Parental refusal of prenatal screening for aneuploidies.

OBJECTIVES: To analyze the reasons for refusal of aneuploidy screening in a multicultural Middle Eastern population. METHODS: The study included patients delivering in a university hospital, who had refused aneuploidy screening during their pregnancy. We evaluated through a questionnaire submitted during the postpartum period the sociodemographic characteristics, beliefs, attitudes, and the main reason underpinning their choice. Religious, ethical, and financial factors, personal beliefs, medical information, perceived media information, and familial input were assessed through a Likert scale. RESULTS: Our pilot study included 70 patients. The main reason (33 %) was the refusal to terminate pregnancy if the screening tests ultimately led to a diagnosis of aneuploidy. Lack of adequate information on the availability and benefits of this screening method (28 %), religious beliefs (17 %), in addition to other minor reasons such as financial considerations, familial recommendations, late pregnancy follow-ups, and media influence were also identified as contributing factors. CONCLUSIONS: Aneuploidy screening is routinely offered to couples, with varying uptake rates observed worldwide. Sufficient information on prenatal screening and diagnosis should be provided to all pregnant women, presenting all available options, thus enabling them to make a free and informed choice during their pregnancy.

Management of preterm labor: Clinical practice guideline and recommendation by the WAPM-World Association of Perinatal Medicine and the PMF-Perinatal Medicine Foundation.

This practice guideline follows the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation, bringing together groups and individuals throughout the world, with the goal of improving the management of preterm labor. In fact, this document provides further guidance for healthcare practitioners on the appropriate use of examinations with the aim to improve the accuracy in diagnosing preterm labor and allow timely and appropriate administration of tocolytics, antenatal corticosteroids and magnesium sulphate and avoid unnecessary or excessive interventions. Therefore, it is not intended to establish a legal standard of care. This document is based on consensus among perinatal experts throughout the world in the light of scientific literature and serves as a guideline for use in clinical practice.

Uterine Scar Evaluation during the Postpartum: Pleading for Extradecidual Suturing during Cesarean Section.

OBJECTIVE: Our objective is to evaluate ultrasound differences in uterine scar between techniques using extramucosal suturing and full thickness suturing of the uterine incision. STUDY DESIGN: A retrospective observational study included cases of primary cesarean section. At 6-week postpartum, we evaluated by endovaginal ultrasound two elements in the sagittal view: the thickness of the uterine scar and the surface of defect (niche). Hysterotomy sites closed using a running full-thickness technique including the uterine mucosa (group 1) were compared to hysterotomies operated by the same surgeon but with extramucosal suturing (group 2). The operator switched from the running suture technique to extramucosal in 2013. RESULTS: The study included 241 patients (115 cases in group 1 that were compared to 126 cases in group 2). There were no significant differences in age or body mass index between the two groups. Cesarean scar and niche were detectable in the entire studied population. There was a significant difference in both uterine scar thickness (5.8 vs. 6.2 mm, p = 0.02) and the presence and size of the niche (49 vs. 40 mm2, p = 0.001) in transvaginal ultrasound performed at 6-week postpartum. CONCLUSION: Extramucosal suturing of the uterine scar seems to be associated with a better outcome on the postpartum ultrasound evaluation. KEY POINTS: · The technique for suturing the hysterotomy can be the source of healing changes.. · An extramucosal suturing of the uterus seems to give a better aspect at the postpartum ultrasound.. · Decreasing the niche at cesarean scar may be beneficial for future pregnancies..

The rate of cesarean delivery changes after internal audit based on the Robson Ten Group Classification System in Lebanon.

OBJECTIVE: To evaluate the efficiency of the Robson classification as an internal clinical audit and feedback of the high rate of cesarean delivery at Hotel Dieu de France, a tertiary referral hospital. METHODS: A pre-post study was conducted, with a retrospective approach in 2018 and 2019, identified as the pre-period (before the implementation of the Robson classification), and with a prospective approach in 2020 and 2021, labeled the post-period. RESULTS: The total number of deliveries during the study period was 2560; 1305 patients were included in the pre-period and 1255 patients delivered in the post-period. No significant differences between the two groups were found. No significant difference was found in the overall rate of cesarean delivery between the first and second periods (57.86% vs 56.72%; P = 0.2). However, a significant decrease in the absolute contribution of groups 3 and 4 (multiparous women without a previous uterine scar with a single cephalic pregnancy, ≥37 weeks of gestation, with spontaneous labor or induced labor) in the overall rate of cesarean delivery was remarked (P = 0.02 and 0.01, respectively). CONCLUSION: The Robson classification seems to be appropriate to monitor and audit the rate of cesarean delivery, but not sufficient to decrease the rate and change the practice.

Prenatal care in the era of economic collapse.

OBJECTIVES: To describe the effect of economic collapse on prenatal care. METHODS: This is an observational study aiming to depict the changes that occur in prenatal care in the case of an economic collapse. Biochemical screening and ultrasound examinations, as well as medical emigration and private-public sector activity, are discussed. RESULTS: Starting October 2019, Lebanon experienced significant and unprecedented economic degradation leading to 81% degradation of the local currency, 85% inflation, and socio-economic suffering, and the situation is currently still deteriorating. The impact on the medical infrastructure has been global and hit all areas. The crisis is multifaceted, varied in the way it played out across public and private sectors, and did not affect them equally. Some were better prepared than others to cope with severe fiscal pressure mainly through the support of non-governmental organizations. All aspects of prenatal care are affected by the crisis. CONCLUSIONS: Given the multiple strains on the Lebanese health care system today, the plight of antenatal care providers needs assistance to ensure adequate follow-up of pregnancies.

Dietary patterns and birth outcomes of healthy Lebanese pregnant women.

Background: The aim of this study was to define the dietary patterns (DPs) of a sample of Lebanese pregnant women and to establish their correlation with maternal and neonatal outcomes. Methods: A cross-sectional study was conducted among 358 Lebanese pregnant women. Maternal socio-demographic variables, anthropometric measurements, gestational weight gain and neonatal outcomes such as weight, length, head circumference and Apgar score were collected by qualified dietitians. Dietary intake was assessed by a validated food frequency questionnaire and three 24-h dietary recalls. DPs were determined, a posteriori, by a factor analysis to distinguish the inter-correlations between the food groups and a cluster analysis method to assemble the participants into groupings based on similarities in food consumption. Results: The identified DPs were not exclusively composed of specific food groups, since some components were overlapping in the DPs. The first one was characterized by a high consumption of starchy vegetables, unsaturated fats and unhealthy foods, the second was rich in fruits and vegetables, seeds, rice and pasta, and in fried local meals and the third was mainly based on protein-rich foods like poultry, fish, eggs and dairy products. They were named respectively as "Westernized," "Mixed" and "Neo-Mediterranean" by the research team. Women having the lowest pre-gestational body mass index (BMI) and higher gestational age followed mainly the "Neo-Mediterranean" eating pattern. Conclusion: The three identified DPs among Lebanese pregnant women were correlated with the pre-gestational BMI, and some maternal variables. However, neither the maternal nor the neonatal outcomes were correlated with the DP adopted by the mothers.

Association between Fetal Adrenal Gland Ultrasound Measurements in the 9th Month and Mode of Delivery.

OBJECTIVE: Several studies have previously assessed the value of changes in the fetal adrenal gland to predict preterm labor. The aim of this study is to evaluate the correlation between fetal adrenal gland measurements after 36 weeks and obstetrical outcomes. METHODS: Abdominal two-dimensional (2D) ultrasound is used to measure in the transversal plane the length of fetal zone (D1), the width (D2), and the length (D3) of fetal adrenal gland, and, subsequently, the fetal zone enlargement (FZE), in 98 primigravida women after 36 weeks. Labor and delivery outcomes were assessed and compared with these measurements. RESULTS: FZE changes had no association with spontaneous onset of labor. No association was found between all adrenal gland measurements and delivery onset. There was a significant relationship between D1, D2, and D3 and the delivery method. Patients delivered by cesarean section had smaller fetal adrenal gland dimensions, defining D1= 0.16 cm, D2 = 0.7 cm, and D3 = 2.37 cm as cutoff levels based on receiver operator characteristics curves. CONCLUSION: The 2D measurement of the fetal adrenal gland after 36 weeks seems to predict the delivery method in low-risk primigravida women. KEY POINTS: · We evaluate fetal adrenal gland measurements after 36 weeks versus the obstetrical outcome.. · No association was found between all adrenal gland measurements and delivery onset.. · Patients delivered by cesarean section had smaller fetal adrenal gland dimensions..

Cesarean section rates in a tertiary referral hospital in Beirut from 2018 to 2020: Our experience using the Robson Classification.

OBJECTIVE: To evaluate the cesarean section rate using the Robson Classification for the first time in Lebanon, at Hôtel-Dieu de France University Hospital, a tertiary referral center in Beirut. METHODS: Routine medical record data that included all live births from January 1, 2018 to September 30, 2020 was investigated. The overall cesarean section rate was recorded, and the size, cesarean section rate, and absolute and relative contributions were calculated within each group. RESULTS: The overall cesarean section rate was 56.8%. The highest relative contribution to this rate came from Robson groups 5, 2 and 10, respectively. A decrease in cesarean section rate was noted in 2020 among women admitted for induction of labor (groups 2 and 4) following the implementation of new department policies and the restrictions caused by the coronavirus disease 2019 pandemic. CONCLUSION: More than 50% of the deliveries in our department were by cesarean sections (CS). Strategies to reduce this rate should include stricter departmental policies for avoidance of unindicated primary CS and raising practitioners' and patients' awareness about trial of labor after cesarean section.

Characteristics and outcome in prenatally diagnosed vascular aorta-umbilical vein malformation.

Congenital arteriovenous fistulas involving the abdominal aorta are very rare. We report an unusual presentation involving the umbilical vein and characterized by the occurrence of a postnatal thrombosis and a favorable outcome.Synopsis: Fetal abdominal arteriovenous fistulas are rare involve branches from the aorta and can lead to umbilical vein thrombosis.

Unusual Findings in Down's Syndrome: Hand Agenesis and Hypospadias.

A baby with Down syndrome presented initial findings at the first-trimester ultrasound of increased nuchal thickness and unilateral hand agenesis. During follow-up, other elements were found mainly hypospadias. This report emphasizes through prenatal and postnatal imaging the phenotypic variability of Down syndrome babies.

Characteristics and Outcome in Non-Puerperal Uterine Inversion.

Chronic non-puerperal uterine inversion is rare and usually associated with uterine pathology with a diagnosis that is challenging. We present the case of a 47-year-old para 4 Caucasian woman with a history of polyfibromatous uterus who was admitted for severe vaginal bleeding for the past 48 hours associated with hemodynamical instability and was refusing any surgery. Pelvic MRI showed the uterus presenting an unusual appearance with a highly vascularized intracavitary leiomyoma protruding through the cervix. Upon deterioration of her status despite an optimal blood transfusion, resuscitation and anti-fibrinolytic treatment, she accepted total abdominal hysterectomy. The diagnosis of uterine inversion was made intraoperatively and confirmed on histopathologic examination. It revealed two side-by-side benign fundal leiomyomas which had collapsed the fundus and protruded partly from the cervix. Non-puerperal chronic inversion of the uterus is rare, and its diagnosis should be based on ultrasound, pelvic MRI and a high index of suspicion, allowing rapid diagnosis and treatment and thus decreasing patient morbidity and mortality.

Normal values of cardiac axis (CA) measurements in healthy fetuses during the first trimester screening ultrasound.

OBJECTIVES: To report the normal fetal cardiac axis (CA) values at the time of the first trimester screening ultrasound. METHODS: Standardized images and measurement of the CA were obtained from 100 healthy fetuses between 11+0 and 13+6 weeks of gestation along with the nucal thichkness (NT), Crown-rump length (CRL) and other measurements. We excluded cases with abnormal NT, later diagnosis of abnormalities, and suspected fetal cardiopathy during the pregnancy follow-up. Data analysis was performed after all the patients delivered and cardiopathy was excluded. RESULTS: CA was measurable in all the cases. Higher CRL was associated with a decrease in the CA. The mean ± SD embryonic/fetal CA was 48±5,2°, ranging from 39 to 60°, The 2.5 percentile was defined at 40° and the 97.5 percentile at 59°. The Pearson test resulted in a significant correlation between CA and CRL with a coefficient R of 70% and p-value <0.01. CONCLUSIONS: CA tends to decrease at the 11 to 13+6 gestational ages. We defined 2.5 and 97.5% curves for the normal values of CA in our Middle Eastern population. A larger study will be required to differentiate normal and abnormal values for the early detection of heart abnormalities.

Fascia suturing during cesarean may be linked to the later occurrence of cesarean scar endometrioma.

The most common type of abdominal wall endometriosis is cesarean scar endometriosis (CSE), defined as the presence of endometrial tissue outside the uterine cavity. Multiple hypotheses can explain the implantation theory. Endometrioma are most commonly located on the fascia-muscles layer and on both side corners of the cesarean-section scar. By reviewing the surgical techniques used in the cesarean section, we hypothesize that the type of suture material, the knot in itself, and the angiogenesis could be factors that influence CSE development.

Ultrasound characteristics and outcome of prenatally diagnosed fetal cholelithiasis.

AIM: To investigate ultrasound characteristics and outcome in fetuses with cholelithiasis. MATERIALS AND METHODS: We report a small case series of three patients with prenatally diagnosed fetal cholelithiasis. Ultrasound features, pregnancy outcome and neonatal follow-up are presented and discussed. RESULTS: Sonographic pattern associated to fetal cholelithiasis is variable. Pregnancy issue is globally good with no ominous fetal or neonatal events. CONCLUSIONS: Prenatally diagnosed fetal cholelithiasis is a rare finding and doesn't seem to carry an adverse effect on the pregnancy.

Discrepancies among different tools evaluating Mediterranean diet adherence during pregnancy, correlated to maternal anthropometric, dietary and biochemical characteristics.

BACKGROUND & AIMS: Scientific evidence confirms the favorable impact of Mediterranean diets (MD) on maternal and neonatal outcomes. However, the assessment of this dietary pattern requires valid indexes with scoring systems adapted to pregnant females. The aim of this cross-sectional study was to compare the adherence to MD, through 5 internationally validated tools, in pregnant women following a Mediterranean eating pattern, correlated to maternal anthropometric, dietary and biochemical markers. METHODS: 100 healthy pregnant females completed a sociodemographic questionnaire, a dietary recall and a food frequency questionnaire compatible with the MD. 10 ml of maternal blood were drawn for the analysis of biological markers such as C-reactive protein (CRP), leptin and adiponectin. RESULTS: We used the 50th percentile as cut-off of each scale (low or high adherence) to avoid the discrepancies noted in the literature among the large range of cut-offs points for the different tools. The % of agreement was high between the Mediterranean Food Pattern, MD Score, the MD Score and the Short MD Questionnaire. The MD Scale presented small agreement in relation to the other tested tools. All the tested indexes were significantly correlated with CRP levels, except for the MDScale. Significant correlations were reached regarding adiponectin and the MFP (p value = 0.04) and the MDScale (p value 0.03) tools. Pre-gestational body mass index was significantly correlated with all the tested biological markers. Significant correlations were seen between CRP on one hand and maternal age (p value = 0.033), adiponectin (p value = 0.028), and leptin (p value = 0.003) on the other. Fiber intake was significantly and negatively correlated to CRP (p value = 0.008) and positively to adiponectin levels (p value = 0.000). CONCLUSIONS: None of the tested tools were adapted for pregnancy, since a-priori scores were attributed for components already not consumed by pregnant females such as alcohol or recommended for daily or weekly consumptions such as whole dairy products and fish, respectively. In addition, the lack of inclusion of some traditional food ingredients of the MD implies the urge to create a new index adapted to pregnancy.

Prenatal diagnosis of ectopia cordis in a twin fetus.

We report images of the 7th case worldwide of a twin fetus with a complete isolated ectopia cordis in a dichorionic diamniotic twin gestation. There is no consanguinity, family history of abnormalities, IVF, or first trimester medication. The diagnosis of this isolated anomaly was done at 23 weeks in one fetus, while the other had normal morphology; the pregnancy was complicated by preterm labor and a cesarean delivery followed at 34 weeks. The affected baby weighed 1800 g and had an outcome complicated by episodes of desaturation and deceased at day 8. Parents did not wish either in utero termination of pregnancy or postnatal surgery for reintegration in the thorax and chose instead palliative care.