Hypertensive Disorders of Pregnancy: Diagnosis, Management and Timing of Birth.

Hypertensive disorders of pregnancy are significant contributors to maternal and perinatal morbidity and mortality. The definition, classification, and management of these disorders have evolved over time. Notably, the disease classification enables caretakers to manage the disease as well as safeguard maternal and fetal health. The approach and management for pregnancies with gestational and chronic hypertension or pre-eclampsia with or without severe features should be adequately elucidated to mitigate adverse perinatal outcomes. This review aimed to present the most recent definition and classification of hypertensive disorders of pregnancy to address their management, determine the optimal timing of birth, and establish short- and long-term follow-up protocols following parturition.

What is new in peripartum hysterectomy? A seventeen year experience in a tertiary hospital.

OBJECTIVE: To identify changing trends in peripartum hysterectomy (PH), both elective. cesarean hysterectomy and emergency cesarean hysterectomy, at a single training and research hospital over the last 17 years in Istanbul, Turkey. MATERIALS AND METHODS: A retrospective cohort study was performed between January 2001 and September 2017. The records of all patients who had PH at Kanuni Sultan Süleyman Training and Research Hospital were analyzed. RESULTS: There were 243 cases of PH during the study period. A total of 266,386 births occurred, of which 60.1% were vaginal deliveries and 39.8% were cesarean sections. The incidence of PH increased from 0.67 per 1000 deliveries to 1.14 per 1000 deliveries during 2001-2008 and 2009-2017, respectively, with an overall incidence of 0.91 per 1000 deliveries during the 17 years. The main indication for PH changed significantly during this time from uterine atony (57.1%) to placenta accreta spectrum (85%). About 37% of women who underwent PH had at least one previous cesarean delivery during 2001-2008, whereas that percentage increased to 95.4% during 2009-2017. CONCLUSION: Placenta accreta spectrum was the leading cause of PH and was associated with significant maternal morbidity and mortality.

Ability of Bedside Ultrasonography to Detect Pediatric Nasal Bone Fractures.

OBJECTIVES/HYPOTHESIS: The aims of this study were to evaluate the diagnostic test features of bedside ultrasonography in pediatric patients with nasal trauma and to investigate whether it is a preferable alternative method to conventional radiography (CR). STUDY DESIGN: Cross-sectional prospective study. METHODS: This prospective study was conducted from March 1, 2019, through November 1, 2019. Thirty-one patients under the age of 18 years who had nasal trauma were consecutively included. CR and ultrasonographic imaging tests were investigated in patients with clinical indications for nasal bone fracture. The sensitivity, specificity, and accuracy of ultrasonography and CR were calculated with respect to detecting nasal fractures according to the gold standard method. RESULTS: Participants were between 3 and 16 years old and the median age was 8 (5-13) years. Nasal bone fracture was clinically detected in 18 patients. While 13 of these fractures were detected with ultrasonography, only 11 were also detected with CR. The sensitivity and specificity of ultrasonography and CR in detecting nasal fractures were 72.2% (95% confidence interval [CI]: 46.5-90.3) and 76.9% (95% CI: 46.2-95.0) for ultrasonography and 61.1% (95% CI: 35.8-82.7) and 69.2% (95% CI: 38.6-90.9) for CR. CONCLUSIONS: According to the results of this study, ultrasonography may be used with confidence as a first imaging method in the investigation of nasal fractures, particularly with consideration for avoiding the effects of radiation as much as possible. Our findings point to the next step of conducting trials with a greater number of patients in order to define the diagnostic test features of ultrasonography in pediatric patients. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:1398-1403, 2021.

Solitary Bone Cyst Like Areas in Myositis Ossificans: A Breast Mass in a Child.

BACKGROUND: Myositis ossificans is an extraosseous, benign tumor-like condition characterized by prominent heterotopic ossification. Cystic degeneration in myositis ossificans is an uncommon entity. Case report: A 13-year-old girl presented with a large and painful breast lump. Physical examination revealed a mobile, hard mass, clinically resembling a fibroadenoma. The mass was excised and diagnosed as myositis ossificans with central bone cyst like changes. Conclusion: Our case represents the first myositis ossificans case with central bone cyst like changes in a child.

Increased maternal C1q/TNF-related protein-1 (CTRP-1) serum levels in pregnancies with preeclampsia.

Objective: Metabolic changes and inflammation are involved in the pathogenesis of preeclampsia. Complement C1q tumor necrosis factor-related protein-1 (CTRP-1) is a pleiotropic molecule that possesses insulin-sensitizing effects and is also involved in lipid metabolism and inflammatory responses. The aim of the study was to investigate CTRP-1 levels in pregnancies with preeclampsia.Material and methods: Serum concentrations of CTRP-1 were measured in 29 pregnant women with early-onset preeclampsia (EOPE), 24 pregnant women with late-onset preeclampsia (LOPE), and 26 women with uncomplicated pregnancies using an enzyme-linked immunosorbent assay method.Results: Patients with both EOPE and LOPE had significantly higher serum concentrations of CTRP-1 compared to the healthy controls (p < .001). However, no significant difference was found between the EOPE and LOPE groups regarding CTRP-1 levels (p = 1.000). Correlation analysis showed that CTRP-1 levels were positively correlated with systolic blood pressure (p < .001), diastolic blood pressure (p < .001), and mean UtA PI (p < .001) but negatively correlated with gestational age at delivery (p = .001) and birth weight (p < .001).Conclusions: Serum CTRP-1 levels were significantly higher in patients with both EOPE and LOPE than in healthy pregnant women.

Expression of von Willebrand factor and caldesmon in the placental tissues of pregnancies complicated with intrauterine growth restriction.

PURPOSE: The decreased placental perfusion is the underlying reason for intrauterine growth restriction that in turn leads to reduced placental perfusion and ischemia. However, there are several issues to be understood in the pathophysiology of intrauterine growth restriction. We aimed to study whether any compensatory response in placental vascular bed occur in pregnancies complicated with intrauterine growth restriction by the immunohistochemical staining of von Willebrand factor and caldesmon in placental tissues. MATERIALS AND METHODS: A total of 103 pregnant women was enrolled in the study including 50 patients who were complicated with IUGR and 50 uncomplicated control patients. The study was designed in a prospective manner. All placentas were also stained with von Willebrand factor and caldesmon monoclonal kits. RESULTS: The immunohistochemical staining of von Willebrand factor and caldesmon expressions in placental tissues were different between normal and intrauterine growth restriction group. The percentages of 2+ and 3+ von Willebrand factor expression were higher in the intrauterine growth restriction group comparing with the normal group, although the difference was not statistically significant. The intensity of caldesmon expression was significantly lower in the intrauterine growth restriction group in comparison with the normal group (p < .001). CONCLUSION: Angiogenesis occurs as a placental response to intrauterine growth restriction which is a hypoxic condition. But newly formed vessels are immature and not strong enough. Our study is important to clarify the pathophysiology and placental compensatory responses in intrauterine growth restriction.

The efficiency of the uterocervical angle in the prediction of second-trimester pregnancy terminations in multiparous women.

Aim: To show how uterocervical angles are used for the prediction of second-trimester pregnancy terminations in multiparous women. Material and methods: A total of 148 multiparous singleton women in their second trimesters were enrolled in this prospective study. The intracervical Foley catheter was used for the induction of delivery. The cervical length (CL) and the uterocervical angle (UCA) were measured before the beginning of induction. The study population was subdivided into four groups; successful and failed terminations at the end of 24 and 48 h time frames. A stepwise multiple regression analysis was carried out to examine the contribution of UCA and other parameters to the induction-to-delivery time. A survival analysis was conducted to compare two groups defined by the cut-off value. Results: The UCA was broader in the successful termination group compared to the failed termination group in 24 h of induction (112.50° ± 29.00° versus 100.68° ± 27.13°, p = .02). A negative correlation was found between the UCA and the induction-to-delivery time (r = -0.27, p = .0007). A cut-off value of 97.5° was found for the UCA in predicting induction outcomes. During the 24-h period, 63.1% of women with the UCA ≥97.5° terminated successfully while 36.8% of women with the UCA <97.5° terminated successfully (p = .001). The mean induction-to-delivery time was significantly shorter in the UCA ≥97.5° group compared to the UCA <97.5° group (38.2 ± 19.5 h versus 47.8 ± 27.5 h, p = .02). The binary logistic regression analysis showed that the UCA was the only contributor to a successful termination (OR = 1.01, 95% CI: 1-1.02, p = .02). Conclusion: The UCA is broader in multiparous women who successfully terminated and is linked to a shorter duration of induction. The UCA by itself is the only significant contributor to the outcome of second trimester pregnancy terminations.

Efficiency of the Foley catheter versus the double balloon catheter during the induction of second trimester pregnancy terminations: a randomized controlled trial.

PURPOSE: To compare induction-to-delivery intervals of Foley catheters and double balloon catheters in second trimester pregnancy terminations. METHODS: This randomized parallel study was conducted on women who underwent second trimester terminations between December 2016 and December 2017. Pregnant women in the second trimester with a Bishop score < 6 were included in the study. Participants were randomized into two groups, the first being the Foley catheter group and the second being the double balloon catheter group. The time frames from insertion of catheters to the delivery were recorded in each group. A multiple regression analysis was carried out to examine the contribution of factors to the induction-to-delivery interval. A survival analysis was conducted to compare the Foley method and the double balloon method. RESULTS: A total of 91 pregnant women were included in the final analysis. The induction-to-delivery interval was shorter in the Foley catheter group than in the double balloon catheter group (38 h 54 min ± 21 h 6 min versus 58 h 17 min ± 25 h 56 min). We also found that women with intrauterine fetal death (IUFD) had a shorter time to delivery compared to women with live fetuses (39 h 12 min ± 18 h 46 min vs 51 h 30 min ± 26 h 42 min, p = 0.04). Women with a history of vaginal delivery also had a shorter induction-to-delivery time compared to women who never delivered vaginally before (38 h 12 min ± 17 h 42 min vs 53 h 54 min ± 27 h 18 min, p = 0.004). In the multiple regression analysis, the most significant contributor to the induction-to-delivery time was the method used for induction of labor and followed by other factors including the viability of the fetus (live/IUFD), history of vaginal delivery and PPROM. The survival analysis showed that the induction-to-delivery interval was significantly shorter in the Foley catheter group than in the double balloon catheter group (HR 2.51, 95% CI 1.57-4.00, p = 0.001). CONCLUSION: During the termination of second trimester pregnancies time from induction of labor to delivery is shorter with the Foley catheter compared to double balloon catheter.

Flecainide as first-line treatment for fetal supraventricular tachycardia.

OBJECTIVE: The aim of this study was to evaluate utilization, efficacy, and side effects of flecainide treatment as first-line agent in patients with fetal supraventricular tachycardia (SVT). METHOD: This retrospective review was conducted on 23 consecutive fetal tachyarrhythmia cases that met inclusion criteria. If the treatment was necessary, then flecainide was used as first-line treatment in all cases. RESULT: Among the study group, there were 21 (91.3%) cases of SVT and 2 (8.6%) cases of Atrial Flutter (AF). Sixteen fetuses had persistent SVT and five fetuses had intermittent SVT. We treated 17 fetuses with flecainide monotherapy and 15 of them converted to sinus rhythm and remaining two fetuses were refractory to monotherapy. The median time to conversion to sinus rhythm was 3.8 ± 1.6 days. Only one fetus (20%) among the intermittent SVT cases required anti-arrhythmic treatment. CONCLUSION: Our study has demonstrated that flecainide is an effective first-line treatment for fetal SVT with high success rate (88.2%), low side effect profile and relatively easy utilization. Based on the current study and recently published article results, flecainide can be recommended as the drug of first choice for treatment of fetal SVT cases.

Do triple test results predict risk for neonatal hyperbilirubinemia?

OBJECTIVE: Neonatal jaundice is the most common condition that requires hospital admission and outpatient follow-up after discharge in neonates. The values of more than 17 mg/dL in term infants are accepted as neonatal significant hyperbilirubinemia. We aimed to define if there is any relationship between second trimester serum markers and neonatal severe hyperbilirubinemia to protect the neonates from its neurological damage. METHODS: Total 1372 pregnant women were enrolled who had done triple test between April 2014 and 2015 and then given birth at our hospital. Our primary outcome was neonatal significant hyperbilirubinemia. RESULTS: The mean age of our study population was 27.9±5.6. A total of 59 patients had babies with neonatal hyperbilirubinemia after exclusion of Rh incompatibility. We detected that the presence of in vitro pregnancy, maternal health problems or poor obstetric history had no effect on the risk for neonatal hyperbilirubinemia. Neonatal hyperbilirubinemia was related with low E3 levels. The ratios of AFP/E3 and hCG/E3 were the most helpful to predict the neonatal hyperbilirubinemia. CONCLUSIONS: According to our results, low E3 levels in the triple test result can be helpful to predict the development of the neonatal hyperbilirubinemia. However, this is a bit expensive and many developing countries may not afford it.

Alterations in optic nerve sheath diameter according to cerebrovascular disease sub-groups.

BACKGROUND: ONSD (optic nerve sheath diameter) is a method used for indirect measurement of the increased intracranial pressure. In previous studies, the relation between the increased intracranial pressure and ONSD was analyzed in the patients suffering from cerebrovascular diseases (CVD). In our study, the patients suffering from ischemic CVD were categorized into 4 subgroups according to Oxfordshire Community Stroke Project classification (OCSP); the relationship between each group and ONSD, and the influence on each eye were analyzed. METHODS: The study included the patients over the age of 18 applying to the emergency department of Malatya State Hospital with the symptoms of stroke between the dates of 1/1/2015 and 1/9/2016. The patients diagnosed with stroke by means of clinical and neuroradiological imaging were examined in 4 subgroups according to Oxfordshire Community Stroke Project. The aim of the study is to predict the intracranial pressure (ICP) levels of the patients through ONSD measurement and CT images. RESULTS: In the comparison of the right and left optic nerve sheath diameters of CVD group and control group, the obtained results were found to be statistically significant (p<0.001). When the CVD subgroups were compared with the control group in terms of right and left optic nerve sheath diameters, the highest right-left optic nerve sheath diameter was detected to be in TACI (Total Anterior Circulation Infarction) group (p<0.001). DISCUSSION/CONCLUSION: In the early cases of CVD, mortality and morbidity can be decreased through the early diagnosis of the possible existence of ICP increase according to ONSD level.

The utility of first trimester uterine artery Doppler, placental volume and PAPP-A levels alone and in combination to predict preeclampsia.

In this study, we aimed to evaluate the detection of pre-eclampsia (PE) by integrating uterine artery Doppler, placental volume, and pregnancy-associated plasma protein A (PAPP-A) levels in the first trimester. We prospectively recruited 602 women that underwent 11-13weeks' aneuploidy screening. The mean pulsatility index (PI) of the uterine arteries and the placental volume were measured by ultrasonography. Measurement of PAPP-A levels has been performed at the same day of ultrasonographic examinations. The 90th percentile of uterine artery PI and the 10th percentile of placental volume and PAPP-A levels were used as cut-offs. Uterine artery PI, placental volume, and PAPP-A levels had similar sensitivities in predicting PE (53.66%, 63.41%, and 70.73%, respectively). Use of the parameters in combination had better sensitivity. If one parameter was positive, the sensitivity was 92.68% with 85.20% specificity. If at least two parameters were positive, the sensitivity was 85.37% with 98.89% specificity. In conclusion, the combination of increased PI of uterine artery with low placental volume and low PAPP-A levels in the first trimester achieved better results than either test alone in the prediction of PE.

Contraceptive failure with Copper T380A intrauterine device (IUD): A single tertiary center experience.

OBJECTIVE: The objective of this study was to assess the risk factors of pregnancy with Copper (Cu)T380A IUD and pregnancy outcomes. METHODS: A retrospective study evaluating the risk factors and pregnancy outcomes of 81 patients who conceived with CuT380A IUD in situ. RESULTS: Four ectopic pregnancies and 77 intrauterine pregnancies were detected. Twenty-six pregnancies (33.76%, 26/77) were terminated according to maternal desire. Twenty-five patients (32.46%, 25/77) whose IUDs were removed constituted the Removed IUD Group, and the remaining 26 patients constituted IUD Left in situ Group. Term pregnancy rates (76% vs. 20.8%, p=0.002) were significantly higher in the Removed IUD Group compared with the IUD Left in situ Group. Abortion rates (16% vs. 53.84%, p=0.008) were detected significantly higher in the IUD Left in situ Group. CONCLUSION: The main result of our study was that pregnancy with CuT380A in situ is a significant risk factor for adverse perinatal outcome. Adjusting the scheduled follow-ups for checking the IUD seems to be important in order to prevent accidental pregnancy.

Alanine aminotransferase as a predictor of adverse perinatal outcomes in women with intrahepatic cholestasis of pregnancy.

OBJECTIVE: To evaluate the associations between adverse perinatal outcomes and serum transaminase levels at the time of diagnosis in patients with intrahepatic cholestasis of pregnancy. METHODS: We performed a retrospective analysis of patients hospitalized for evaluation of intrahepatic cholestasis of pregnancy from January 2013 to June 2014 in a tertiary center. Seventy-one patients were divided into two groups according to the presence (Group I) or absence of adverse perinatal outcomes (Group II). RESULTS: The mean aminotransferase levels and conjugated bilirubin levels at the time of diagnosis were significantly higher in Group I than in Group II. Receiver operating characteristic curve analysis revealed that the alanine aminotransferase level could predict adverse perinatal outcomes with 76.47% sensitivity and 78.38% specificity, and the cut-off value was 95 IU/L. Among patients with intrahepatic cholestasis of pregnancy, those with adverse perinatal outcomes were significantly older, had an earlier diagnosis, and had higher alanine aminotransferase levels. Using the 95-IU/L cut-off value, patients with intrahepatic cholestasis of pregnancy had a 3.54-fold increased risk for adverse perinatal outcomes. CONCLUSIONS: Patients with intrahepatic cholestasis of pregnancy and high alanineaminotransferase levels should be followed up for possible adverse perinatal outcomes.

Utility of ductus venosus blood flow in the study of cardiac function in fetuses with intracardiac echogenic focus.

PURPOSE: The purpose of this study was to investigate fetal ductus venosus (DV) wave velocities, DV velocity ratios, and DV diastolic time intervals to derive additional information on fetal cardiac function in the presence of an intracardiac echogenic focus (IEF). METHODS: Seventy fetuses at 19-28 weeks of gestation with an IEF and 63 control fetuses were screened using two-dimensional and power Doppler echocardiography. DV wave velocities, DV velocity ratios, and diastolic time intervals were measured. The aortic peak velocity, pulmonary artery peak velocity, left ventricular shortening fraction, and right ventricular shortening fraction, atrioventricular early-diastolic filling velocity (E), atrial contraction velocity (A), and E/A ratio were also measured. RESULTS: The study and control groups were similar in terms of maternal age, body mass index, and gestational age in weeks at the time of examination (p > 0.05). Significant between-group differences were found in DV v-descent (p = 0.03) and a-wave velocities (p = 0.04). CONCLUSIONS: Although the presence of an IEF in the fetal heart does not influence conventional measurements (DV velocity ratios and DV diastolic time intervals), it is associated with changes in DV v-descent and a-wave velocities. These changes may be indirectly related to reduced end-systolic relaxation and augmented atrial contraction in the fetal heart. We therefore suggest examination of DV flow velocities in fetuses with IEF.

Role of spiramycin in prevention of fetal toxoplasmosis.

OBJECTIVE: The aim of this study is to evaluate the efficacy of spiramycin in prevention of mother-to-child transmission of Toxoplasma gondii infection. METHODS: Patients within first trimester of their pregnancy with Toxoplasma IgM positivity (>0.65 index, ELISA, VIDAS) and IgG positivity (>8 IU/ml), who had low IgG avidity (<0.50 index, ELISA, Architet) were considered as having acute toxoplasmosis. These patients who had amniocentesis at the 19th-21st week of pregnancy were examined for the detection of Toxoplasma DNA. Detailed ultrasonographic examinations performed between the 20th and 24th gestational weeks and the mothers and babies were followed for at least one year. RESULTS: Out of 61 patients, 55 (90.2%) had received Spy prophylaxis while 6 (9.8%) cases refused Spy prophylaxis. Toxoplasma PCR test was found to be positive in amniotic fluid of 4 (6.6%) patients obtained by amniocentesis at the 19th-21st week of pregnancy. All four of these patients had refused Spy prophylaxis had positive Toxoplasma PCR in amniotic fluid (p < 0.01). CONCLUSION: Our results seem to encourage the use of spiramycin in women with toxoplasmosis during pregnancy.

The outcome of pregnancy with new onset proteinuria without hypertension: retrospective observational study.

OBJECTIVE: The aim of this study was to evaluate preeclampsia progression of isolated proteinuria and associations with pregnancy outcome. METHOD: We performed a retrospective analysis in patients who were hospitalized for evaluation of new onset proteinuria without hypertension after 20 weeks of gestation between January 2012 and January 2014. One hundred fifty-seven patients who met the inclusion criteria were enrolled the study. RESULTS: After detection of new onset proteinuria, 53 of 157 (33.7%) patients developed preeclampsia and the incidence of gestational proteinuria was found to be 0.33%. Twenty-four hours urine proteinuria testing results were significantly higher in preeclampsia (PE) group compared with the gestational proteinuria (GP) group (p < 0.01). Patients who developed preeclampsia delivered significantly earlier than the GP group (p < 0.01). The weights of the infants born to mothers in the PE group were significantly lower than the other group (p < 0.01). CONCLUSION: The incidence of gestational proteinuria was lower than the previous studies. Preeclampsia developed in 33% of patients with new onset proteinuria in pregnancy. In patients who developed PE had significantly higher proteinuria, lower delivery time and birth weight in their infants. Therefore, patients with new onset proteinuria should be followed-up for preeclampsia development and associated morbidities.