intraventricular hemorrhage or cystic periventricular leukomalacia (PVL). RESULTS: This study included 16 cases of sIUFD diagnosed at a median of 22.5 weeks of gestation (range: 18-25 weeks). The median interval in hours between diagnosis of fetal demise and IUT was approximately 4.2 (0-22) hours. All cases achieved IUT without significant intraoperative complications. Four cases experienced a fetal loss of the co-twin, whereas 12 co-twins were born alive (including 9 preterm births), with only 1 poor outcome in a preterm infant with PVL. CONCLUSION: IUT may be a feasible prenatal intervention for surviving co-twins with AFFH. However, more extensive or pooled studies are needed to determine the efficacy of this intervention.

Perinatal Determinants of Child Maltreatment in Japan.

Background: Child maltreatment induces significant health problems, both during childhood and into adulthood. To prevent child maltreatment, it is important to detect perinatal risk factors for earlier intervention. The aim of this study was to evaluate the perinatal risk factors associated with child maltreatment during pregnancy. Methods: A case-control study was conducted to compare perinatal data from the Maternal and Child Health Handbook between the case and control groups. Cases were collected from children registered in two Child Guidance Centers in Japan. The control group consisted of 3.5-year-old children in a city in Osaka Prefecture whose mothers responded to questionnaires containing information from the Maternal and Child Health Handbook. The association between perinatal factors and child maltreatment was assessed using multiple logistic regression analysis. Results: The data of 70 cases and 345 controls were collected. The following were found to be perinatal factors related to child maltreatment: teenage pregnancy (OR: 257.3, 95% CI: 17.3-3832.7), a mother aged 20-24 years (OR: 22.8, 95% CI: 4.4-117.8), a father who is older than the mother by 10 years or more (OR: 14.1, 95% CI: 2.1-94.8), an unmarried mother (OR: 15.7, 95% CI: 2.6-93.6), maternal mental disorder (OR: 48.9, 95% CI: 9.3-258.3), the first maternal prenatal visit being later than 20 weeks (OR: 132, 95% CI: 12.7-1384.7), little prenatal care (<10 visits) (OR: 21.4, 95% CI: 2.9-157.1), a low-birth-weight baby (OR: 5.1, 95% CI: 1.1-24.1), and congenital disease (OR: 7.9, 95% CI: 1.1-56.4). Conclusions: This study revealed that young mothers, fathers much older than mothers, unmarried mothers, and maternal mental disorder, mothers with late first visit or little perinatal care, and low-birth-weight babies and babies with congenital disease were associated with child maltreatment. These findings can be used to detect high-risk families for child maltreatment during or after pregnancy.

Pre-conception status, obstetric outcome and use of medications during pregnancy of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) in Japan: Multi-center retrospective descriptive study.

Objective: To describe the pre-conception status, pregnancy outcomes, and medication prevalence in systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), Crohn's disease (CD), and ulcerative colitis (UC).Methods: E-mail-based questionnaire survey for the Japan Maternal Fetal Intensive Care Unit Network hospitals inquiring prevalence and clinical features of SLE, RA, CD and UC complicated pregnancies for 2 years.Results: The number of SLE, RA, CD and UC among 69,810 deliveries was 184, 139, 27 and 178, respectively. Less than half of pregnancies were planned. Assisted reproductive technology (ART) pregnancy rates were higher in SLE, RA and UC than in the general population (11.4, 23.0 and 7.4 vs 5.1%, p < .001 each). Preterm delivery, preeclampsia, and fetal growth restriction (FGR) were more frequent in SLE than in the general population (39.4 vs. 5.6% p < .001, 15.0 vs. 6.0% p < .001, 12.9 vs 4.2% p < .001). Prevalence of preterm delivery in RA and UC (27.5 vs. 5.6% p < .001, 11.3 vs. 5.6% p < .05) and FGR in CD (28.6 vs. 4.2% p < .001) was also higher than that in the general population.Conclusion: SLE, RA, CD, and UC complicated pregnancies were at high risks of obstetric adverse outcome. High ART rates necessitate pre-conception counseling in SLE, RA, and UC pregnancies.

The incidence of unexpected critical complications in monochorionic diamniotic twin pregnancies according to the interval period between ultrasonographic evaluations.

AIM: This study aimed to evaluate the incidence of unexpected critical complications (UCC) in monochorionic diamniotic (MCDA) twin pregnancies according to ultrasonographic scan interval. METHODS: This retrospective single-center cohort study, conducted between January 2005 and April 2015, investigated the incidence of UCC in patients with MCDA twin pregnancies undergoing weekly ultrasound (Group A) and those undergoing biweekly ultrasound (Group B). We also examined the incidence of predictable critical complications according to ultrasound interval. RESULTS: Of all 385 cases, the total incidence of UCC was 20 (5.2%), including 14 cases of twin-twin transfusion syndrome and 6 cases of intrauterine fetal death. The incidence of UCC was 3.9% in Group A and 9.0% in Group B (P = 0.046). In contrast, the incidence of predictable critical complications was 6.7% in Group A and 9.0% in Group B (P = 0.440). CONCLUSION: The incidence of UCC in patients with MCDA twin pregnancies was significantly lower in patients undergoing weekly ultrasound. Our results suggest that weekly ultrasound evaluation for patients with MCDA pregnancy is more effective for early detection of UCC such as intrauterine fetal death and twin-twin transfusion syndrome ; however, further investigations are needed to determine whether weekly ultrasound evaluation can improve clinical outcomes.

Incidence of and risk factors for severe maternal complications associated with hypertensive disorders after 36 weeks' gestation in uncomplicated twin pregnancies: A prospective cohort study.

AIM: To elucidate the incidence of and risk factors for severe hypertensive disorders (HD) and related maternal complications in uncomplicated twin pregnancies that reached 36 weeks' gestation. METHODS: We conducted a prospective cohort study of twin pregnancies delivered after 36 weeks' gestation. Cases of twin-twin transfusion syndrome, twin anemia-polycythemia sequence, malformed fetuses, monoamniotic twins, selective reduction, fetal therapy and HD or fetal death before 35 weeks' gestation were excluded. The study's primary outcome was the incidence of severe maternal complications, including severe HD, eclampsia, placental abruption, HELLP (hemolysis, elevated liver enzyme and low platelet) syndrome, pulmonary edema and cerebrovascular disease. Perinatal factors associated with the primary outcome were identified using a multivariate logistic regression model. RESULTS: In 330 enrolled women, the number of cases with the primary outcome was 28 (8.5%; 95% confidence interval 5.9-12.0), including 25 cases of severe HD and each one case of placental abruption, HELLP syndrome and eclampsia. The rate of severe maternal complications significantly increased with gestational age, demonstrating 1.2% at 36 weeks, 3.9% at 37 weeks and 6.4% at 38 weeks. Only gestational proteinuria was identified as the independent risk factor for severe maternal complications (adjusted odds ratio 17.1 [95% confidence interval 6.71-45.4]). CONCLUSION: Severe maternal HD and related complications increased from late preterm to early term; particularly, patients with gestational proteinuria were at high risk.

Ovarian insufficiency following allogeneic hematopoietic stem cell transplantation.

Ovarian insufficiency is a serious complication for young women who undergo hematopoietic stem cell transplantation (HSCT). Reduced-intensity conditioning (RIC) has been utilized more widely due to its reduced toxicity; however, there is a lack of data concerning ovarian function after HSCT with RIC. We investigated the ovarian function in patients who received HSCT with RIC, compared to those who received myeloablative conditioning (MAC). The records of 69 female patients who received allogeneic HSCT at the institution under 40 years of age at transplantation from 1991 to 2012 were retrospectively analyzed. Prevalence of ovarian insufficiency was significantly lower in patients conditioned with RIC than in those conditioned with MAC (4/27 = 14.8% for RIC and 36/42 = 85.7% for MAC, p < 0.0001). A younger age at HSCT was associated with a lower risk of ovarian insufficiency. Among the 40 patients with ovarian insufficiency, four patients recovered ovarian function, and two conceived following hormone-replacement therapy (HRT). A higher serum E2 level prior to HRT was a significant predictor for the restoration of ovarian function (p = 0.0028). In conclusion, RIC was significantly less toxic to ovarian function compared with MAC. HSCT-associated ovarian insufficiency is not irreversible, and a higher E2 level may predict the restoration of ovarian function.

Perinatal complications of monochorionic diamniotic twin gestations with discordant crown-rump length determined at mid-first trimester.

AIM: The aim of this study was to investigate the value of discordance of crown-rump length (DCRL) at mid-first trimester to predict adverse outcomes in monochorionic diamniotic twin gestations (MD). MATERIAL AND METHODS: This was a retrospective cohort study of the perinatal outcome in MD pregnancies managed from the first trimester onward. DCRL was evaluated between 8 and 10 weeks of gestation. The association between DCRL and perinatal complications, including fetal death, twin-twin transfusion syndrome, severe discordant birthweight (DB), and twin anemia-polycythemia sequence, was assessed. RESULTS: Among 126 cases, a single fetal demise occurred in two (2%) and demise of both fetuses occurred in eight (6%). Five pregnancies (4%) were complicated with twin-twin transfusion syndrome; one case (1%) was twin anemia-polycythemia sequence and 13 (10%) were DB. Neonatal death occurred in one pair. At 28 days of age, in 115 cases (91%) both twins were alive. In 117 cases (93%), at least one twin survived until 28 days of age. DCRL >12.0% was not related to any perinatal complications but DB (P < 0.01; relative risk: 1.40; 95% confidence interval: 1.06-1.84). CONCLUSIONS: DCRL in MD during the mid-first trimester might be useful for predicting DB.