Splenic artery aneurysm in obstetrical patients: A series of four cases with different clinical presentation and outcome.

OBJECTIVE: To describe four consecutive cases of splenic artery aneurysm (SAA) with different clinical patterns of presentation among obstetrical patients. METHODS: A series of four cases of SAA diagnosed in pregnant or postpartum women at our University center between January 1998 and December 2020. Clinical and radiologic data were retrospectively obtained by reviewing paper and electronic medical records after acquiring patient's consent. RESULTS: One case was completely asymptomatic and incidentally identified at the beginning of pregnancy, thus allowing for multidisciplinary treatment. The other three cases were unknown: two manifested with maternal collapse due to aneurysm rupture in the third trimester of gestation, whereas one presented with acute abdominal pain during the postpartum period and was successfully managed before rupture occurred. CONCLUSION: Although extremely rare, SAA rupture in obstetrical patients can be associated with dramatic consequences. Early suspicion and prompt intervention are essential to avoid fatal outcomes, so promotion of knowledge of all the potential clinical patterns of presentation of SAA rupture among obstetrical patients is mandatory.

Treatment of first trimester miscarriage: a prospective cohort study in a large tertiary care center in Northern Italy.

OBJECTIVE: To assess acceptability, efficacy, and short- and medium-term complications of vaginal misoprostol therapy for the treatment of first trimester miscarriage. STUDY DESIGN: A prospective cohort study including women admitted to the Unit of Obstetrics, MBBM Foundation, San Gerardo Hospital (Monza, Italy) for medical or surgical treatment of first trimester miscarriage between October 2014 and March 2018. As per Institutional protocol, patients in the medical therapy group received 800 µg of misoprostol vaginally. A second dose could be considered 3 days after the first administration if that was ineffective. Surgical treatment consisted of uterine vacuum aspiration. Success of misoprostol treatment was defined as the expulsion of the gestational sac with no need for subsequent surgery. RESULTS: During the study period, 967 patients were diagnosed with first trimester miscarriage and were included in the study. Of these, 514 (53.2%) women were eligible for and consented to medical therapy. Surgical treatment was performed in the remaining 453 (46.8%) patients due to either medical contraindication to misoprostol or patient's choice. Acceptance of misoprostol as first therapeutic choice increased over time, becoming the preferred treatment after approximately 18 months of use in clinical practice. One dose of misoprostol was successful in 69.8% (n = 359) of patients, whereas 20 women required urgent surgery for bleeding (n = 19) or suspected infection (n = 1). Among the remaining 135 patients, 20 (14.8%) refused the second dose of misoprostol and opted for surgery. Expulsion of the gestational sac was obtained in 74 additional cases who completed the medical protocol, for an overall success rate of 87.7% (433/494). The majority of women receiving misoprostol did not experience any short-term complication (92.0%) or side effect (93.8%). Eight (1.6%) cases requiring delayed surgery (hysteroscopy or vacuum aspiration) for retained product of conception were identified at the postmedical treatment follow up, thus leading to an actual success rate of misoprostol of 86.0% (n = 425). CONCLUSIONS: This is the first study assessing the acceptability, efficacy, and complication rate of medical management of first trimester miscarriage in an Italian tertiary care center. Our results confirm that misoprostol alone is an effective as well as a safe therapeutic option for the treatment of first trimester miscarriage.

Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis.

OBJECTIVE: We performed an individual participant data (IPD) metaanalysis to calculate the recurrence risk of hypertensive disorders of pregnancy (HDP) and recurrence of individual hypertensive syndromes. STUDY DESIGN: We performed an electronic literature search for cohort studies that reported on women experiencing HDP and who had a subsequent pregnancy. The principal investigators were contacted and informed of our study; we requested their original study data. The data were merged to form one combined database. The results will be presented as percentages with 95% confidence interval (CI) and odds ratios with 95% CI. RESULTS: Of 94 eligible cohort studies, we obtained IPD of 22 studies, including a total of 99,415 women. Pooled data of 64 studies that used published data (IPD where available) showed a recurrence rate of 18.1% (n=152,213; 95% CI, 17.9-18.3%). In the 22 studies that are included in our IPD, the recurrence rate of a HDP was 20.7% (95% CI, 20.4-20.9%). Recurrence manifested as preeclampsia in 13.8% of the studies (95% CI,13.6-14.1%), gestational hypertension in 8.6% of the studies (95% CI, 8.4-8.8%) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome in 0.2% of the studies (95% CI, 0.16-0.25%). The delivery of a small-for-gestational-age child accompanied the recurrent HDP in 3.4% of the studies (95% CI, 3.2-3.6%). Concomitant HELLP syndrome or delivery of a small-for-gestational-age child increased the risk of recurrence of HDP. Recurrence increased with decreasing gestational age at delivery in the index pregnancy. If the HDP recurred, in general it was milder, regarding maximum diastolic blood pressure, proteinuria, the use of oral antihypertensive and anticonvulsive medication, the delivery of a small-for-gestational-age child, premature delivery, and perinatal death. Normotensive women experienced chronic hypertension after pregnancy more often after experiencing recurrence (odds ratio, 3.7; 95% CI, 2.3-6.1). CONCLUSION: Among women that experience hypertension in pregnancy, the recurrence rate in a next pregnancy is relatively low, and the course of disease is milder for most women with recurrent disease. These reassuring data should be used for shared decision-making in women who consider a new pregnancy after a pregnancy that was complicated by hypertension.

Infants weighing <1500 g: better born too small or too soon?

OBJECTIVE: To evaluate the influence of intrauterine growth on intact neurological outcome at 12 to 24 months in a cohort of infants weighing <1500 g at birth. STUDY DESIGN: This retrospective study was conducted in the Department of Obstetrics and Gynecology, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy. Perinatal variables were correlated with occurrence of composite adverse outcome, including neonatal death or adverse neurodevelopmental outcome (ANDO), at 12 to 24 months' follow-up, in 240 consecutive very low-birth-weight (VLBW) neonates prenatally classified as growth restricted (IUGR; n = 100) or appropriate for gestational age (n = 140). RESULTS: Among the 214 surviving neonates, neurological follow-up was available in 163. ANDO was present in 46 children (28%). At multivariate analysis, only gestational age at delivery was independently related to the composite outcome (p < 0.001, odds ratio = 0.69, 95% confidence interval 0.59, 0.81), whereas diagnosis of IUGR was not. CONCLUSION: Only gestational age at delivery was significantly associated with composite adverse outcome in VLBW preterm infants.

Prediction of superimposed preeclampsia using uterine artery Doppler velocimetry in women with chronic hypertension.

OBJECTIVE: To assess the role of uterine artery (UtA) Doppler to predict superimposed preeclampsia in women with chronic hypertension. METHODS: In a cohort of 182 women with chronic hypertension, UtA Doppler studies were performed before 25 weeks (mean 19.7 +/- 2.1 weeks) and repeated later in pregnancy (mean 28.5 +/- 3.7 weeks). RESULTS: The incidence of preeclampsia was 13% (24/182). Rates of preeclampsia increased with advancing gestation of abnormal UtA Doppler: 7% when UtA Doppler were normal at early exam, 18% when abnormal at early exam, and 28% when abnormal at late exam (Chi-square for trend: P < 0.001). The rate of preeclampsia among 40 women with abnormal early but normal late UtA Doppler was similar to that of women with normal findings at early exam (8 vs 7%; P = 1.00). Logistic regression analysis showed that the ability of UtA Doppler to predict preeclampsia was independent from other variables [Odds Ratio (OR) 7.1, 95% Confidence Interval (CI) 2.6-18.9). Receiver operating characteristic (ROC) curve identified a UtA value of 0.58 as the optimal threshold for the prediction of preeclampsia. CONCLUSION: The later in pregnancy the abnormal UtA Doppler findings are observed, the greater the risk of preeclampsia. Normalization of UtA Doppler after 25 weeks reduces the risk of preeclampsia to 8%.

Antenatal predictors of neonatal outcome in fetal growth restriction with absent end-diastolic flow in the umbilical artery.

OBJECTIVE: Absent end-diastolic blood flow in the umbilical artery identifies growth-restricted fetuses at high risk of perinatal mortality and severe morbidity. We explored antenatal variables predictive of perinatal mortality or severe neonatal morbidity in such fetuses. STUDY DESIGN: We accessed a cohort of 39 singleton, non-malformed, growth-restricted fetuses with absent end-diastolic blood flow at less than 34 weeks between January 1995 and December 2004. The ratio of umbilical artery pulsatility index to middle cerebral artery pulsatility index was calculated to assess redistribution of the fetal arterial circulation. Prenatal and neonatal variables were compared between subjects with versus those without perinatal mortality or severe morbidity using unpaired Student t test or Fisher exact test. Statistical analysis included stepwise logistic regression and receiver operating characteristic curve analysis. P < .05 was considered significant. RESULTS: Stepwise logistic regression analysis demonstrated that the last umbilical artery/middle cerebral artery ratio (P = .02) and estimated fetal weight before delivery (P = .02) were independent predictors of adverse neonatal outcome, with an umbilical artery/middle cerebral artery ratio 1.9 or greater having a sensitivity of 75% and a 13% false-positive rate. Umbilical artery/middle cerebral artery ratio alone accounted for 54% of the variability in outcome. CONCLUSIONS: Among preterm growth-restricted fetuses with absent end-diastolic blood flow in the umbilical artery, the umbilical artery/middle cerebral artery ratio is the best predictor of neonatal mortality or severe morbidity.