Surgical embolectomy in a 34-week pregnant woman with high risk pulmonary embolism and haemodynamic instability.

Pulmonary embolism represents the leading cause of maternal mortality in developed countries. The optimal treatment of high-risk pulmonary embolism with cardiovascular instability and at high hemorrhagic risk is still debated but surgical embolectomy represents an effective option. We describe the case of a 35-year-old woman in week 34 of pregnancy who was referred to our hospital because of exertional dyspnea and tachycardia and a few hours later became hypotensive and hypoxic. Pulmonary embolism was detected by performing an angio-computed tomography (CT) scan. After a successful cesarean section, emergent embolectomy was performed without inducing uterine hemorrhage. Both mother and the newborn recovered without postoperative sequelae.

Correction to: Management of pregnancy-related issues in multiple sclerosis patients: the need for an interdisciplinary approach.

The original version contained a mistake. The authors have specified only in a few paragraphs that all the contents of the paper are meant for Copaxone but not for unbranded glatiramer acetate, Authors ask to add the specification of Copaxone or branded glatiramer acetate everytime.

Management of pregnancy-related issues in multiple sclerosis patients: the need for an interdisciplinary approach.

Multiple sclerosis (MS) is a demyelinating and neurodegenerative disease of the central nervous system (CNS), most probably autoimmune in origin, usually occurring in young adults with a female/male prevalence of approximately 3:1. Women with MS in the reproductive age may face challenging issues in reconciling the desire for parenthood with their condition, owing to the possible influence both on the ongoing or planned treatment with the possible consequences on the disease course and on the potential negative effects of treatments on foetal and pregnancy outcomes. At MS diagnosis, timely counselling should promote informed parenthood, while disease evolution should be assessed before making therapeutic decisions. Current guidelines advise the discontinuation of any treatment during pregnancy, with possible exceptions for some treatments in patients with very active disease. Relapses decline during pregnancy but are more frequent during puerperium, when MS therapy should be promptly resumed in most of the cases. First-line immunomodulatory agents, such as interferon-ß (IFN-ß) and glatiramer acetate (GA), significantly reduce the post-partum risk of relapse. Due to substantial evidence of safety with the use of GA during pregnancy, a recent change in European marketing authorization removed the pregnancy contraindication for GA. This paper reports a consensus of Italian experts involved in MS management, including neurologists, gynaecologists and psychologists. This consensus, based on a review of the available scientific evidence, promoted an interdisciplinary approach to the management of pregnancy in MS women.

Head-to-body delivery interval using 'two-step' approach in vaginal deliveries: effect on umbilical artery pH.

OBJECTIVE: To assess the duration of head-to-body interval using a 'two-step' approach to delivery that include waiting for the next contraction to deliver the shoulders; and its effect on umbilical artery pH and neonatal outcome. STUDY DESIGN: Prospective observational study on vaginal deliveries with singleton cephalic fetuses at term from June to December 2005. Clinical variables were evaluated in reference to umbilical artery pH and evidence of neonatal acidemia, defined as pH  ≤ 7.10 or base excess (BE) ≤ -12 in a multivariate model. RESULTS: Head-to-body interval was timed and recorded in 789 deliveries. The mean head-to-body interval was 88 ± 61 s. Although head-to-body interval was significantly correlated to umbilical artery pH (p = 0.02), the decline in umbilical artery pH in relation to the head-to-body interval was clinically not significant (0.0078 units for every additional minute of the interval). At the multivariate analysis, umbilical artery pH  ≤ 7.10 and/or BE  ≤ -12 were significantly related to abnormal fetal heart rate tracing during the second stage (p = 0.012) and operative vaginal delivery (p = 0.045), but not to head-to-body interval (p = 0.25). Shoulder dystocia occurred in three cases (0.38%). CONCLUSION: A 'two-step' approach to birth does not significantly increase the risk of neonatal acidemia.

Randomized study on removable PGE2 vaginal insert versus PGE2 cervical gel for cervical priming and labor induction in low-Bishop-score pregnancy.

BACKGROUND: Dinoprostone vaginal insert has been compared to Dinoprostone cervical gel in few studies, whose cases presented different Bishop scores and gestational ages at admission, and various treatment strategies in control arms. The present study compares the vaginal insert to the cervical gel in patients with low Bishop score at term. METHODS: Prospective multicenter randomized trial, with parity-based randomization. Admission criteria: single pregnancy with Bishop score of 0-4, gestational age of 37-41 weeks, intact membranes, no previous cesarean section, no bleeding or abnormal cardiotocography at admission. RESULTS: Vaginal prostaglandins were required as a second-line induction procedure in 25% of study patients versus 47.1% of controls (p < 0.03, chi2). Study patients experienced shorter induction-to-delivery time (920 +/- 428 versus 1,266 +/- 740 min, p <0,01), with a mean difference of 5 h and 46 min between the groups. Even though patients that received vaginal insert showed a trend of increased incidence of abnormal cardiotocography during labor (12% versus 6.3%) and hyperkinetic labor (11.8% versus 2.1%), the incidence of cesarean sections (21.4% versus 21.6%), cesareans for fetal distress (12.5% versus 11.8%), and umbilical artery pH <7.10 (4.9% versus 2.5%) was comparable between the two groups. CONCLUSIONS: Dinoprostone vaginal insert is more efficient than cervical gel in promoting cervical priming and labor induction in low-Bishop-score patients at term. The vaginal insert placement seems to be safe for the mother and the newborn, although larger studies are required to investigate uterine hyperstimulation incidence.

Predictors of perinatal survival in a cohort of pregnancies with severe oligohydramnios due to premature rupture of membranes at <26 weeks managed with serial amnioinfusions.

OBJECTIVE: To evaluate whether successful amnioinfusion is an independent predictor of perinatal survival in a cohort of cases with extreme and persistent oligohydramnios due to preterm premature rupture of membranes (pPROM) who reached viability and were managed with serial amnioinfusions. STUDY DESIGN: We included all consecutive singleton pregnancies with pPROM at <26 weeks and oligohydramnios lasting >4 days between 1/1991 and 12/2001 and who consented to undergo amnioinfusion (n=77). Women received serial transabdominal amnioinfusions in an attempt to maintain a pocket of fluid >2 cm. The procedure was deemed successful if the median deepest pocket of fluid during the latency period was >2 cm. Excluded were miscarriages (n=10), fetal deaths before viability (24 weeks) (n=15), and cases that did not develop oligohydramnios (n=17). Prenatal predictors of outcome were compared between cases who survived the perinatal period and those who did not using Wilcoxon rank-sum test, Fisher's exact test and stepwise logistic regression analysis, with a two-tailed P<0.05 considered significant. RESULTS: Of the 35 patients fulfilling the study criteria, 20 (57%) survived the perinatal period. Perinatal survivors had similar gestational age at pPROM (P=0.68) and at first amnioinfusion (P=0.53) as those who died in the perinatal period, but longer latency (P=0.013). Consequently, median gestational age at delivery [29.2 (25.4-35.3) weeks versus 26.1 (24.0-34.0) weeks, P<0.001] and median birth weight [1220 (650-2240) g versus 863 (520-2200) g, P=0.001] were significantly greater among survivors than among those who died. Significant predictors of survival at univariate analysis were entered into a stepwise logistic regression analysis in the chronological order in which they normally occur. The analysis demonstrated that successful amnioinfusion (OR=6.9, 95% CI 1.2-40.4) and administration of steroids (OR=14.6, 95% CI 1.5-144.1) were independent and significant predictors of perinatal survival. CONCLUSION: In a cohort of women with pPROM at <26 weeks and severe oligohydramnios managed with serial amnioinfusions, successful procedures and prenatal administration of corticosteroids are the only independent predictors of perinatal survival.

Fetal arrhythmias: natural history and management.

The aim was to delineate the significance and natural history of fetal arrhythmias and provide information about their management. A cohort of 114 infants with fetal arrhythmias detected during prenatal ultrasound (US) screening were studied. All subjects underwent echocardiography and were treated as clinically indicated. Postnatal outcome was obtained in 100% of infants until 1 year of age. The incidence of fetal arrhythmias was 0.3%. Among the 87 fetuses with atrial extrasystoles, 2.3% developed supraventricular tachycardia (SVT) in utero. Of the 10 SVT cases, only five required antiarrhythmic therapy in utero with digoxin and propafenone, which successfully restored sinus rhythm in 100% of fetuses, both nonhydropic and hydropic. Sinus bradycardia was associated with structural anomalies in 5 of 6 patients and only 2 of 4 fetuses with atrioventricular block survived. It is concluded that prognosis is good for most fetal tachyarrhythmias, whereas it is less favorable for bradyarrhythmias.

A prospective study of the role of ultrasound in the management of adnexal masses in pregnancy.

OBJECTIVE: To assess the clinical relevance of adnexal masses in pregnancy and the usefulness of ultrasound in their management. DESIGN: A prospective study on pregnancy complicated by adnexal masses. SETTING: Department of Obstetrics and Gynaecology in Italy. POPULATION: 6636 women with pregnancy in utero followed in our clinic from January 1996 to December 1999. METHODS: From 1996 to 1999, all ovarian cysts with a diameter exceeding 3 cm were prospectively recorded and followed. The management was expectant except in case of symptoms or suspected malignant features. Cysts suggestive of borderline tumours were treated expectantly. MAIN OUTCOME MEASURES: Clinical relevance of adnexal masses in pregnancy, the outcome of these pregnancies and the usefulness of ultrasound examination in their management. RESULTS: We detected 82 cysts in 79 of 6636 women (1.2 in 100 term pregnancies). Sixty-eight women were asymptomatic at the time of diagnosis, whereas 11 (13.9%) were diagnosed because of pain. Diagnosis occurred in the first trimester for 57 cases and in the second or third trimester in 22 (27.8%). One-half of the cysts were simple and anechoic at ultrasound. Fifty-seven had a diameter not exceeding 5 cm. Forty-two cyst resolved in pregnancy without treatment. Three cysts required surgery within few days (torsion). One woman required laparotomy at the 37th week of gestation, due to torsion. When one case of termination was excluded, 78 women delivered at term (66 vaginally, 12 by caesarean section). Nineteen women underwent surgery after pregnancy. We recorded three Stage Ia borderline tumours, accounting for 3/82 cysts (3.6%) and 3/30 persisting masses (10%). CONCLUSION: Ultrasound allows definition of ovarian cysts in pregnancy and this positively impacts on management. The incidence of cancer among persistent masses is lower than previously reported. Acute complications in stable cysts are extremely uncommon after the first trimester. An expectant management is successful in the majority of cases and should be considered more often. Routine removal of persistent cysts is not justified.

Caveats for the use of humerus length in the prediction of fetal Down syndrome.

OBJECTIVE: To assess the reliability and reproducibility of fetal humerus length in the diagnosis of trisomy 21. METHODS: Cohort study inclusive of 22 trisomy 21 fetuses, who underwent ultrasonographic examination between 14 and 22 weeks' gestation, and 457 euploid controls. Regression analysis was performed for humerus length as function of biparietal diameter. Based on the generated regression equation in euploid fetuses, expected values of humerus length for a given biparietal diameter were calculated. The ratios of observed to expected (O/E) humerus length values were compared between euploid and trisomy 21 fetuses using Student's t test. Receiver operating characteristic (ROC) curve analysis was used to detect optimal thresholds of O/E humerus length for diagnosis of trisomy 21. In addition, a MEDLINE search was conducted for articles published on humerus length as predictor of trisomy 21. RESULTS: No differences were present between the regression lines of trisomy 21 and euploid fetuses (mean +/- standard deviation O/E humerus length in euploid and aneuploid fetuses: 1.00 +/- 0.10 vs. 0.97 +/- 0.11, p = 0.21). The optimal threshold O/E humerus length <0.88 identified by ROC curve analysis had a sensitivity of 18% and a false-positive rate of 9% for the diagnosis of trisomy 21. From a review of the evidence provided by the 17 published series on humerus length as predictor of Down syndrome, the following caveats emerge: (1) with a median false-positive rate of 5% (range 1-12%), the median sensitivity of humerus length was only 28% (range 15-64%); (2) differences were present among centers in the regression lines of euploid fetuses and in the optimal diagnostic thresholds of humerus length, suggesting inter-center variability, and (3) most populations studied were at high genetic risk for trisomy 21, hence the diagnostic ability of humerus length in low risk populations has not been tested. CONCLUSIONS: The ability of humerus length to predict trisomy 21 is inconsistent. Only institutions with locally generated regression equations and documented predictive ability of this marker should utilize humerus length as a screening test for trisomy 21, alone or incorporated into diagnostic algorithms with serum or other sonographic markers of trisomy 21. The diagnostic ability of humerus length in low risk populations is currently unknown.