Diffuse peritonitis secondary to urachal cyst abscess in a postpartum patient.

INTRODUCTION AND IMPORTANCE: Urachal cyst infections during pregnancy are exceptionally rare, posing diagnostic challenges. This case report contributes to the limited literature, emphasizing the rarity, diagnostic difficulties, and the need for heightened healthcare provider awareness for timely intervention. PRESENTATION OF CASE: A 32-year-old pregnant woman with persistent pelvic pain, fever, and urinary symptoms sought care with inconclusive initial diagnoses despite multiple ER visits. Labor revealed a palpable mass, and postpartum, a CT scan identified a urachal cyst abscess. Urgent laparoscopy confirmed peritonitis, leading to cyst removal, antibiotics, and a subsequent laparotomy. Histology confirmed an abscessed urachal cyst. DISCUSSION: Urachal cyst infections in pregnancy, exceptionally rare and diagnostically challenging, highlight the importance of considering them in abdominal pain differentials. Diagnostic tools, such as ultrasound and CT scans, can be misleading, emphasizing the necessity for a multidisciplinary approach. CONCLUSION: This case report underscores the challenges in diagnosing and managing an infected urachal cyst during pregnancy, stressing the need for awareness and a comprehensive diagnostic approach for optimal outcomes. The rarity of such cases warrants increased attention within the medical community.

A national survey on current practice of ultrasound in labor ward.

OBJECTIVES: Use of ultrasonography has been suggested as an accurate adjunct to clinical evaluation of fetal position and station during labor. There are no available reports concerning its actual use in delivery wards. The aim of this survey was to evaluate the current practice regarding the use of ultrasonography during labor. METHODS: A questionnaire was sent to members of the Italian Society of Ultrasound in Obstetrics and Gynecology employed in delivery wards. The qFeuestionnaire was made up of 22 questions evaluating participant characteristics and the current use of ultrasound in labor in their hospital of employment. The answers were grouped according to participant characteristics. RESULTS: A total of 200 participants replied. Ultrasound was considered useful before an operative vaginal delivery by 59.6 % of respondents, while 51.8 and 52.5 % considered it useful in the management of prolonged first and second stages of labor, respectively. The major indication for ultrasound use during labor was the assessment of fetal occiput position. The major difficulties in its application were the perceived lack of training and the complexity of the ultrasound equipment use. Participants that reported fewer difficulties were those employed in hospitals with a higher number of deliveries or having delivery units with more years of experience using ultrasound in labor, or those who had attended specific training courses. CONCLUSIONS: The results indicate that, despite the reported evidence of a higher accuracy of ultrasound compared to clinical evaluation in assessing fetal position and station, its use is still limited, even amongst maternal-fetal medicine practitioners specialized in ultrasonography.

Intra-Amniotic Inflammation or Infection: Suspected and Confirmed Diagnosis of "Triple I" at Term.

Chorioamnionitis (CA) at term of pregnancy can have an infectious and/or inflammatory origin and is associated with adverse outcomes. Triple I (intrauterine inflammation, infection, or both, TI) has been proposed to reduce the overdiagnosis of infection and neonatal overtreatment. The aim of this study is to identify clinical and histological variables that could predict adverse outcomes when TI is suspected and/or confirmed. This retrospective cohort study included 404 pregnancies (gestational age ≥ 37 weeks) that were divided into 5 all-inclusive and mutually exclusive groups. TI was defined according to the NICHD definition of 2015, and it could be confirmed (TI+) or not confirmed (TI-) via histological examination. Signs of infection/inflammation that did not conform to the definition of TI were classified as "clinical suspicion" and could be supported (CS+) or not supported (CS-) by histology. Cases of histological chorioamnionitis (HCA) without clinical manifestation represented a fifth group. Whole placental involvement (WPLI) was defined as a histological inflammation involving the maternal and fetal sides. There were 113 TI+, 30 TI-, 186 CS+, 35 CS-, and 40 isolated HCA cases. WPLI was diagnosed in 133 cases (39.2%). Composite neonatal outcome (CNO) occurred in 114 cases (28.2%) while composite maternal outcome (CMO) occurred in 192 cases (47.5%). Compared with CS+, TI+ was more predictive of CNO (p = 0.001), CMO (p < 0.001), and WPLI (p = 0.005). WPLI was related both to CNO (p < 0.001) and to CMO (p = 0.046). TI+ and WPLI showed similar sensitivity but different specificity in predicting CNO. At logistic regression, CNO was independently predicted by TI+ (OR 2.21; p = 0.001) and by WPLI (OR 2.23; p = 0.001). Compared with CS, TI is a better predictor of CNO and can be useful for the identification of newborns at risk.

SARS-CoV-2 infection testing at delivery: a clinical and epidemiological priority.

BACKGROUND: Universal testing has been suggested as a useful strategy for a safe exit from the total lockdown, without recurrence of COVID-19 epidemic, delivering women being considered a sentinel population. Further universal testing for pregnant women may be useful in order to define appropriate access to COVID19 areas, dedicated neonatal care, and personal protective equipment. METHODS: During the period 10-26 April, all consecutive women admitted for delivery at the Maternity Hospitals of the city of Milan and in six provinces of Lombardy: Brescia, Como, Lecco Monza, Pavia, and Sondrio. areas were tested with nasopharyngeal swabs.Results and conclusion: Out of 1566 women, 49 were tested positive for SARS-Cov-2 (3.1%, 95% Confidence Interval (CI) 2.3-4.0). This value is largely higher than Heath Authorities estimate. Of tested positive women, 22 (44.9%) had symptoms or reported close contacts with positive patients, that is were found at risk by the itemized questionnaire. In conclusion, routine estimate of frequency of positivity among delivering women can be consider a useful methods to monitor positivity at least in females in their fertile ages.

Mode of birth in women with low-lying placenta: protocol for a prospective multicentre 1:3 matched case-control study in Italy (the MODEL-PLACENTA study).

INTRODUCTION: The term placenta praevia defines a placenta that lies over the internal os, whereas the term low-lying placenta identifies a placenta that is partially implanted in the lower uterine segment with the inferior placental edge located at 1-20 mm from the internal cervical os (internal-os-distance). The most appropriate mode of birth in women with low-lying placenta is still controversial, with the majority of them undergoing caesarean section. The current project aims to evaluate the rate of vaginal birth and caesarean section in labour due to bleeding by offering a trial of labour to all women with an internal-os-distance >5 mm as assessed by transvaginal sonography in the late third trimester. METHODS AND ANALYSIS: The MODEL-PLACENTA is a prospective, multicentre, 1:3 matched case-control study involving 17 Maternity Units across Lombardy and Emilia-Romagna regions, Italy. The study includes women with a placenta located in the lower uterine segment at the second trimester scan. Women with a normally located placenta will be enrolled as controls. A sample size of 30 women with an internal-os-distance >5 mm at the late third trimester scan is needed at each participating Unit. Since the incidence of low-lying placenta decreases from 2% in the second trimester to 0.4% at the end of pregnancy, 150 women should be recruited at each centre at the second trimester scan. A vaginal birth rate ≥60% in women with an internal-os-distance >5 mm will be considered appropriate to start routinely admitting to labour these women. ETHICS AND DISSEMINATION: Ethical approval for the study was given by the Brianza Ethics Committee (No 3157, 2019). Written informed consent will be obtained from study participants. Results will be disseminated by publication in peer-reviewed journals and presentation in international conferences. TRIAL REGISTRATION NUMBER: NCT04827433 (pre-results stage).

Operative vacuum vaginal delivery: effect of compliance with recommended checklist.

PURPOSE: Even if the prerequisites and the technique of vacuum extraction are largely established, the role of a checklist in this field has not been tested. To evaluate the role of a checklist implementation on the compliance with the recommended rules in operative vacuum vaginal delivery (OVD) and on maternal and perinatal outcomes. MATERIALS AND METHODS: Retrospective cohort study on OVD between January 2012 and December 2015 at two hospitals with a tradition of teaching of OVD. A checklist for OVD was introduced in 2014. Three rules had to be recorded: fetal head station and position determination, no more than four tractions, and no more than three cup applications. Adverse maternal outcomes included third- and fourth-degree perineal tears. Adverse neonatal outcome included asphyxia, need for neonatal resuscitation, NICU admission, major head injuries, scalp injuries, and bone or brachial plexus injuries. RESULTS: Introduction of a checklist for OVD resulted in an increase in the compliance with the rules (83.3 versus 62.8%, p < .001). Cases in which the rules were respected had lower incidence of third- and fourth-degree perineal lacerations after controlling for episiotomy, nulliparity, and indication for OVD (OR = 0.4, 95% CI 0.18-0.89), but similar rates of failure of OVD (2.1 versus 2.2%, p = 1) and adverse neonatal outcome (10.8 versus 11.7%, p=.71). CONCLUSION: Knowledge and documented compliance with a checklist of recommended rules in OVD may assist in achieving a lower rate of severe perineal and anal sphincter injury but does not alter the success of the procedure or neonatal outcome.

Umbilical cord management strategies at cesarean section.

AIM: To evaluate the effect of different strategies to improve placental transfusion in cesarean section (CS). METHODS: Retrospective analysis of all singleton term pregnancies that underwent CS over 6 months. Delayed umbilical cord clamping (dUCC) was defined as one done at least 60 s after birth. Umbilical cord milking (UCM) was an option when waiting 60 s was deemed unsafe. The two strategies were compared against early (<60 s) umbilical cord clamping (eUCC) without milking. Neonatal hematocrit (Hct) at 48 h was the main outcome variable. RESULTS: Of the 223 CS in the cohort, 100 were performed in labor and 123 were elective. dUCC was performed in 137, eUCC without milking in 53 and UCM in 33 cases. Neonatal Hct was higher in CS carried out in labor versus in elective CS (59.76% ± 6.17 vs 56.91% ± 5.95, P = 0.001). At multivariate analysis, CS performed in labor (coefficient [coeff.] 3.44, confidence interval [CI] 1.75-5.13, P < 0.001), UCM (coeff. 3.88, CI 1.61-6.14, P = 0.001) and birth weight (coeff. -0.003, CI -0.005 to -0.001, P = 0.001) were the only variables independently associated with neonatal Hct. In elective CS, UCM led to higher neonatal Hct (61.5% ± 5.5) compared to eUCC without milking (55.1% ± 5.5) and dUCC (56.4% ± 5.7, P = 0.001), while in CS performed in labor there were no significant differences among the placental transfusion strategies. CONCLUSION: In term CS, neonatal Hct is significantly higher when the CS is performed in labor or with UCM. In elective CS, UCM could be a valid option to favor placental transfusion.

Cesarean delivery rates and obstetric culture - an Italian register-based study.

INTRODUCTION: Cesarean delivery rates are rising due to multiple factors, including less use of operative vaginal delivery and vaginal birth after cesarean delivery, which often reflect local obstetric practices. Objectives of the study were to analyze the relations between cesarean delivery, these practices, and perinatal outcomes. MATERIAL AND METHODS: We included all deliveries in the 72 hospitals of Lombardia, a region in northern Italy, during the year 2013. The delivery certificate was used as data source. Pearson's correlation coefficient and logistic regression were used for statistical analysis. RESULTS: We included 87 896 deliveries. The number of deliveries per hospital ranged from 140 to 6123. The rate of cesarean delivery was 28.3% (range 9.9-86.4%), operative vaginal delivery 4.7% (range 0.2-10.0%), and vaginal birth after cesarean 17.3% (range 0-79.2%). We found a significant inverse correlation between rates of overall cesarean delivery and operative vaginal delivery (r = -0.25, p = 0.04). The correlation between rate of overall cesarean delivery and vaginal birth after cesarean was also inverse and significant (r = -0.57, p < 0.001). There was no association between overall cesarean delivery rate and the rates of Apgar score at 5 min <7 in term and late preterm neonates (r = -0.92, p = 0.46) and of perinatal mortality (r = -0.19, p = 0.13), respectively. The associations were independent of hospital volume of activity. CONCLUSIONS: An obstetric practice that encourages vaginal instrumental delivery in delayed second stage of labor or vaginal birth after previous cesarean delivery, could reduce the rising cesarean delivery rate. This will require a change in obstetric culture, continuing education of healthcare providers, and leadership.

Premature rupture of membranes at term in low risk women: how long should we wait in the "latent phase"?

AIM: How long the waiting time may be for the onset of spontaneous labor after prelabor rupture of fetal membranes at term (tPROM) remains controversial. METHODS: The study is an observational cohort study of 6032 women. All obstetric patients with no obstetric risk factors, other than tPROM, were included. The analysis focused on the onset of labor (spontaneous vs. induction), maternal morbidity [cesarean section (CS) and chorioamnionitis] and neonatal morbidity (suspected infection) related to a policy of waiting for the onset of spontaneous labor within 48 h of tPROM. RESULTS: tPROM was experienced by 1439 women. A careful clinical management shows a very low rate of clinical chorioamnionitis (2.3%) and neonatal infection rate (2.8%), even after 24 h from tPROM. The overall incidence of CS was 4.5%. Furthermore, a policy of waiting for the onset of spontaneous labor within 48 h of tPROM is associated with a low rate of CS, less than induced labor (OR=1.76; 95% confidence interval 1.03-3.02; P<0.004). CONCLUSIONS: Fetal and/or maternal morbidity in tPROM women may not increase if there is a strict analysis of maternal and or fetal risk factors added to a careful clinical management. Moreover, it may be useful to wait for spontaneous labor in order to enhance the patient's chance of vaginal delivery.

Comparison of six sonographic signs in the prenatal diagnosis of spina bifida.

AIMS: To compare the diagnostic accuracy of sonographic signs that may be looked for in fetuses with spina bifida. METHODS: Forty-nine fetuses affected by spina bifida were enrolled, at a gestational age of 18-28 weeks. The following sonographic signs were looked for: "lemon" sign, small cerebellum, effaced cisterna magna, small posterior fossa, ventriculomegaly and direct visualization of a spinal defect. RESULTS: The "lemon" sign was present in 53%, a small cerebellum in 96%, an effaced cisterna magna in 93%, a small posterior fossa in 96%. Ventriculomegaly was present in 40/49 (81%) cases and was severe in 20 fetuses and borderline in the remaining 20. The spinal defect was missed in one fetus presenting the cerebellar and posterior fossa signs. In two fetuses, the myelomeningocele was present without cranial signs of Chiari II malformation and in both cases the defect was covered by intact skin. CONCLUSIONS: Our results confirm the usefulness of evaluation of the posterior fossa in the diagnosis of spina bifida, particularly in cases of small spinal defects that may be missed at ultrasound. Conversely, myelomeningocele covered by intact skin was not associated with the cranial signs of Chiari II malformation.

Sonographic diagnosis of fetal cerebral ventriculomegaly: an update.

Dilatation of the fetal cerebral ventricles (ventriculomegaly) is a generic sonographic sign that is common to several pathological entities carrying different prognoses. The main causes of fetal ventriculomegaly are aqueductal stenosis, Chiari II malformation, Dandy-Walker complex, and agenesis of the corpus callosum. Ventriculomegaly is easily recognized by ultrasound by measuring the atrial width. This simple measure allows the recognition of mild forms of ventricular dilatation and is used in screening for ventriculomegaly. However, although the diagnosis of ventriculomegaly is easy, the prenatal identification of the cause of ventricular dilatation is a more difficult task. For this purpose the evaluation of the posterior fossa in association with the visualization of the corpus callosum is useful. Research into the causes of ventriculomegaly is clinically useful, since the prognosis mainly depends on the etiology and on the presence of associated abnormalities. In this article the role of prenatal sonography in determining the cause of the ventriculomegaly is reviewed, as well as the prognostic value of the prenatal sonographic findings.

The midsagittal view of the fetal brain: a useful landmark in recognizing the cause of fetal cerebral ventriculomegaly.

AIM: To evaluate the positive predictive value of the midsagittal view of the fetal brain in recognizing the cause of ventriculomegaly diagnosed with traditional axial scan. METHODS: Fifty-eight pregnant women, referred to our Center following a generic diagnosis of ventriculomegaly have been evaluated: 38 had marked and 20 had borderline ventriculomegaly. The fetal brain was scanned by the midsagittal view using a transabdominal probe in fetuses in breech presentation or transverse lie and a transvaginal probe in fetuses in cephalic presentation. The possible cause of ventriculomegaly was postulated by combining the findings of the corpus callosum/cavum septi pellucidi complex with those of the posterior fossa. The prenatal diagnoses were compared with the anatomical specimens of aborted fetuses or with postnatal neuroimaging. RESULTS: The prenatal diagnoses were confirmed in 54/58 cases (PPV 93.1%). In the marked ventriculomegaly group, one case of partial agenesis of the corpus callosum was mistaken for a complete agenesis. In the group of borderline ventriculomegaly, two cases of partial agenesis of the corpus callosum were confused with a complete agenesis, while one case of suspected isolated ventriculomegaly was diagnosed after birth as partial agenesis of the corpus callosum. CONCLUSIONS: The sagittal scan of the fetal brain is a useful source of information and allows the contemporary view of both corpus callosum and posterior fossa, where various typical sonographic findings are present in ventriculomegaly.