Novel method for trisomy 21 screening in the first trimester of pregnancy: fetal brain angle.

OBJECTIVES: The present study was performed to examine the utility of a new first trimester marker called the "brain angle" (BA) in screening for trisomy 21. We postulate that differences in the midbrain anatomy between euploid fetuses and those that are affected by trisomy 21 are reflected in changes in BA measurements. METHODS: In fetuses at 11+0-13+6 weeks of gestations, which were at high risk for trisomy 21, the angle was measured between the line crossing the thalamus and mesencephalon cranial border tangentially and the line crossing the brainstem lower limit. This angle was compared between fetuses with trisomy 21 (based on karyotyping) and those with a normal karyotype. RESULTS: Trisomy 21 was detected in 45 (8%) of 560 fetuses. Receiver operating characteristic analysis showed that, at BA≥94°, the sensitivity and specificity for determining trisomy 21 were 97.8% (95% CI=88.2-99.9%) and 100% (95% CI=99.2-100%), respectively. CONCLUSIONS: Fetal BA appears to be a promising new first trimester marker in screening for trisomy 21.

Ductus venosus-systemic shunt. Report of six cases and systematic review of the literature.

Objective: To evaluate the ultrasonographic features and pregnancy outcomes in women with ductus venosus-systemic shunt and systematic review of the literature.Method: A computerized search was conducted to identify cases of ductus venosus-systemic shunt between September 2016 and January 2018. Six patients were identified. Antenatal records and neonatal outcomes are presented. A systematic Embase, SCOPUS, and Medline search of published literature from 1991 to 2018 was performed using the terms "ductus venosus," "agenesis," "absence," "absent," "missing," "aberrant," and "variant."Results: Additional structural anomaly such as esophageal atresia with tracheoesophageal fistula was observed in one case. In other case, termination of pregnancy was performed due to Down syndrome. Other two of the six fetuses were monochorionic multiple pregnancies. In our review of the literature, additional anomalies were observed in 9 (42%) of the 21 cases.Conclusion: Our observation suggests that ductus venosus-systemic shunt can be associated with Down syndrome. Detailed examination should be performed to rule out additional abnormalities. Prognosis is good if the pathology is isolated.

Are complicated monochorionic twins more susceptible to indomethacin-induced fetal ductal constriction? Two cases of laser surgery for Twin-Twin Transfusion syndrome.

Indomethacin is a commonly used medication against preterm delivery. Several reports of fetal ductal constriction have been described after indomethacin use in the literature; however, there are no previously documented reports describing an association between Twin-Twin Transfusion syndrome and a constrictor effect of indomethacin on the ductus arteriosus. Two patients were referred to our department for Twin-Twin Transfusion syndrome and each underwent placental laser surgery. Constriction of the ductus arteriosus occurred as early as 20 and 24 weeks' gestation following maternal use of indomethacin after laser surgery. Spontaneous amelioration was observed after discontinuation of the drug. The constrictor effect of indomethacin on the ductus arteriosus can be observed even after a single dose and as early as 20 weeks of gestation in complicated monochorionic twin pregnancies. We emphasize meticulous use of indomethacin in complicated monochorionic twin pregnancies because the constrictive effect seems to be independent of gestational age.

Outcome after prenatal diagnosis of fetal urinary tract abnormalities: A tertiary center experience

Objective: With the widespread use of ultrasonography for fetal screening, the detection and management of congenital urinary tract abnormalities has become crucial. In this study, we aimed to describe the clinical approaches in patients with prenatally detected urinary tract abnormalities. Material and Methods: This study is a retrospective, single-center study performed at a perinatology unit of a university hospital, between 2010 and 2016. The outcomes of 124 patients who were prenatally diagnosed as having urinary tract abnormalities are reported. Variables included in the analysis were fetal sex, birth week and weight, persistency, and necessity surgery after birth for renal pelvic dilatation. Low-risk renal pelvic dilatation was determined as an anterior-posterior (AP) diameter of 4-7 mm at 16-28 weeks, 7-10 mm after 28 weeks, whereas high-risk dilatation was defined as AP measurements of ≥7 mm at 16-28 weeks, ≥10 mm after 28 weeks, respectively. Results: The majority of patients consisted of male fetuses with bilateral pelviectasis (62.9%, 20.2%, respectively). The mean age was 28.8±6.4 years. The mean gestational age at birth was 34.2±7.8 weeks. The mean birth weight was 2593±1253.3 g. The need for surgery was greater in high-risk patients than in low-risk patients (58.3% vs. 8.7%) (p<0.002). Conclusion: Patients with high-risk antenatal renal pelvic dilatation require surgical treatment after delivery. Close prenatal and postnatal follow-up is mandatory in specialized centers. Perinatologists, neonatologists, pediatricians and pediatric nephrologists, and radiologists should treat these children with a multidisciplinary approach.

Maternal serum irisin levels in early and late-onset pre-eclamptic and healthy pregnancies.

The aim of the study was to investigate whether plasma irisin concentrations differ between uncomplicated, early-onset and late-onset pre-eclamptic pregnancies. This cross-sectional study was conducted on 27 women with early-onset, 27 women with late-onset pre-eclampsia (PE) and 26 healthy pregnant women. Maternal levels of serum irisin were measured with the use of an enzyme-linked immunosorbent assay kit. The mean maternal serum irisin level of early-onset PE was significantly lower than late-onset PE (1.14 ± 0.56 vs. 1.46 ± 0.59, p < .05) and control subjects (1.14 ± 0.56 vs. 3.14 ± 0.81, p < 0.001). The mean maternal serum irisin level of late-onset PE was significantly lower than the control group (1.46 ± 0.59 vs. 3.14 ± 0.81, p < 0.001). Maternal serum irisin levels are decreased in pre-eclamptic pregnancies. Low levels of irisin may be the result or the cause of pathologic changes in PE. Impact statement What is already known on this subject? There are only two studies in the literature evaluating maternal serum irisin levels in pre-eclamptic pregnancies. One study demonstrated decreased maternal serum irisin levels in pre-eclamptic patients and the other found no significant difference between pre-eclamptic and control pregnancies. What do the results of this study add? The present study demonstrates that serum irisin levels were significantly lower in pre-eclampsia than normotensive pregnancies. Furthermore, we have also demonstrated for the first time that women with EO-PE had significantly lower levels of serum irsin than women with LO-PE. What are the implications of these findings for clinical practice and/or further research? Low levels of irisin may be the result or the cause of pathologic changes in pre-eclampsia. More studies are needed to evaluate the relationship between irisin and pre-eclampsia.

The utility of tumor markers and neutrophil lymphocyte ratio in patients with an intraoperative diagnosis of mucinous borderline ovarian tumor.

OBJECTIVE: To evaluate the utility of tumor markers and complete blood count to increase the diagnostic accuracy to detect malignant cases that are intraoperatively reported as mucinous borderline ovarian tumors (BOT). STUDY DESIGN: Patients who underwent laparotomy at our gynecologic oncology clinic between 2007 and 2015 for evaluation of an adnexal mass with an intraoperative frozen section report of mucinous BOT were retrospectively analyzed. Patients were grouped according to the final pathological diagnoses (malignant, borderline and benign), and were compared in terms of tumor marker levels and complete blood count parameters. Significant parameters were evaluated together with frozen section results, and were assessed for diagnostic accuracy. RESULTS: A total of 63 patients were included in the study. Of these, 41 patients had borderline, 11 patients had benign, and 11 patients had malignant mucinous ovarian tumors. Patient age, menopausal status, hemoglobin, platelet and lymphocyte counts were similar among the groups (p>0.05). On the other hand, white blood cell, neutrophil counts and neutrophil/lymphocyte ratio (NLR) were significantly higher in malignant cases (p<0.05). Similarly, CA125 and CA19-9 were significantly higher in malignant group (p<0.05). When evaluated with the frozen section results, CA19-9 and NLR had the highest sensitivity to detect mucinous cancers (81 and 78 percent, respectively). CONCLUSIONS: In patients who have an intraoperative frozen section diagnosis of borderline mucinous ovarian tumors, CA19-9, NLR and CA125 were significant predictors of malignancy. In light of larger future studies, we believe that integrating these parameters into routine clinical practice may decrease the rate of under diagnosis.

Does diurnal variation affect the first trimester fetal aneuploidy screening test biochemical parameters of fetuses with normal nuchal translucency?

OBJECTIVE: The purpose of this study was to investigate the effect of diurnal variation on biochemical results of first trimester aneuploidy screening test. METHODS: A total of 2725 singleton pregnant female, who had normal fetal nuchal translucency (NT) thickness, were included in the study during this period. Individuals were divided into two groups according to the sampling time (morning group: 09:00-11:00 am and afternoon group: 02:00-04:00 pm). Hormonal parameters (free-beta human chorionic gonadotropin [free ß-hCG] and pregnancy-associated plasma protein-A [PAPP-A] multiples of median [MoM] levels) of first trimester (11(+0)-13(+6) weeks) combined aneuploidy screening test were compared between morning and afternoon groups. RESULTS: PAPP-A MoM levels were significantly lower in the afternoon group when compared to the morning group (p = 0.001), whereas free ß-hCG MoM levels were similar in the both groups (p = 0.392). Rate of high risk for Down syndrome (Combine risk >1/300) and amniocentesis ratio were found higher in the afternoon group than morning group, but there were no difference between groups for the number of fetuses with Down syndrome. CONCLUSION: Receiving the venous blood sample for first trimester aneuploidy screening test in the afternoon causes low PAPP-A MoM levels.

Nausea and Vomiting in Early Pregnancy of Adolescents: Relationship with Depressive Symptoms.

STUDY OBJECTIVE: To determine the relationship between severity of nausea and vomiting during pregnancy (NVP) and depressive symptoms in pregnant adolescents. DESIGN: Prospective cross-sectional study. SETTING: A maternity research hospital outpatient clinic, Ankara, Turkey. PARTICIPANTS: A total of 200 pregnant adolescents. INTERVENTIONS AND MAIN OUTCOME MEASURES: Demographic features and obstetric histories of the participants were assessed. The Rhodes test was performed to determine nausea and vomiting severity in a face-to-face interview, and the self-reported Edinburgh Postnatal Depression Scale was administered with supervision. RESULTS: The Rhodes test results showed that 52/200 patients (26%) were classified with none, 83/200 patients (41.5%) with mild, 48/200 patients (24.0%) with moderate, and 17/200 patients (8.5%) with severe symptoms. The mean depression score in the severe vomiting group was significantly higher than that in the no NVP and mild NVP groups (P = .028 and .041, respectively). No differences were found between the other groups. CONCLUSION: Severe nausea and vomiting was associated with greater depressive symptom severity in pregnant adolescents.

The effect of inherited thrombophilia on second trimester combined aneuploidy screening test markers.

PURPOSE: To determine whether inherited thrombophilia affects components of second trimester combined aneuploidy screening test. METHODS: A case-control study was performed between 1 December 2010 and 1 February 2012, at a tertiary referral hospital. Singleton pregnancies with inherited thrombophilia that underwent second trimester (16-19(+6) week) combined aneuploidy screening test were included in the study. Maternal serum alfa fetoprotein, unconjugated estriol, human chorionic gonadotropin levels and multiple of median (MoM) levels were compared between the study group and controls. RESULTS: Within the study period, 18,943 women with singleton pregnancies had a combined second trimester aneuploidy screening test at our institution. Among these, 26 women met the criteria of thrombophilia. A control group that comprised 275 women with similar gestational age was generated, using a 1:1 ratio. Unconjugated estriol MoM levels were significantly lower in women with inherited thrombophilia (p = 0.02). But there was no statistically significant difference for unconjugated estriol levels, human chorionic gonadotropin, alfa fetoprotein and their MoM levels. CONCLUSIONS: Our study suggest that in patients with hereditary thrombophilia a new correction factor should be used, when calculating unconjugated estriol MoM value, which is one of the markers of second trimester aneuploidy screening test.

Roles of neutrophil/lymphocyte and platelet/lymphocyte ratios in the early diagnosis of malignant ovarian masses.

BACKGROUND: The present study aimed to investigate the utility and importance of the various parameters of complete blood count panel for benign-malignant differentiation of adnexal masses. MATERIALS AND METHODS: This retrospective study involved 316 patients with documented benign and 253 patients with malignant adnexal masses who underwent primary surgical treatment at a tertiary referral center. Prior to the study, all benign and malignant cases were compared within their own groups and then the benign and malignant cases were compared to each other. For all cases, cut-off, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for the neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), neutrophil, lymphocyte, platelet and CA-125 parameters, and the results were compared in regards to the groups. RESULTS: NLR, PLR, neutrophil, CA-125, and platelet values were higher in the malignant compared to the benign cases (p<0.01). The lymphocyte value was lower in the malignant cases (p<0.01). No significant differences were found for basophils and eosinophils (p > 0.05). For CA-125, the sensitivity, specificity, PPV and NPV for all cases were 78%, 62%, 62% and 78%, respectively. For NLR, they were 65.6%, 72.1%, 65.3%, and 72.3%, and for PLR, 48%, 81%, 67%, and 66%. Additionally, the sensitivity and specificity were 55% and 77% for CA-125, 66% and 58% for NLR, and 61% and 58% for PLR in early malignant cases. CONCLUSIONS: NLR and PLR appear to be useful methods that can be applied together with CA-125 due to the relatively high sensitivity values for the malign-benign differentiation of ovarian masses. Although the specificity of these parameters is lower than CA-125, especially in cases with early malignant ovarian pathology, their sensitivity being higher is promising for the early diagnosis of ovarian cancer. It can be used to detect ovarian malignancies in the early stages, and it will increase the treatment options and improve survival rates.

Do we need readjustment of the biochemical parameters in first trimester combined aneuploidy screening test in women with polycystic ovary syndrome?

OBJECTIVE: The aim of this study was to determine whether polycystic ovary syndrome (PCOS) affects the biochemical components of first trimester combined aneuploidy screening test. METHOD: A case-control study was performed at a tertiary referral hospital between years 2007-2013. Singleton pregnancies in the first trimester (11(+0) -13(+6) week) who had a history of PCOS and underwent first trimester combined aneuploidy screening test were included in the study. Three hundred and seventeen women met the criteria for inclusion. Control group was formed by 942 healthy pregnant women with similar gestational and maternal ages using a 1 : 3 ratio. Pregnancy-associated plasma protein-A (PAPP-A), free ß-human chorionic gonadotropin (fß-hCG) and fetal nuchal translucency were compared between the study group and the controls. RESULTS: The biochemical components PAPP-A and fß-hCG were significantly lower in the PCOS group compared with the control group (p = 0.001). There was no difference among groups with regard to the nuchal translucency measurements (p = 0.128). CONCLUSION: Our study shows that the levels of biochemical components of first trimester combined aneuploidy screening test (PAPP-A and fß-hCG) are altered in pregnant women with PCOS. Future trials of larger scale are needed to asses any need for readjustment of the risk in the patient population with PCOS.

Role of spiral artery Doppler to screen type 2 endometrial cancer cases.

OBJECTIVE: The purpose of this study was to determine the value of endometrial blood flow assessment in predicting type 2 endometrial carcinoma. MATERIAL AND METHODS: Sixty-five consecutive post-menopoausal women who had vaginal bleeding were enrolled in the study. All subjects were directed to transvaginal sonography to determine endometrial blood flow and underwent endometrial biopsy. Doppler findings were analysed to predict endometrial pathology. Subjects with unsatisfactory Doppler analyses were excluded from the study. RESULTS: Mean age of the study population was 50.1±6.9 years (42-73). Mean endometrial thickness was 10.1±2.9 mm (4-15 mm) and mean cancer antigen 125 (CA125) level was 20.1±17.4 U/mL (3-92). Histopathological evaluation revealed 14 cases of type 2 endometrial cancer and 18 cases of endometrial hyperplasia without atypia, while the other 33 cases had normal endometrial tissue. CA125 (Area under curve (AUC)=0.853, p=0.000), spiral artery resistance index (AUC=0.905, p=0.000), and spiral artery peak systolic velocity (AUC=0.822, p=0.000) were significant predictors for the type 2 endometrial cancer cases. Endometrial thickness did not significantly predict pathologic cases (p>0.05). Hyperplasia cases were not predicted by any of these diagnostic modalities (p>0.05). CONCLUSION: In patients with postmenopausal bleeding, spiral artery Doppler ultrasound, could play a role in refining the diagnosis of type 2 endometrial carcinoma; however, its predictive value should be evaluated with further studies.

The impact of inherited thrombophilia on first trimester combined aneuploidy screening test parameters.

OBJECTIVE: To determine whether inherited thrombophilia affects components of first trimester combined aneuploidy screening test. METHOD: A case-control study was performed between January 1st and December 31st 2011, at a tertiary referral hospital. Singleton pregnancies with inherited thrombophilia that underwent first trimester (11-13(+6) week) combined aneuploidy screening test were included in the study. Pregnancy associated plasma protein-A (PAPP-A), free beta-human chorionic gonadotropin (fbHCG) and fetal nuchal translucency (NT) were compared between the study group and controls. RESULTS: Within the study period, 15,881 women with singleton pregnancies had a combined first trimester aneuploidy screening test at our institution. Among these, 207 women met the inclusion criteria. A control group that comprised 625 women with similar gestational age was generated, using a 1:3 ratio. PAPP-A levels were significantly higher, whereas fbHCG levels and fetal NT measurements were lower in women with inherited thrombophilia (p < 0.001). CONCLUSION: Our study suggested that PAPP-A, free b-HCG and NT MoM levels display alterations in women with inherited thrombophilia. Future trials are needed to assess the need for readjustment of risk in these patients.

Comparison of oxidative stress in pregnancies with and without first trimester iron supplement: a randomized double-blind controlled trial.

OBJECTIVE: Iron supplementation was found to be a cause of oxidative stress. The aim of this study was to compare oxidative stress in pregnancies with and without iron supplementation in the first trimester pregnancies. METHODS: One hundred and eight women in the first trimester of normal pregnancies were randomly assigned to three groups. Patients were grouped as following: Group 1 received placebo (n = 36), group 2 received folate supplementation (n = 36) and group 3 was directed to the iron supplementation (n = 36). Oxidative stress was assessed at 14th week of gestation by the utilization of serum γ-glutamyl transferase level. Pregnancies were followed until delivery. Relationship between the oxidative stress and pregnancy outcome was assessed among groups. RESULTS: Mean age was similar among groups, mean gravidity and parity were significantly lower in group with Fe supplementation (p < 0.05). Maternal weight and weight gain during pregnancy were also significantly lower in group 3 (p < 0.05). Mean serum albumin levels were similar among groups while serum γ-glutamyl transferase (GGT) levels were significantly higher in group 3. There were 10 cases of oligohydramnios in group 3, two cases in group 2 and no cases in group 1 (p < 0.001). CONCLUSION: Iron supplementation during first trimester pregnancy was found to be associated with an increased oxidative stress.

The impact of parity on perinatal outcomes in pregnancies complicated by advanced maternal age.

OBJECTIVE: The purpose of this study was to investigate the impact of parity on perinatal outcomes in pregnancies complicated by advanced maternal age. MATERIAL AND METHODS: A total of 11 587 pregnancies were reviewed retrospectively from patient medical records. Singleton pregnancies greater than 24 weeks of gestation were included. The study group consisted of women ≥40 years old at the time of delivery, and the control group consisted of women aged between 20 and 30 years old. Data regarding age, parity, gestational age, mode of delivery, and obstetric and neonatal complications were collected. Firstly, pregnancies ≥40 years and the younger control group were compared altogether with respect to the obstetric and neonatal complications. Secondly, both groups were divided into subgroups according to parity, and a second comparison was made with controls. RESULTS: Mean maternal age in the study and control groups was 43±2.2 and 24±2.8 years, respectively. In women ≥40 years old, all of the investigated obstetric and neonatal complications except postpartum haemorrhage and foetal malformations were higher when compared to younger controls (p<0.05). In the nulliparous ≥40 year old group, the most significant complications were preterm delivery (45.3%), low 5-minute Apgar score (15.2%), and neonatal intensive care unit admission (15.2%). On the other hand, in the multiparous group, preeclampsia (16.6%), abruptio placentae (5.1%), foetal demise (7.2%), and macrosomia (9.6%) were found to be significantly higher when compared to controls. CONCLUSION: The study suggests that pregnancies of maternal age ≥40 years carry increased risks for both neonatal and obstetric complications, and these risks seem to be effected by parity.