The prognostic value of antenatal ultrasound in cases complicated by fetal ovarian cysts.

OBJECTIVE: Ovarian cysts are relatively common prenatal findings in female fetuses. The aim of this study is to evaluate the ability of antenatal ultrasound in predicting spontaneous regression or a need for surgery. DESIGN: All cases of fetal ovarian cysts treated in our Department between 2007 and 2016 were included. Patients underwent a sonographic monitoring in utero and after birth until spontaneous or surgical resolution. Subjects were divided into two groups according to their postnatal management. Receiver-operating characteristics (ROC) curves were used to test the predictive ability for postnatal surgery of the cyst's mean and maximum diameters; their optimal cut off points were also determined. RESULTS: 38 cases of antenatally-detected fetal ovarian cysts were included. 12/38 cases underwent surgery (Group A). 26/38 cases were resolved spontaneously (Group B). Cyst size of those which were surgically excised significantly differed from those that regressed spontaneously. ROC curve pointed to 45 mm and 47 mm as optimal cut off points for the mean and the maximum cystic diameters, respectively. CONCLUSIONS: Cyst size and echo-structure seemed good predictors for prognosis after birth. The optimal cut off points of the cysts mean and maximum diameters in predicting postnatal surgery have been identified as 45 mm and 47 mm, respectively.

Frailty Related Factors as Predictors of Functional Recovery in Geriatric Rehabilitation: The Sarcopenia And Function in Aging Rehabilitation (SAFARI) Multi-Centric study.

BACKGROUND: Frailty-related characteristics, such as sarcopenia, malnutrition and cognitive impairment, are often overlooked, both in clinical practice and research, as potential contributors to functional recovery during geriatric rehabilitation. OBJECTIVE: The aim of the study was to identify frailty-related characteristics associated with functional recovery in a cohort of post-orthopedic surgery and post-stroke older adults. DESIGN: Multi-centric cohort study. Participanst and Settings: Patients over 65 years, admitted to three geriatric rehabilitation units, in Spain and Italy, after an orthopedic event or a stroke, from December 2014 to May 2016. MEASUREMENTS: The Absolute Functional Gain (AFG) defined as the difference between Barthel Index score at discharge and at admission, and the Relative Functional Gain (RFG) that represents the percentage of recovery of the function lost due to the event, were selected as outcomes. Both outcomes were analyzed as continuous and dichotomous variables. Analyses were also stratified as diagnostic at admission. RESULTS: We enrolled 459 patients (mean age±SD=80.75±8.21 years), 66.2% women, 69.5% with orthopedic conditions and with a length of stay of 28.8±9.1 days. Admission after a stroke (Odds Ratio=0.36, 95% Confidence Interval=0.22-0.59]) and a better functional status at admission (OR=0.96, 95% CI=0.94-0.97), were associated with a lower likelihood of AFG, while a better pre-event Barthel index (OR=1.03 for each point in score, 95% CI=1.01-1.04), being able to walk (OR=2.07, 95% CI=1.16-3.70), and a better cognitive status at admission (OR=1.05, 95% CI=1.01-1.09), were associated with a higher chance of AFG. Post-stroke patients with delirium at admission had a re-duced chance of AFG (OR=0.25, 95% CI=0.07-0.91]). Patients admitted after an ortho-pedic event with better pre-event functional status (OR=1.04, 95% CI=1.02-1.06) and able to walk at admission (OR=2.79, 95% CI=1.29-6.03]) had an increased chance of AFG. Additionally, in both diagnostics groups, a better handgrip strength increased the chance of RFG. CONCLUSIONS: Among frailty-related variables, physical, cognitive and muscular function at admission could be relevant for functional improvement during geriatric reha-bilitation. If confirmed, this data might orient targeted interventions.

PP057. The role of uterine artery pulsatility index for prediction of pregnancy outcome, in women affected by pre-eclampsia.

INTRODUCTION: Uterine artery (UtA) Pulsatility index assessed in the second trimester is known to be the best predictor of Pre-eclampsia (PE) in women with risk factors. The role of this index when PE occurs seems to be related with clinical outcome. OBJECTIVES: To detect if there does exist a correlation between mean UtA PI, assessed at diagnosis of PE, and: (A) Gestational Age (GA) at delivery; (B) birth weight (BW) percentile. To detect the predictive value of mean UtA PI and the development of adverse pregnancy outcome (APO). METHODS: Cohort study on 100 consecutive singleton pregnancies complicated with pre-eclampsia referred to our Department from January 2010 and December 2011. Doppler evaluations were performed from diagnosis to delivery. Mean UtA PI obtained at time of diagnosis of PE were analysed. PE was defined according to ISSHP criteria. Clinical and perinatal outcomes were reviewed. APO was defined as Apgar score less than 7 at five minutes, pH <7.20; birth weight <5th percentile (SGA), stillbirth or neonatal death. Receiver-operating characteristics (ROC) curve was used to determine the predictive ability for subsequent development of APO. RESULTS: Maternal characteristics and main pregnancy outcomes are shown in Table 1. Fifty-six pregnancies developed APO. One case of stillbirth and four cases of neonatal death were observed. SGA occurred in 56/100 neonates; 52/95 (55%) live births were admitted to Neonatal Intensive Care Unit. Table 1. Mean UtA PI at diagnosis of PE was 1.40 (SD±0.28) in women that developed APO and 1.10 (SD±0.41) in women that did not develop APO (p=0.02). Pearson's Correlation coefficient for mean UtA PI and GA at Delivery was -0.533 (p=0.002); while for mean UtA PI and BW percentile was -0.466 (p=0.007). The prediction of subsequent development of APO, expressed as the area under ROC curve, was 61.6 (95% CI 0.44-0.79) for UtA PI at Diagnosis of PE. CONCLUSION: Our data confirm that mean UtA PI, assessed at diagnosis of PE, represent a good independent predictor for GA at delivery end BW percentile. However the predictive value for development of APO seems to be poor.

PP173. The role of mean artery blood pressure in the prediction of pre-eclampsia in pregnancies complicated with chronic hypertension.

INTRODUCTION: Chronic hypertension (CH) is a common disorder occurring in approximately 1-5% of pregnant women. Many studies emphasize that the development of superimposed preeclampsia (PE) is associated with high rates of adverse pregnancy outcome. Accurate prediction of women at risk for PE is crucial to judicious allocation of monitoring resources and use of preventive treatment, in order to improve maternal and neonatal outcome. Recent systematic review and meta-analysis showed that mean arterial pressure (MAP) is a better predictor for pre-eclampsia than systolic blood pressure and diastolic blood pressure OBJECTIVES: To detect the value of MAP in the first and second trimesters to predict PE in women with CH. To determine if MAP, assessed in the second trimester, can increase the predictive value for PE of II trimester UtA PI. METHODS: Cohort study on 100 consecutive singleton pregnancies complicated with CH referred to our Department from January 2008 to June 2011. Blood pressure was measured by a mercury sphygmomanometer at 11-14+6w and 23+0-25+6w, MAP was calculated. Doppler-velocimetry was performed at 23+0-25+6w, mean UtA PI was calculated. PE and CH were defined according to ISSHP criteria. Clinical and perinatal outcomes were reviewed. Receiver-operating characteristic (ROC) curves were used to determine the predictive ability of I and II trimesters MAP and II trimester mean UtA PI for subsequent development of PE. Logistic regression analysis was run to assess the additional value of II trimester MAP to II trimester UtA PI. RESULTS: Mean maternal age was 36 years (SD ±5yy); mean Body mass Index was 24Kg/mq (SD ±5Kg/mq); GA at I Trimester evaluation was 11+4w (SD ±1+5w); I trimester MAP was 100.46mmHg (mean, SD ±9.94mmHg); GA at Doppler and II trimester MAP was 24+4w (SD ±4dd); II trimester MAP 97.53mmHg (mean, SD ±10.27mmHg). Nineteen cases of PE were observed. Seventy patients were under prophylactic ASA 100mg oid. Fifty-two patients were under anti-hypertensive therapy from the first trimester. No differences in prevalence of PE were observed between patients in and out prophylactic treatment, as well as no differences in prevalence of PE were observed between patients under anti-hypertensive treatment or not. The prediction of subsequent development of PE, expressed as the area under ROC curve, was 0.469 (95% CI 0.34-0.59) for I trimester MAP; 0.659 (95% CI 0.55-0.76) for II trimester MAP; 0.748 (95% CI 0.65-0.83) for II trimester mean UtA PI; GA at delivery was 37+4w(mean, SD ±3+2w); mean BW was 2958g (SD ±735g); BW percentile was 38 (mean SD ±29 percentiles); mean BW z-Score was -0.63 (SD ±1.6). Logistic regression analysis showed that MAP does not increase the predictive ability of II trimester UtA PI in women with CH. CONCLUSION: In our findings, MAP seems not to be a good predictor for subsequent development of PE in women with CH, moreover, it seems to be not useful to increase the predictive value for PE of II trimester UtA PI. II trimester UtA PI has been confirmed to be the best predictor for subsequent development of PE.

Transabdominal uterine artery Doppler between 11 and 14 weeks of gestation for the prediction of outcome in high-risk pregnancies.

OBJECTIVE: To assess the value of early transabdominal uterine artery Doppler ultrasound for the prediction of gestational outcomes in pregnancies at high risk for preeclampsia. METHODS: This was an observational study. Doppler ultrasound of the uterine arteries at 11-14 weeks of gestation was performed in 76 women at high risk for preeclampsia. Abnormal uterine Doppler was defined by the presence of bilateral notching or by a mean resistance index (RI) >0.80. Adverse outcomes evaluated were preeclampsia, fetal growth restriction, placental abruption, intrauterine death, and complications requiring delivery before 34 weeks of gestation. RESULTS: Among 76 women, 30 (39%) had abnormal uterine Doppler and 46 (61%) had normal Doppler waveform configuration and RI. Abnormal uterine flow was related to a significantly higher incidence of preeclampsia (17% vs. 0%; p = 0.0041), fetal growth restriction (27% vs. 0%; p = 0.0002), intrauterine death (13% vs. 0%; p = 0.0109), and iatrogenic preterm delivery (20% vs. 2%; p = 0.0086). When the Doppler was normal, the negative predictive value for complications requiring delivery before 34 weeks was 98%. CONCLUSIONS: Normal impedance to flow in uterine arteries between 11 and 14 weeks of gestation is strongly related to a normal pregnancy outcome in women at high risk for preeclampsia.

Uterine artery velocimetry in patients with gestational hypertension.

OBJECTIVE: To evaluate whether abnormal uterine artery velocimetry in patients with pregnancy-induced hypertension is more predictive of the outcome of pregnancy than the presence of proteinuria and the severity of hypertension. METHODS: A retrospective study was conducted on 344 hypertensive pregnant women who underwent uterine artery Doppler investigation. Patients were classified as either preeclamptic or with gestational hypertension at follow-up 2 months after delivery. Pregnancy outcomes of patients with preeclampsia and gestational hypertension were correlated to uterine artery velocimetry. A further analysis was done dividing patients into mild and severe groups. RESULTS: An abnormal uterine Doppler was related to a significantly earlier week of delivery (32.5 versus 35.3 in preeclampsia, 33.6 versus 38.1 in gestational hypertension), a lower mean birth weight (1494 g versus 2320 g in preeclampsia, 1690 g versus 2848 g in gestational hypertension), and a higher number of growth-restricted fetuses (70% versus 23% in preeclampsia, 75% versus 20% in gestational hypertension). In both mild and severe hypertensive groups, abnormal uterine velocimetry was associated with a worse pregnancy outcome (delivery at week 33.1, versus 37.9 in the mild group; 32.7 versus 37.3 in the severe group; birth weight 1574 g versus 2741 g in the mild group; 1539 g versus 2742 g in the severe group). A multivariable analysis of the presence of proteinuria, severity of hypertension, and uterine Doppler revealed that only an abnormal uterine Doppler was significantly related to adverse perinatal outcome (P <.001). CONCLUSION: Abnormal uterine Doppler was the variable that was more frequently associated with adverse pregnancy outcome.

Management of hirsutism.

This review reports our own experience with, and literature studies of, the pharmacological management of hirsutism in women with hyperandrogenism (polycystic ovary syndrome) or with normal serum androgen levels and regular ovulatory menstrual cycles (idiopathic hirsutism). Treatment consists of suppressing ovarian or adrenal androgen secretion, or blocking androgen actions in the skin. The major drugs used are gonadotropin-releasing hormone (GnRH) agonists, combined oral contraceptives (COCs), and steroidal (cyproterone acetate and spironolactone) or nonsteroidal (flutamide and finasteride) antiandrogens. GnRH agonists, suppressing the pituitary, decrease androgen and estradiol secretion and improve severe hirsutism. To avoid estrogen deficiency problems, 'add back' therapy with estrogen-progestogen or COCs is advisable. This method of treatment is complicated and expensive, limiting its use to severe forms of ovarian hyperandrogenism with hyperinsulinemia. The third-generation COCs, containing new progestogens or cyproterone, have very restricted effectiveness in the short term (6 cycles), but their long term use (> 12 cycles) cures mild-to-moderate hirsutism and improves severe hirsutism. As well as suppressing gonadotropins and ovarian androgen steroidogenesis, these formulations decrease free testosterone levels and may also decrease adrenal androgen production. In women being treated with antiandrogens, COCs are important to provide control of the menstrual cycle and contraception. Cyproterone, a progestational agent, inhibits gonadotropin secretion and blocks androgen action. It is used in COCs or in a reverse sequential regimen. In the latter, it is very effective in the short term treatment of hirsutism. Spironolactone blocks androgen receptors. Its effectiveness in hirsutism is dosage-dependent: low dosages are less active than other antiandrogens, whereas high dosages (200 mg/day) are very effective at the cost of several adverse effects (particularly dysfunctional uterine bleeding), but the concomitant use of a COC may prevent these. Flutamide is a pure antiandrogen that blocks androgen receptors and inhibits hair growth. It is very effective in treating hirsutism within 6 to 12 months. Dry skin is very frequent during treatment with flutamide, and hepatotoxicity is possible at high dosages. Finasteride, a 5 alpha-reductase type 2 inhibitor, is the least effective antiandrogen, but a dosage of 5 mg/day decreases hirsutism without adverse effects. Pregnancy must be avoided during therapy with antiandrogens because of the possible risk of abnormal development of a male fetus. Antiandrogens, especially flutamide (250 to 500 mg/day) and cyproterone (12.5 to 50 mg/day in a reverse sequential regimen), alone or in association with COCs, seem to be the most effective agents for the treatment of hirsutism.