Combined therapy with vaginal progesterone, Arabin cervical pessary and cervical cerclage to prevent preterm delivery in high-risk women.

PURPOSE: Preterm birth is the leading cause of perinatal morbidity and mortality. Vaginal progesterone cervical cerclage and Arabin cervical pessary are considered as preventive treatments in women at risk for preterm birth. However, there is less evidence as to which of these interventions is the preferred management. The current study aims was to compare the outcome of pregnancy in women with a short cervical length managed with 4 different treatment protocols: therapy with vaginal progesterone, cervical cerclage and an Arabin cervical pessary (group A), Arabin cervical pessary and vaginal progesterone (group B), cervical cerclage and vaginal progesterone (group C), or vaginal progesterone alone (group D). METHODS: A retrospective cohort study of singleton pregnancies managed in three tertiary medical centers between September 2011 and December 2017. RESULTS: In the study period, 286 pregnant women underwent vaginal ultrasonography between 15 and 29 weeks gestation. They all had a short cervical length (≤25 mm). Of these, 18 (6.3%), 120 (41.9%), 38 (13.3%) and 110 (38.5%) patients received treatment classifying them into groups A, B, C, and D, respectively. A significantly higher rate of patients in group A had either a history of cervical incompetence (44.4 versus 9.2 versus 7.9 and 0.9%, respectively, p = .0001) or a cervical procedure (61.1 versus 37.5 versus 28.9 and 27.3%, respectively, p = .027) compared to patients in group B, C, and D. Despite having a shorter cervical length at recruitment in group A (median (range); 14.5 (0-25) versus 15 (0-25) versus 15.5 (0-25) and 19 (2-25) mm, respectively, p = .002) the rate of spontaneous preterm delivery <37-week gestation was similar across groups (44.4 versus 32.5 versus 36.8 versus 32.7%, respectively, p = .665). CONCLUSION: A combined rescue therapy involving vaginal progesterone, cervical cerclage, and Arabin cervical pessary emerges as a promising management strategy in pregnant women who have a short cervical length and a high background risk for preterm delivery. This combination may prolong their pregnancy and safely bring them near term. Additional studies are needed to confirm these preliminary findings.

Down's syndrome screening at 11-14 weeks' gestation using prenasal thickness and nasal bone length.

PURPOSE: To perform a multicenter prospective study of ultrasound prenasal thickness (PT), and nasal bone length (NBL) measurement at 11-14 weeks' gestation. METHODS: Ultrasound PT and NBL determination was performed in 504 normal fetuses and 17 fetuses with Down's syndrome (DS). Measurements were made from mid-sagittal 2D images acquired using a standardized technique during nuchal translucency (NT) examination. PT and NBL values were expressed in multiples of the gestation-specific normal median (MoM) and as the PT/NBL ratio. Information on PT and NBL MoMs was also combined using logistic regression. Results were classified as positive according to whether they were greater than the normal 95th centile for PT, PT/NBL and the DS risk from logistic regression equation or below the 5th centile for NBL. RESULTS: The median value in DS cases and unaffected controls were: PT 1.26 and 0.996 MoM; and NBL 0.596 and 0.993 MoM. The proportion of DS fetuses with positive results was 41% for PT, 65% for NBL, and 82% for both the PT/NBL ratio and DS risk from the logistic regression equation. PT/NBL levels did not vary according to gestational age. CONCLUSION: The PT/NBL ratio is a valuable first trimester DS screening marker that can be easily determined concomitant with the NT measurement.

Prediction of Premalignant and Malignant Endometrial Polyps by Clinical and Hysteroscopic Features.

STUDY OBJECTIVE: To investigate whether hysteroscopic features can contribute to the diagnosis of malignancy in endometrial polyps. DESIGN: Retrospective review. SETTING: Obstetrics and gynecology department. PATIENTS: All women who underwent operative hysteroscopy for the removal of endometrial polyps between January 2012 and September 2017. Their medical records were reviewed, and information on medical, surgical, and obstetric history and hysteroscopic findings (including the number, size, and vascular appearance of the polyps) were abstracted. INTERVENTIONS: Operative hysteroscopy with resection or biopsy of endometrial polyps. MEASUREMENTS AND MAIN RESULTS: Five hundred fifty-six women were included in the study. Their mean age was 55.4 ± 12.4 years, and 322 (57.9%) were menopausal. Endometrial carcinoma was found in 26 (4.7%) cases, whereas endometrial hyperplasia was found in 5 (0.9%) cases. Endometrial carcinoma or hyperplasia was significantly associated with patients' age, menopausal status, increased polyp vascularity on hysteroscopy, and the presence of 3 or more polyps on hysteroscopy (p <.01 for all comparisons). However, the size of the largest polyp was not associated with endometrial carcinoma or hyperplasia. On logistic regression analysis, only increased polyp vascularity was associated with endometrial carcinoma or hyperplasia (odds ratio =13.5; 95% confidence interval, 5.6-32.3; p <.001). The sensitivity, specificity, positive predictive value, and negative predictive value of polyp vascularity for the diagnosis of polyps of nonbenign pathology were 51.6%, 94.3%, 34.8%, and 97.1%, respectively. CONCLUSION: Hysteroscopic findings of increased vascularity of endometrial polyps and numerous endometrial polyps may suggest the diagnosis of malignant polyps, in addition to demographic parameters such as age and menopausal status.

[THE SECOND VICTIM: TREATING THE HEALTH CARE PROVIDERS].

INTRODUCTION: During their professional careers, physicians and other health care providers are repeatedly exposed to emotional stress. This is usually secondary to coping with the results of a medical error or complicated medical event. Generally, in the above cases, the patient and his/her family are in the center of the medical system, being "the first victim" of such an event, while the involved caregiver, who provided the medical service, is categorized as the "second victim". "Second victims" may feel anxiety, fear, guilt or anger and experience social withdrawal, which may lead to troubling memories, depression and insomnia. Over the years, this situation may lead to deterioration in his/her work and personal life and, in rare circumstances, may lead to pharmaceutical and even alcohol consumption. In the literature there are even some rare case reports of "second victims" who have committed suicide. To meet these challenges, several leading institutions in western countries have developed formal support programmes that allow health care providers to cope with their emotional distress by obtaining timely support in an emphatic, confidential, non-judgmental environment. The above scheme of support is not meant to disrupt any correct medical investigation or to stand between the "second victim" and his superiors, but rather to allow them to cope with these events. We believe that the time has come to develop national support programs appropriate to our culture and behavioural circumstances. Local health care organizations should build a supporting scheme for the "second victims", helping them to cope with these events, thereby assisting them to return to their daily work and former routine.

Intrapartum fever at term: clinical characteristics and placental pathology.

OBJECTIVES: To investigate the association between clinical characteristics and placental histopathology in women with intrapartum fever (IPF) at term. METHODS: Maternal characteristics, intrapartum parameters, neonatal outcome and placental pathology were compared between 120 patients with IPF (≥ 380C) and a control group matched for mode of delivery. Placental lesions were classified as consistent with maternal circulation abnormalities or fetal thrombo-occlusive disease or inflammatory responses of maternal (MIR) or fetal (FIR) origin. RESULTS: Compared to controls the study group was characterized by significantly higher rates of nulliparity, extra-amniotic balloon induction of labor, and epidural anesthesia, higher gestational age, higher white blood cell count, and more vaginal examinations. On multivariate logistic regression analysis, multiple vaginal examinations were independently associated with IPF. MIR was detected in 71% of the study group compared to 21% of controls (p < 0.001), and FIR, in 32.5% and 7.5%, respectively (p < 0.001). IPF was independently associated with inflammation of maternal origin (adjusted odds ratio (OR) 8.0, 95% CI 4.2-15.2, p < 0.001) and fetal origin (adjusted OR 5.2, 95% CI 2.07-13.4, p < 0.001). Neonatal outcome was similar in the two groups. CONCLUSIONS: Multiple vaginal examinations are a significant risk factor for the development of IPF. IPF at term is independently associated with placental inflammatory lesions.