New Findings in the Multidisciplinary Management of a Fetal Intrapericardial Teratoma: A Case Report.

INTRODUCTION: Fetal intrapericardial teratoma is a rare tumor that can be diagnosed by antenatal ultrasonography early in pregnancy. CASE PRESENTATION: A fetal intrapericardial teratoma was detected on routine ultrasonography in the second trimester of pregnancy. At 31 weeks gestation, a marked increase in tumor size, fetal ascites, and pericardial effusion were observed, indicating that preterm delivery would be inevitable. Corticosteroid prophylaxis (24 mg of betamethasone in two doses of 12 mg 24 h apart) initiated for prophylaxis of respiratory distress syndrome led to a reduction in fetal ascites and pericardial effusion. Betamethasone therapy (4 mg/per day) was continued with the aim to postpone the expected date of delivery. Gestation was extended for more than 2 weeks. At 33 weeks and 5 days gestation, the neonate was delivered by elective cesarean section with ex utero intrapartum treatment and immediately submitted to fetal cardiac surgery. The infant was discharged from the hospital in good health about 4 months later. CONCLUSION: The present report draws attention to improvement in fetal status and extension of gestation achieved with maternal low-dose corticosteroid therapy on antenatal ultrasound finding of fetal ascites and pericardial effusion due to intrapericardial teratoma.

Uterine smooth muscle tumors: a multicenter, retrospective, comparative study of clinical and ultrasound features.

OBJECTIVE: To evaluate a wide range of clinical and ultrasound characteristics of different uterine smooth muscle tumors to identify features capable of discriminating between these types. METHODS: This was a retrospective, multicenter study that included 285 patients diagnosed with uterine smooth muscle tumors (50 leiomyosarcomas, 35 smooth muscle tumors of uncertain malignant potential, and 200 leiomyomas). The patients were divided into three groups based on the histological type of their tumors, and the groups were compared according to the variables collected. RESULTS: Leiomyosarcomas were more common in older and post-menopausal women. Compared with leiomyomas, smooth muscle tumors of uncertain malignant potential and leiomyosarcomas had similar ultrasound features such as absence of normal myometrium, multilocular appearance, hyper-echogenicity in case of uniform echogenicity, absence of posterior shadows, echogenic areas, and hyperechoic rim. Leiomyosarcomas were larger, had more cystic areas, and were associated with a higher prevalence of pelvic free fluid. Smooth muscle tumors of uncertain malignant potential were characterized by a higher frequency of International Federation of Gynecology and Obstetrics (FIGO) type 6-7, the absence of internal shadows, and, in the case of cystic area, the presence of a regular internal wall. Tumor outline varied among the three histological types. A color score of 1 was typical of leiomyoma, a color score 2 was mainly observed in leiomyomas and smooth muscle tumors of uncertain malignant potential, a color score 3 did not differ among the tumors, while a color of score 4 was related to leiomyosarcomas. When combining color scores 3 and 4, leiomyosarcomas and smooth muscle tumors of uncertain malignant potential showed a high percentage of both circumferential and intra-lesional vascularization. A cooked appearance was not statistically different among the tumors. CONCLUSIONS: Based on our findings, specific ultrasonographic features as well as age and menopausal status are associated with different uterine smooth muscle tumor types. Integration of these data can help the pre-operative assessment of these lesions for proper management.

Special Issue "Wearable and BAN Sensors for Physical Rehabilitation and eHealth Architectures".

The demographic shift of the population toward an increased number of elder citizens, together with the sedentary lifestyle we are adopting, is reflected in the increasingly debilitated physical health of the population [...].

Cell-free DNA screening for fetal aneuploidy using the rolling circle method: A step towards non invasive prenatal testing simplification.

OBJECTIVE: To assess the efficacy of cell-free (cf)DNA screening for aneuploidy using the automated system based on rolling circle replication. METHODS: A prospective study among women referred for invasive prenatal diagnosis between July 2018 and December 2019. The plasma fraction was extracted within 5 days from blood collection, stored at -20°C and cfDNA measured between January and December 2019. RESULTS: A total of 805 women were recruited; 778 with singleton pregnancies and 27 twins. There were 48 Down syndrome, 25 Edwards syndrome and 3 Patau syndrome cases. Overall, the no-call rate was 2.6% (95% confidence interval 1.6%-3.9%) which reduced from 4.7% to 1.1% after relocation of the system (p < 0.002) to ensure a constant ambient temperature below 25°C. In singletons the Down syndrome detection rate (DR) was 100% (93%-100%) and false-positive rate (FPR) 0.14% (0.00%-0.79%). The Edwards syndrome DR was 96% (80%-100%) and FPR 0.78% (0.29%-1.7%). One false-positive had a confined placental trisomy 18 and the remaining five a z-score requiring sample repetition; all the false-positives occurred before system relocation (p < 0.005). Patau syndrome DR and FPR were 67% (9.4%-99%) and 0.26% (0.03%-0.95%). CONCLUSION: The cfDNA rolling circle method yields similar results to other methods provided that room temperature is adequately controlled.

Vasa previa: when antenatal diagnosis can change fetal prognosis.

OBJECTIVES: Evaluate ultrasound diagnostic accuracy, maternal-fetal characteristics and outcomes in case of vasa previa diagnosed antenatally, postnatally or with spontaneous resolution before delivery. METHODS: Monocentric retrospective study enrolling women with antenatal or postnatal diagnosis of vasa previa at Sant'Anna Hospital in Turin from 2007 to 2018. Vasa previa were defined as fetal vessels that lay 2 cm within the uterine internal os using 2D and Color Doppler transvaginal ultrasound. Diagnosis was confirmed at delivery and on histopathological exam. Vasa previa with spontaneous resolutions were defined as fetal vessels that migrate >2 cm from uterine internal os during scheduled ultrasound follow-ups in pregnancy. RESULTS: We enrolled 29 patients (incidence of 0.03%). Ultrasound antenatally diagnosed 25 vasa previa (five had a spontaneous resolution) while four were diagnosed postnatally, with an overall sensitivity of 96.2%, specificity of 100%, positive predictive value of 96.2%, and negative predictive value of 100%. Early gestational age at diagnosis is significally associate with spontaneously resolution (p 0.023; aOR 1.63; 95% IC 1.18-2.89). Nearly 93% of our patient had a risk factor for vasa previa: placenta previa at second trimester or low-lying placenta, bilobated placenta, succenturiate cotyledon, velametous cord insertion or assisted reproduction technologies. CONCLUSIONS: Maternal and fetal outcomes in case of vasa previa antenatally diagnosed are significally improved. Our data support the evaluation of umbilical cord insertion during routine second trimester ultrasound and a targeted screening for vasa previa in women with risk factor: it allows identification of fetus at high risk, reducing fetal mortality in otherwise healthy newborns.

Prenatal Biochemical and Ultrasound Markers in COVID-19 Pregnant Patients: A Prospective Case-Control Study.

This prospective observational study aimed to evaluate whether women with SARS-CoV-2 infection during the first trimester of pregnancy are at higher risk of noninvasive prenatal screening test alterations and/or of congenital fetal anomalies at the second-trimester fetal anatomy scan. Maternal symptoms were secondly investigated. The study was carried out on 12-week pregnant women admitted for noninvasive prenatal testing (16 April and 22 June 2020). The cohort had seromolecular tests for SARS-CoV-2, after which they were divided into a positive case group and a negative control group. Both groups had 20-week ultrasound screening. Seventeen out of the 164 women tested positive for SARS-CoV-2 (10.3%). There were no significant differences in mean nuchal translucency thickness or biochemical markers (pregnancy-associated plasma protein A, alpha-fetoprotein, human chorionic gonadotropin, unconjugated estriol) between cases and controls (p = 0.77, 0.63, 0.30, 0.40, 0.28) or in the fetal incidence of structural anomalies at the second-trimester fetal anatomy scan (p = 0.21). No pneumonia or hospital admission due to COVID-19-related symptoms were observed. Asymptomatic or mildly symptomatic SARS-CoV-2 infection during the first trimester of pregnancy did not predispose affected women to more fetal anomalies than unaffected women. COVID-19 had a favorable maternal course at the beginning of pregnancy in our healthy cohort.

The "scar" of a pandemic: Cumulative incidence of COVID-19 during the first trimester of pregnancy.

Congenitally- or perinatally-acquired viral infections can be harmful to the fetus but data are limited about prevalence and outcomes of coronavirus disease 2019 (COVID-19) disease during the first trimester of pregnancy. We report epidemiologic data from a study investigating a cohort of women who became pregnant just before or during the COVID-19 pandemic. We recruited 138 consecutive pregnant women attending for first trimester screening (11-13 weeks of gestation) at Sant'Anna Hospital, Turin, Piedmont, Italy, during the plateau and the falling phase of the COVID-19 epidemic curve. Patients were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin M/immunoglobulin G antibody levels and SARS-CoV-2 detection in sera and nasopharyngeal swab samples. COVID-19 cumulative incidence during the first trimester was of 10.1% with high prevalence of asymptomatic patients (42.8%). Similar to the course of the disease in non pregnant adults, 80% to 90% of infections were not severe.The prevalence of reported symptoms was four-fold higher in SARS-CoV-2 positive patients (57%) than in those negative (13%) (P < .001), suggesting that direct self-testing should open doors to confirmatory testing for COVID-19. Our findings support the need for COVID-19 screening in early pregnancy in epidemic areas to plan materno-fetal health surveillance programs.

Ultrasound and clinical characteristics of uterine smooth muscle tumors of uncertain malignant potential (STUMPs).

OBJECTIVE(S): Smooth muscle tumors of uncertain malignant potential are rare uterine neoplasms. Their identification through imaging is still limited due to the few available descriptions in the scientific literature. The objective of this paper is to provide clinical and ultrasound features that could support an early identification of these neoplasms. STUDY DESIGN: We retrospectively evaluated preoperative sonographic data of patients receiving a histopathological diagnosis of smooth muscle tumors of uncertain malignant potential between 2014 and 2019 at the S. Anna Hospital (Turin, Italy), a tertiary gynecological center. Tumors were characterized on the basis of ultrasound images using terms and definitions according to the morphological uterus sonographic assessment group. RESULTS: A total of fourteen patients with smooth muscle tumors of uncertain malignant potential (20 lesions, including 18 pure and 2 with associated leiomyosarcoma) were identified. The median age was 47 years (range 28-77) and nine (64%) patients were of reproductive age. Six patients (43%) were asymptomatic, two (14%) presented with abdominal pain, two (14 %) with menorrhagia and four (29%) with both symptoms. Two (14%) patients developed local recurrences as uterine smooth muscle tumor of uncertain malignant potential and leiomyosarcoma, respectively. At ultrasound imaging, nine (69%) smooth muscle tumors of uncertain malignant potential were poorly or moderately vascularized and nine (82%) showed both circumferential and intra-lesional flows. Only three (15%) showed shadowing. The outlines were well-defined in seventeen cases (85%) and most (90%) showed isoechoic or mixed echogenicity with microcystic anechoic areas in fourteen (70%) of cases. CONCLUSION(S): Sonographic features of smooth muscle tumors of uncertain malignant potential may vary and a pathognomonic description has not been recognized. However, the identification of single or multiple lesions with specific ultrasound features should raise the suspicion of tumors of uncertain malignant potential. These features include isoechogenicity or mixed echogenicity, regular borders, presence of internal microcystic and anechoic areas, circumferential and intralesional vascularization ranging from minimal to high and absence of shadowing.

The ADNEX model to triage adnexal masses: An external validation study and comparison with the IOTA two-step strategy and subjective assessment by an experienced ultrasound operator.

OBJECTIVES: The ADNEX (Assessment of Different NEoplasias in the adneXa) model was developed using parameters collected by experienced (level III) ultrasound examiners. Our primary aim was to externally validate the ADNEX model. Then, the discriminatory performance of ADNEX was compared with the two-step strategy and subjective assessment by an experienced ultrasound operator. METHODS: Between February 2013 and January 2017, all patients who were scheduled for surgery for an adnexal mass at the Sant'Anna Hospital in Turin were enrolled in this study. Preoperative transvaginal sonography was performed, and the two-step strategy was applied for triage of the adnexal mass. Two ultrasound examiners, IOTA certified, applied the ADNEX model to all the collected masses based on the ultrasound reports. Finally, an experienced operator assigned the subjective assessment based on recorded ultrasound images. The discrimination and calibration performance of ADNEX were evaluated. The AUC was calculated for the basic discrimination between benign and malignant tumours. In addition, AUCs were computed for each pair of tumour types using the conditional risk method. RESULTS: A total of 577 patients were included in the analysis: the overall prevalence of malignancy was 25 %. With ADNEX, the AUC to differentiate between benign and malignant masses was 0.9111 (95 % CI 0. 8788-0.9389). At risk cut-offs of 1%, 10 % and 30 %, sensitivities were 100 %, 89.6 % and 79.2 %, respectively, and specificities were 2.8 %, 76.2 % and 89.6 %, respectively. Discrimination between benign and stage II-IV tumours was good (AUC 0.935). The model had the most difficulties discriminating between borderline and stage I tumours (AUC 0.666), and between stages II-IV invasive and secondary metastatic tumours (AUC 0.736). The polytomous discrimination index (PDI) was 0.61 for ADNEX, whereas PDI for random performance would be 0.25. ADNEX proved to be equally or more accurate than the subjective assessment or the two-step strategy in the discrimination between benign and malignant adnexal masses. CONCLUSIONS: the ADNEX model could probably be successfully applied when an expert examiner is not available and, therefore both a subjective assessment and the two-step strategy cannot be performed.

Ultrasound accuracy in prenatal diagnosis of abnormal placentation of posterior placenta previa.

OBJECTIVES: To evaluate the accuracy of ultrasound in prenatal diagnosis of Placenta accrete spectrum disorders in patients with posterior placenta previa, and to assess the impact of prenatal diagnosis in our population. STUDY DESIGN: We prospectively enrolled 198 women with posterior placenta previa from 2011 to 2017. We performed transabdominal and transvaginal ultrasound examinations (Grey-scale and colour/power Doppler). The diagnosis of placenta accreta spectrum disorders was based on detection of at least two of the following criteria: loss of retroplacental clear zone, interruption of uterine serosa-bladder wall interface, turbulent placental lacunae with high velocity flow, myometrial thickness <1 mm, increased vascularity of uterine serosa-bladder wall interface, loss of vascular arch parallel to basal plate and/or irregular intraplacental vascularization. Definitive diagnosis was made at delivery with Caesarean section. Furthermore, we compared maternal outcomes in cases diagnosed antenatal versus that one's diagnosed at delivery. RESULTS: There were 20/198 cases of placenta accreta spectrum disorders. The two-criteria system identified 12 cases of placenta accreta, providing a 60.0% of sensitivity, 98.8% of specificity, 85.7% of positive and 95.7% of negative predictive value. Maternal outcomes were better in women with prenatal diagnosis of placenta accreta spectrum disorders, although not statistical significant. CONCLUSIONS: Our data showed that grey-scale and Color-Doppler ultrasound evaluation for detecting placenta accreta spectrum disorders on posterior placenta previa have high specificity, positive and negative predictive value, but a low sensitivity. Nevertheless, an antenatal diagnosis of placenta accreta spectrum disorders for posterior placenta previa should be encouraged.

The prenatal diagnosis of, and short-term outcome for, patients with congenitally corrected transposition.

Congenitally corrected transposition is a rare congenital anomaly, with only a few cases diagnosed and reported prenatally even in the largest fetal series. To determine the morphologic features and outcome for the lesion as recognized during fetal life, we reviewed the fetal and postnatal echocardiograms and medical records of 11 consecutive cases of congenitally corrected transposition. These were identified among 230 (4.7%) consecutive cases of structural cardiac disease referred to our fetal cardiology unit over a period of 4 years. The mean gestational age at diagnosis was 24.7 weeks. Reasons for referral were suspected complete transposition, abnormal position of the heart, and bradyarrhythmias. Associated cardiac lesions included an abnormal cardiac position in 6 cases, ventricular septal defect in 8, obstruction of the subpulmonary outflow tract in 6, tricuspid valvar displacement in 5, and complete atrioventricular block in 2. Only 3 of the cases had mild tricuspid regurgitation prior to birth. Termination was chosen in 4 cases with severe obstruction to pulmonary flow. Of the remaining cases, 2 patients died at 3 and 12 months after birth, respectively. Both developed significant tricuspid regurgitation associated with unexpected major arrhythmias. The remaining 5 patients are alive and relatively well at a mean follow-up of 25.4 months. An epicardial pacemaker was inserted in 1 because of complete atrioventricular block. We conclude that prenatal counseling must be guarded following the diagnosis of congenitally corrected transposition, even in fetuses with an apparently favorable state at initial examination. Some of these cases may undergo major and unexpected changes, particularly with regard to cardiac rhythm and tricuspid valvar function, with concomitant significant changes in prognosis.