Proposed clinical management of pregnancies after combined screening for pre-eclampsia at 19-24 weeks' gestation.

OBJECTIVE: To estimate the patient-specific risk of pre-eclampsia (PE) at 19-24 weeks' gestation by a combination of maternal characteristics and medical history with multiples of the median (MoM) values of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFlt-1), and stratify women into high-, intermediate- and low-risk management groups. METHODS: This was a prospective observational study in women attending a second-trimester ultrasound scan at 19-24 weeks as part of routine pregnancy care. Patient-specific risks of delivery with PE < 32 weeks and < 36 weeks' gestation were calculated using the competing-risks model to combine the prior risk from maternal characteristics and medical history with MoM values of MAP, UtA-PI, PlGF and sFlt-1. On the basis of these risks, the population was stratified into high-, intermediate- and low-risk groups. Different risk cut-offs were used to vary the proportion of the population stratified into each risk category and the performance of screening for delivery with PE at < 32 weeks' gestation, at 32-35 weeks and at ≥ 36 weeks was estimated. In addition to empirical performance, we also derived model-based performance because the number of cases of PE delivering < 32 weeks was low. RESULTS: The study population of 7748 singleton pregnancies included 268 (3.5%) that subsequently developed PE. Using a risk cut-off of 1 in 100 for PE delivering < 32 weeks' gestation and a risk cut-off of 1 in 300 for PE delivering < 36 weeks, the proportion of the population stratified into high-, intermediate- and low-risk was 0.9%, 17.2% and 81.9%, respectively. The high-risk group contained 97% of pregnancies with PE < 32 weeks and 45% of those with PE at 32-35 weeks. The intermediate-risk group contained a further 46% of women with PE at 32-35 weeks. The low-risk group contained only 0.03% of pregnancies with PE < 32 weeks and 9% of those with PE at 32-35 weeks. CONCLUSION: Risk stratification of PE by the combined test at 19-24 weeks' gestation can identify, first, a group which constitutes < 1% of the total population and contains > 95% of those that will develop PE < 32 weeks and are in need of intensive monitoring at 24-31 weeks and, second, a group which constitutes < 20% of the total and contains > 90% of those that will develop PE at 32-35 weeks and are in need of reassessment at 32 weeks. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Impact of holoprosencephaly, exomphalos, megacystis and increased nuchal translucency on first-trimester screening for chromosomal abnormalities.

OBJECTIVES: To examine the prevalence of alobar holoprosencephaly, exomphalos, megacystis and nuchal translucency thickness (NT) ≥ 3.5 mm, the incidence and types of chromosomal abnormalities associated with these conditions and their overall impact on the rate of invasive testing and performance of screening at 11-14 weeks. METHODS: This was a prospective screening study for trisomies 21, 18 and 13 by the first-trimester combined test at three maternity units in England. RESULTS: In the study population of 108 982 singleton pregnancies, 870 (0.8%) had abnormal karyotype, including 654 (75.2%) with trisomies 21, 18 or 13 and 216 (24.8%) with other chromosomal abnormalities. The prevalence of alobar holoprosencephaly, exomphalos, megacystis and NT ≥ 3.5 mm was 1 in 2945, 1 in 419, 1 in 1345 and 1 in 119, respectively. Chromosomal abnormalities were observed in 78.4% of cases of holoprosencephaly, 40.8% of exomphalos, 18.5% of megacystis and 48.5% of those with NT ≥ 3.5 mm. The most common chromosomal abnormality associated with holoprosencephaly was trisomy 13, with exomphalos and megacystis was trisomy 18 and with increased NT was trisomy 21. Fetal karyotyping of cases with major fetal defects or increased NT would potentially detect 57% of all chromosomal abnormalities at an invasive testing rate of 1.1%. CONCLUSION: Major fetal defects and increased NT at 11-13 weeks' gestation are associated with a high risk of chromosomal abnormalities and merit invasive fetal testing. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Minilaparotomic myomectomy for large symptomatic uterine myomas: a prospective study.

AIM: The aim of this paper was to evaluate the feasibility, morbidity, and reproductive performance of fertile women undergoing minilaparotomic myomectomy for large uterine myomas. METHODS: Ninety-nine consecutive women with symptomatic myomas underwent myomectomy through a skin incision ≤8 cm. Operative, postoperative and reproductive data were prospectively collected. RESULTS: Median (range) age and Body Mass Index (BMI) were 37 years (23-44) and 23 (18-43), respectively. Median (range) myoma diameter was 7 cm (4-20), and the median number of myomas removed was 1 (range 1-31). Myomas were intramural in 76 (76%) cases. Median incision length was 7 cm (range 4-13) and median duration of surgery was 70 min (range 40-180). Operative time and length of skin incision were not correlated with the progressive number of interventions. An incision larger than 8 cm was necessary in 7 (7%) patients and the length of incision was significantly correlated with the diameter of the largest myoma (P<0.01). The feasibility of minilaparotomy was significantly reduced when the diameter of the largest myoma was >12 cm (P<0.05). Operative time was significantly longer in patients having >1 myoma (P<0.05). Three (3%) patients underwent blood transfusion. Median (range) postoperative stay was 2 days (range 2-12). Fever occurred in 8 (8%) patients, and wound complications in 5 (5%). CONCLUSION: Myomectomy by minilaparotomy is a feasible procedure in more than 90% of unselected patients with large symptomatic myomas. Feasibility is questionable when the myoma is >12 cm. This technique is a mini-invasive option to treat patients with large and multiple myomas.