Successful rescue hysteroscopic resection of a cervical ectopic pregnancy previously treated with methotrexate with no combined safety precautions.

BACKGROUND: Cervical pregnancy (CP) is a life-threatening condition that represents less than one percent of all ectopic pregnancies. Transvaginal sonography (TVS) is the gold standard for an accurate diagnosis. For hemodinamically stable women the available treatments involve a medical therapy, alone or in combination with interventional measures (hysteroscopy, angiographic embolization or laparoscopic ligation of uterine arteries). MATERIALS AND METHODS: The authors describe a CP unsuccessfully treated with methotrexate (MTX), but resolved with hysteroscopy. CASE REPORT: A nulliparous woman arrived with low abdominal pain without vaginal bleeding at six weeks of amenorrhea. TVS revealed a gestational sac implanted in the isthmic cervical region, with a serum beta-hCG of 1,100 mUI/ml, that raised to 4,274 mUI/ml in a week, despite one intrasaccular-MTX injections and two systemic doses. The authors arranged for a hysteroscopic resection with no previous dilatation of the cervix. They did not adopt any safety precautions to their procedure. CONCLUSION: It is difficult to define the exact role of hysteroscopy regarding CP. Despite some authors dispute on its complementary function to MTX, the authors believe that it could be used as a rescue method in case of MTX failure. The final aims of a proper management are to minimize the risk of haemorrhage and preserve women's fertility.

First trimester maternal serum PIGF, free ß-hCG, PAPP-A, PP-13, uterine artery Doppler and maternal history for the prediction of preeclampsia.

OBJECTIVE: To evaluate the detection of pregnancy hypertensive disorders by integrating maternal history, serum biomarkers and uterine artery Doppler in the first trimester. METHODS: We prospectively recruited 2118 women that underwent an 11-13 weeks aneuploidy screening. We gathered information on maternal history, uterine artery Doppler and serum biomarkers (PAPP-A, PlGF, PP-13 and free ß-hCG). Models were developed for the prediction of overall preeclampsia (PE), early-onset PE, late-onset PE and gestational hypertension (GH). For each outcome, we performed a multivariate logistic regression starting from the saturated model: adopting a step-down procedure we excluded all factors not statistically significant (p > 0.05). Sensitivity models only for statistically significant parameters were calculated from the ROC curves for fixed false-positive rates (FPR). RESULTS: Among 2118 women, 46 (2.17%) developed GH and 25 (1.18%) were diagnosed with PE, including 12 (0.57%) early-onset PE and 13 (0.61%) late-onset PE. For a fixed FPR of 10 and 5%, serum PlGF, free ß-hCG and chronic hypertension identified respectively 67 and 75% of women who developed early-onset PE. In the model for the prediction of overall PE the combination of the uterine artery Doppler pulsatility index (UtA PI) with PlGF and chronic hypertension reached a sensitivity of 60% for a 20% of FPR. CONCLUSION: An integration of maternal characteristics and first trimester maternal serum biomarkers (free ß-hCG and PlGF) provided a possible screening for early-onset PE. In the overall PE model, UtA PI turned out to be statistically significant but did not improve the detection rate.

Giant omphaloceles with a small abdominal defect: prenatal diagnosis and neonatal management.

A giant omphalocele is a liver-containing protrusion through an abdominal defect wider than 5 cm in diameter. The giant form with a small abdominal wall defect is a rare condition which, to our knowledge, has not been described previously. We describe three cases with the typical features of elongated vascular liver pedicle and angiomatosis of the hepatic portal system. The abnormal liver organogenesis, due to extra-abdominal development, represented a significant risk factor for hepatic thrombosis after visceral reduction and liver rotation. All the neonates underwent surgery on the first day of postnatal life. One died because of a postoperative liver infarction, and the survivors needed prolonged respiratory support. Prenatal sonographic features, timing, delivery, type of surgical repair, and postnatal outcome are reviewed. A prenatal sonographic diagnosis could be useful to evaluate the abdominal ring and serial ultrasound examinations are recommended to detect promptly ominous signs of hepatic and bowel damage. Color Doppler may be useful to assess the anatomy of the abdominal vessels and their relationships with the herniated organs, although it was not used in any of the cases reported here. This congenital malformation might be considered as a pathological entity separate from giant omphalocele with large abdominal defect, with a severe prognosis due possibly to its different embryological development.

Does cervical length at 13-15 weeks' gestation predict preterm delivery in an unselected population?

OBJECTIVE: To assess the role of early mid-trimester cervical length measurement as a predictor of spontaneous preterm birth in an unselected population. METHODS: In this prospective study, unselected, asymptomatic, Caucasian women with singleton pregnancies underwent standardized transvaginal ultrasonographic (TVS) cervical length measurement at 13-15 weeks' gestation as a screening test for preterm delivery (PTD). Women with multiple gestations, iatrogenic PTD, and previous cervical conization were excluded. The primary outcome measures were spontaneous PTD at < 37 and < 34 weeks. The correlation between cervical length and previous obstetric history was evaluated. RESULTS: A total of 2469 patients met the inclusion criteria. The mean gestational age at cervical assessment was 14 + 2 weeks. The mean gestational age at delivery was 40 + 0 weeks. The rate of spontaneous deliveries before 37 weeks' gestation was 1.7%. In 0.2% the delivery occurred before 34 weeks' gestation. The mean +/- standard deviation cervical length for the entire population was 44.2 +/- 5.4 mm. No difference was observed between cervical length in women that delivered at term and those that delivered either before 37 or before 34 weeks' gestation. Previous obstetric history (prior preterm birth, previous miscarriages and terminations, and parity) did not affect cervical length at 14 weeks of gestation. CONCLUSIONS: Performed at 14 weeks' gestation, TVS measurement of the cervical canal length to predict spontaneous PTD is not a reliable screening procedure.

Does amniotic fluid alpha-fetoprotein have diagnostic or prognostic value at the time of second midtrimester genetic amniocentesis?

In order to assess the usefulness of amniotic fluid alpha-fetoprotein (AFP) levels at the time of midtrimester genetic amniocentesis, 4,430 cases were retrospectively studied to compare the high, normal or low AFP values with the karyotype characteristics and fetal anatomy using ultrasound (US) scanning and confirmed by postnatal evaluation or necroscopy in the case of termination of pregnancy. All the cases presenting malformations were correctly diagnosed by US examinations. AFP levels over the 2nd standard deviation (SD) were found in 112 cases (2.52%) and below the 2nd SD in 11 cases (0.24%). The characteristics of these cases are presented and discussed. According to our results, it is concluded that routine assessment of AFP at the time of midtrimester genetic amniocentesis, if coupled with optimal US scanning, is no longer justified.

Early screening for fetal cardiac anomalies by transvaginal echocardiography in an unselected population: the role of operator experience.

OBJECTIVES: To examine the accuracy of early transvaginal fetal echocardiography performed in an unselected population by operators with different levels of experience and to compare the results with those obtained from a referral population. DESIGN: Prospective study. METHODS: A series of 4785 unselected fetuses and 221 referred fetuses were screened at 13-15 weeks' gestational age by transvaginal echocardiography. For each fetus, visualization of the four-chamber view plus the origin of the great arteries was attempted. Color Doppler imaging was only performed in cases of cardiac malformations already identified by two-dimensional echocardiography. The scans were performed by seven operators with different levels of experience. Reliability was assessed by conventional transabdominal echocardiography at 20-22 weeks, by postnatal follow-up in the first 3 months of life, and/or by autopsy in all cases of termination or fetal death. RESULTS: The rate of complete visualization (four-chamber view plus great arteries) was 47.5% in the unselected population, and 76.9% in the referral population. There were four (0.08%) true positives among the unselected fetuses, and five (2.3%) among referrals, mostly with enlarged nuchal translucency or other malformations. Among the unselected fetuses, nine false negatives were detected by transabdominal echocardiography. Improvement in the operators' ability to recognize cardiac anomalies in unselected population was disappointing and was influenced more by individual approach than by the number of examinations performed. CONCLUSIONS: Early screening for cardiac anomalies among unselected fetuses is ill-advisable. The usefulness of an early approach is confirmed in high risk fetuses or in the presence of enlarged nuchal translucency when performed by expert operators.

Comparisons of first and second trimester screening for fetal anomalies.

Four thousand fifty unselected pregnant women bearing a total of 4,078 fetuses were examined by transvaginal sonography (TVS) at 14 weeks of gestational age and rescreened via transabdominal sonography (TAS) at 21 weeks. Fifty-four of 88 anomalies were correctly identified at first scan whereas 34 were not; of these, 24 were discovered at second trimester rescreening, and the remaining 10 were observed later in pregnancy or after birth. The sensitivity of TVS screening with respect to final outcome was 61.4% (54 of 88 malformations in total) and 69.2% in comparison to TAS screening results (54 malformations detected among 78 recognized within 21 weeks). The association between fetal malformation and chromosomal aberrations was also investigated: in our study population there were 21 aneuploidies, 14 of which were recognized because of abnormal findings at the 14 weeks' TVS, 5 at the TAS rescreening, and 2 after birth in neonates free of structural abnormalities.

Computerised evaluation of fetal heart rate in post-term fetuses: long term variation.

Computerised fetal heart rate records were obtained between 1987 and 1993 using the Sonicaid System 8000 for a cross-sectional study of postdates fetal heart rate variation; 567 singleton pregnancies at 41 and 43 weeks provided 1502 records. In all cases gestational age had been verified by ultrasound examination in early pregnancy. The mean minute range of the long term pulse interval variation, which is known to be correlated with fetal oxygenation was found to decrease progressively from an average value of 48.5 ms at 41 weeks to 46.4 ms and 42.4 ms at 42 and 43 or more weeks, respectively. When conservative management of postdate pregnancies is chosen, accurate measurements are needed to follow the evolution of fetal condition. Reference values for calculated pulse interval variation at later gestational ages are now provided.

[Conservative management of ectopic pregnancy]. / Il management conservativo della gravidanza ectopica.

BACKGROUND: The aim of this retrospective study was to analyze the safety and efficacy of the conservative approach in the management of ectopic pregnancy. METHODS: Thirty-five women with a tubal ectopic pregnancy, from 1990 to 1995, were subdivided into 2 treatment groups. Inclusion criteria were the following: tubal diameter < 3 cm, free fluid < 100 ml, no embryo heart activity, haemodynamic stability. Desire of future fertility and informed consent were requested. Eighteen women were treated with a single intramuscular injection of methotrexate, whereas in 17 cases expectant management was adopted. RESULTS: In the first group 2 cases required surgical treatment (resolution rate = 89%). In the second group no surgery was needed and spontaneous resolution was achieved in all cases (100%). In both groups the average resolution time was about 17 days. Serum hCG-beta levels were monitored daily until resolution. The initial hCG-beta value and its following trend seem to be the most important prognostic factors. CONCLUSIONS: More studies are indeed needed to establish the effect of conservative management on fertility after ectopic pregnancy.

Screening for fetal anomalies by ultrasound at 14 and 21 weeks.

A prospective study of screening for fetal abnormalities and chromosomal defects was carried out by ultrasound examination at 13-15 weeks of gestation and 20-22 weeks; the first scan was performed transvaginally and the second transabdominally. During a 4-year period (1991-95), 3490 unselected consecutive pregnancies with a total of 3514 fetuses were examined. There were 21 chromosomally abnormal fetuses, including ten with trisomy 21, and, in 19 (90.5%), fetal defects were detected at the first and/or second ultrasound examination. The most effective marker for chromosomal defects was increased nuchal translucency thickness (> or = 4 mm) at the 13-15-week scan, which was present in seven of the ten fetuses with trisomy 21 and in six of the 11 with other chromosomal abnormalities.

Conotruncal anomalies in prenatal life.

This retrospective multicenter study represents an analysis of the intrauterine determinants of the prognosis for conotruncal anomalies. Data regarding reason for referral, presence of chromosomal or extracardiac anomalies, pregnancy and surgical outcome were recorded in 67 cases of conotruncal anomalies from three Italian referral units. Chromosomal aberrations effected 11 of the 60 (18.3%) fetuses in which a karyotype was available. Extra-cardiac malformations were present in 25/67 cases (37.3%). No chromosomal anomalies were present in fetuses with complete or corrected transposition of the great arteries. However, tetralogy of Fallot and double-outlet right ventricle were associated with chromosomal anomalies in 22% and 38% of cases, respectively, and with extracardiac anomalies in 45% and 46% of cases, respectively. Only 20 of the 67 (31%) cardiac malformations were associated with an abnormal four-chamber view. There were 28 (41.7%) terminations of pregnancy, six (8.9%) intrauterine deaths and 16 (23.8%) neonatal deaths. Seventeen neonates (25.3%) are currently alive, and 15 of these have undergone reparative surgery. The prognosis of conotruncal anomalies is poorer when the conditions is diagnosed in utero. This is mainly due to the frequent association with chromosomal and/or extracardiac anomalies, often leading to intrauterine or early neonatal death.

[The indications for the management of fetuses with choroid plexus cysts]. / Indicazioni per il management dei feti portatori di cisti dei plessi corioidei.

Choroid plexus cysts (CPC) in the fetus are still the subject of considerable debate in the literature. Because of their association with aneuploidy, and especially with trisomy 18, of which they are an ultrasonographic marker, the detection of fetal CPC now poses the problem of how these cases should be managed, since most occur in young women (there being no correlation between CPC and age), and since the incidence among the general population is fairly high (around 1%). With the aim of contributing further to the debate, a retrospective study was performed of all cases of fetal CPC diagnosed in our Centre between January 1984 and August 1994, together with a review of the relevant literature. There were 95 cases of fetal CPC with complete neonatal and necroptic data available. These cases included women recruited in the course of routine screening for congenital malformations carried out in our Centre at 14 and 21 weeks gestation, women referred to us from other Centres, and women recruited in the course of amniocentesis indicated for those aged over 35. In all cases in which fetal CPC was detected, a careful ultrasonographic examination was performed to exclude the presence of even the smallest morphologic anomaly. Whenever the fetus was found to have an anomaly karyotyping was done. If the CPC was not associated with any morphologic anomaly, karyotyping was proposed only to those women at risk of aneuploidy because of their age. There were 11 cases of trisomy 18, all of which presented morphologic anomalies associated with CPC. Some of these anomalies where "minor", however, and therefore difficult to assess even when a careful ultrasonographic examination was performed by an experienced operator (Intra ventricular septal defect, single umbilical artery). In 2 cases, CPC was associated with trisomy 21. Both women were aged over 35. All the other cases of CPC not associated with morphologic anomaly were normal on postnatal examination. From a meta-analysis of the literature, two distinct management protocols emerge for the problem of "isolated CPC detected at ultrasonographic examination". One group of authors recommends karyotyping for all women with fetal CPC, considering the presence of CPC in itself a risk factor for aneuploidy. The second group, to which we ourselves belong, believes it is sufficient to perform a careful ultrasonographic examination so as to exclude the presence of other morphologic anomalies associated with the CPC. Karyotyping should be proposed only to women at risk of aneuploidy because of their age (> 35). A review of the biggest series reported in the literature shows that, of a total of 1670 fetuses with CPC, 94 were trisomy 18. None of the cases of CPC "in isolation" emerged as being associated with this aneuploidy. However, numerous cases of trisomy 18 have been described in which CPC is associated with "minor" morphologic anomalies in the fetus which may be difficult to detect. It is therefore essential to perform a careful ultrasonographic examination in all cases of CPC, preferably in a Centre with specialist knowledge of ultrasonography. If this option is not available, then karyotyping of all women with fetal CPC is clearly advisable.

Fetal heart screening in low-risk pregnancies.

The aim of this study was to assess whether a screening program for fetal cardiac malformations is justified in a low-risk population, and which factors influence its accuracy. The fetal heart was evaluated in 7024 pregnant women at 20-22 weeks, and evaluation was repeated at a more advanced gestational age in 9% of cases. Cardiological follow-up was continued postnatally until 2 years of age. The overall prevalence of cardiac anomaly was 0.93%. The incidences of major and minor defects were 0.44% and 0.48%, respectively. There were 23 true positives (0.33%): in 20 cases, the diagnosis was made in the second trimester, and 13 women (65%) chose termination of pregnancy. Seventeen of the 20 cases identified in the second trimester were serious malformations. There were 42 false negatives (0.60%). Of these, 12 had signs of cardiac dysfunction at birth or within the 1st month of life, and three of them died as a result of their cardiac anomaly. There were eight false positives (0.11%), all of a minor type. Six abnormal karyotypes, out of a total of 21 performed in the true-positive group (28.5%), were found. In addition, five of the 42 newborns in the false-negative group had trisomy 21. The overall sensitivity was 35.4%, and 61.3% for major defects. The accuracy in two distinct periods was estimated because the level of experience of the operators was different: sensitivity was 45.2% in period 1 (1986-88) (77.8% for major defects) and 26.5% in period 2 (1989-92) (52.9% for major defects). We conclude that a fetal heart screening program in the obstetric population is justified. It defines a high-risk group for karyotyping, allows planning of delivery in a tertiary center or the choice of terminating the pregnancy for the parents and appears to have a positive cost-benefit ratio. A crucial factor is the level of training and experience of the operators, who need specific teaching support.

Endometrial assessment by transvaginal sonography and histological findings after D & C in women with postmenopausal bleeding.

A total of 149 women with postmenopausal bleeding underwent transvaginal sonography, hysteroscopy and dilatation and curettage in order to study the diagnostic accuracy of several ultrasound parameters in assessing endometrial pathology and to determine the most sensitive cut-off value of endometrial thickness for the exclusion of endometrial lesions. In distinguishing pathological from normal endometrium, transvaginal sonography showed a sensitivity of 69.3%, specificity of 82.7%, positive predictive value of 74.1% and negative predictive value of 72.1%. In detecting premalignant and malignant endometrial pathology, transvaginal sonography showed a sensitivity, specificity, positive predictive value and negative predictive value of 55%, 96.1%, 68.7% and 93.2%, respectively. Considering endometrial thickness as a single parameter, the most sensitive cut-off for defining normality was 4 mm; nevertheless, in the group of patients that had an endometrial thickness less than 4 mm, there was one case of malignancy (sensitivity, 95.2%; specificity, 49.4%; positive predictive value, 57.3%; and negative predictive value, 93.5%). Transvaginal sonography combined evaluation (morphology, thickness and color Doppler) showed a poor diagnostic accuracy in detecting endometrial pathology and in differentiating between endometrial benign lesions, endometrial polyps and adenocarcinoma in women with postmenopausal bleeding. Endometrial thickness evaluated with transvaginal sonography was preferable but not sensitive enough to exclude endometrial pathology.

Pilot screening for fetal malformations: possibilities and limits of transvaginal sonography.

Two thousand and ninety-seven unselected pregnant women bearing 2114 fetuses were examined by transvaginal sonography at 14 weeks of gestational age and rescreened via transabdominal sonography at 21 weeks (excluding those who chose termination of pregnancy). Twenty-five of 47 anomalies were correctly identified at the first scan, 15 malformations were missed and detected only during the scan, two were identified later in pregnancy, and five were identified after birth. Ten of 12 abnormalities were detected correctly on the basis of ultrasonographic findings. Transvaginal sonographic screening for fetal malformation, in our experience, permits the detection of more than 50% of all fetal structural defects and 75% of all aneuploidies early in pregnancy.

[The diagnostic capacities of transvaginal echography and hysteroscopy in the characterization of endometrial pathology]. / Capacità diagnostica dell'ecografia transvaginale e dell'isteroscopia nella caratterizzazione della patologia endometriale.

The diagnostic accuracy of transvaginal sonography (TVS) and hysteroscopy in the assessment of endometrial pathology was studied comparing retrospectively both methods with the results of histologic findings after dilatation and curettage (D&C) performed in the last four years on 467 patients, 155 of whom were in postmenopause. Endometrial thickness, tissue texture, myometrial invasion and haemodynamic characteristics were studied with TVS. Uterine cavity, endometrial patterns and superficial vascularization were evaluated by hysteroscopy. For the purpose of this study all histologic findings were subdivided to a) normal (206 cases); b) benign lesions (240 cases); c) atypical hyperplasia or adenocarcinoma (21 cases). In our experience hysteroscopy was superior to TVS in detecting endometrial pathology. Both techniques were more sensitive in detecting premalignant and malignant lesions. Considering endometrial thickness evaluated with TVS as a single parameter in patients in postmenopause, we found that the most sensitive cut-off for defining normality was 3 mm; nevertheless, in the group of patients that had an endometrial thickness equal to or less than 3 mm there were 2 cases of malignancy. Therefore, neither TVS nor hysteroscopy are sufficiently reliable to replace curettage in the diagnosis of endometrial pathology.

Early prenatal ultrasonographic diagnosis of osteogenesis imperfecta: a case report.

A case of lethal osteogenesis imperfecta detected at 14 weeks' gestation by transvaginal ultrasonography is described. The prenatal diagnosis of limb-shortening deformities caused by fractures and their repair is discussed.