Role of recombinant factor VIIa in the clinical management of severe postpartum hemorrhage: consensus among European experts.

OBJECTIVES: There have been significant advances in the medical management of severe postpartum hemorrhage (sPPH) over recent decades, which is reflected in numerous published guidelines. To date, many of the currently available national and international guidelines recommend recombinant factor VIIa (rFVIIa) to be used only at a very late stage in the course of sPPH, as a "last resort", before or after hysterectomy. Based on new safety data, rFVIIa has recently been approved by the European Medicines Agency (EMA) and Swissmedic for use in sPPH, if uterotonics are insufficient to achieve hemostasis, which in fact is significantly earlier in the course of postpartum hemorrhage (PPH). We therefore aimed to develop expert consensus guidance as a step toward standardizing care with the use of rFVIIa for clinicians managing women experiencing life-threatening sPPH. METHODS: The consensus process consisted of one face-to-face meeting with a group of nine experts, including eight obstetrician-gynecologists and a hematologist highly experienced in sPPH care in tertiary care perinatal centers. The panel was representative of multidisciplinary expertise in the European obstetrics community and provided consensus opinion in answer to pre-defined questions around clinical practice with rFVIIa in the management of sPPH. Recommendations have been based on current national and international guidelines, extensive clinical experience, and consensus opinion, as well as the availability of efficacy and new safety data. RESULTS: The expert panel developed 17 consensus statements in response to the 13 pre-defined questions on the use of rFVIIa in the management of sPPH including: available efficacy and safety data and the need for interdisciplinary expertise between obstetricians, anesthesiologists, and hematologists in the management of sPPH. Based on novel data, the experts recommend: (1) earlier administration of rFVIIa in patients with sPPH who do not respond to uterotonic administration to optimize the efficacy of rFVIIa; (2) the importance of hematological parameter prerequisites prior to the administration of rFVIIa to maximize efficacy; and (3) continued evaluation or initiation of further invasive procedures according to standard practice. Furthermore, recommendations on the timing of rFVIIa treatment within the sPPH management algorithm are outlined in a range of specified clinical scenarios and settings, including vaginal delivery, cesarean section, and smaller birthing units before transfer to a tertiary care center. The panel agreed that according to available, and new data, as well as real-world experience, there is no evidence that the use of rFVIIa in patients with sPPH increases the risk of thromboembolism. The authors acknowledge that there is still limited clinical effectiveness data, as well as pharmacoeconomic data, on the use of rFVIIa in sPPH, and recommend further clinical trials and efficacy investigation. CONCLUSIONS: This expert panel provides consensus guidance based on recently available data, clinical experience, and expert opinion, augmented by the recent approval of rFVIIa for use in sPPH by the EMA. These consensus statements are intended to support clinical care for sPPH and may help to provide the impetus and a starting point for updates to existing clinical practice guidelines.

Parir después de los 50 años. Estudio piloto observacional / Birth over 50: A pilot observational study

Objetivos: Evaluar si existe una mayor tasa de resultados obstétricos adversos, incontinencia urinaria posparto y problemas sexuales entre las mujeres que dan a luz después de los 50 años.Material y métodos: Estudio observacional ambispectivo de un solo centro. Se registraron la tasa de parto por cesárea, la diabetes gestacional, la preeclampsia, la restricción del crecimiento intrauterino (RCIU), la prematuridad, la incontinencia urinaria (Cuestionario de incontinencia en formato corto [ICIQ-SF]) y la disfunción sexual (índice de función sexual femenina [FSFI-6]). Resultados: Veinticinco (0,06%) de 38.510 nacimientos ocurrieron en mujeres mayores de 50 años durante el período de estudio en nuestro centro. Hubo 16 (64%) partos por cesárea. Siete (28%) mujeres padecieron diabetes gestacional. Se diagnosticó preeclampsia en 3 (12%) mujeres. Hubo 5 (20%) casos de RCIU. Hubo 5 (20%) partos prematuros. Las diferencias en la tasa de parto por cesárea, diabetes gestacional y RCIU entre el grupo de estudio y la población total fueron estadísticamente significativas. Los resultados de los cuestionarios ICIQ-SF y FSFI-6 se obtuvieron de 17 mujeres. Se encontró algún grado de incontinencia urinaria en 7 (41,1%) y disfunción sexual en 9 (52,9%) mujeres. Conclusiones: Los embarazos en mujeres mayores de 50 años parecen estar asociados con una mayor tasa de diabetes gestacional, RCIU y preeclampsia. Hay una alta prevalencia de incontinencia urinaria y problemas sexuales entre estas mujeres.(AU)

Objectives: To assess whether there is a higher rate of adverse obstetric outcomes, postpartum urinary incontinence, and sexual problems among women who give birth over 50. Material and methods: A single-center ambispective observational study. Rate of cesarean birth, gestational diabetes, preeclampsia, intrauterine growth restriction (IUGR), prematurity, urinary incontinence (Incontinence Questionnaire Short Form [ICIQ-SF]), and sexual dysfunction (Female Sexual Function Index [FSFI-6]) were recorded. Results: Twenty-five (0.06%) of 38,510 births occurred in women over 50 during the study period. There were 16 (64%) cesarean births. Seven (28%) women had gestational diabetes. Preeclampsia was diagnosed in 3 (12%) women. There were 5 (20%) cases of IUGR. There were 5 (20%) preterm births. The differences in the rate of cesarean birth, gestational diabetes, and IUGR between the study group and the total population were statistically significant. The results of the ICIQ-SF and FSFI-6 questionnaires were obtained from 17 women. Some degree of urinary incontinence was found in 7 (41.1%) and sexual dysfunction in 9 (52.9%) women. Conclusions: Pregnancies in women over 50 may be associated with a higher rate of gestational diabetes, IUGR, and preeclampsia. There is a high prevalence of urinary incontinence and sexual problems among these women.(AU)

Utility of cervical pessary in the prevention of preterm birth in triplet pregnancies: A single-center observational retrospective study of 165 triplet pregnancies.

OBJECTIVE: Premature births are a health problem arising in triplet pregnancies, resulting in high levels of morbidity and mortality. The objective of this study is to evaluate the utility of cervical pessaries in reducing prematurity (<34 weeks) in triplet pregnancies. METHODS: This is a single-center, retrospective case-control study regarding triplet pregnancies with follow-up at the La Paz University Hospital between 2000 and 2023. Maternal characteristics, obstetric and perinatal outcomes, and the use of cervical pessaries were examined. RESULTS: 165 triplet pregnancies were analyzed: 87 (52.7 %) in the case group (premature triplet pregnancies) and 78 in the control group (non-premature triplet pregnancies). A cervical pessary was inserted in 15 (17.2 %) triplet pregnancies in the case group and in 12 (16.7 %) triplet pregnancies in the control group (p = 0.92; OR = 1.04 (0.46-2.35)). A pessary was later inserted in the non-premature group (p = 0.01). The risk of preterm labor and the use of tocolytics ± glucocorticoids were found to be significantly more frequent in the premature group, with p = 0.01; OR = 2.30 (1.21-4.36) and p < 0.01; OR = 2.36 (1.23-4.44), respectively. Protocol-based cesarean sections were more frequent in the non-premature group (p < 0.01), while cesarean sections due to maternal complications (p < 0.01) and premature membrane rupture (p < 0.01) were more frequent in the premature group. CONCLUSION: The cervical pessary is not useful in preventing preterm births (< 34 weeks) in triplet pregnancies. It is likely that being pregnant with triplets is a powerful independent factor associated with prematurity, despite other pregnancy conditions. Women who are pregnant with triplets and at risk of preterm labor and those taking tocolytics ± glucocorticoids may benefit from pessary insertion.

Análisis de la tasa de cesáreas en el Hospital Universitario Materno-Infantil La Paz de Madrid (2010-2018) a través de la clasificación de Robson / Analysis of the Caesarean section rate at the La Paz Maternal-Child University Hospital in Madrid (2010–2018) through the Robson classification

Introducción: La necesidad de racionalizar y optimizar el uso de las cesáreas es un reto internacional en salud pública. Para ello, la OMS recomienda el uso de la clasificación Robson, que permite comparar las tasas de cesárea en función del perfil materno-fetal. El objetivo de este trabajo es evaluar la tasa de cesárea en el Hospital Universitario Materno-Infantil La Paz de Madrid entre 2010 y 2018 por medio de la clasificación Robson. Material y métodos: La población analizada corresponde a los datos de los 41.037 partos registrados en el programa Obstetricia del Hospital Universitario Materno-Infantil La Paz de Madrid de 2010 a 2018. Por medio del programa SPSS, se evalúa el cambio temporal en a) el porcentaje de partos (vaginales y por cesárea) respecto al total de nacimientos, b) la tasa de cesárea respecto a los partos vaginales y c) la contribución relativa a la tasa global de cesárea. Resultados: Las más elevadas contribuciones parciales a la tasa global de cesárea correspondieron a nulíparas con parto inducido, con cesárea previa, nulíparas con parto espontáneo y con gestaciones múltiples. El grupo de las nulíparas con parto inducido fue el único que registró un aumento significativo de su contribución a la tasa total de cesárea (30,4% en 2018). Conclusiones: Los resultados de este trabajo indican que el reto en salud pública es seguir evaluando la relación entre inducción del parto y riesgo de cesárea intraparto, particularmente en mujeres nulíparas, el grupo que registra la más alta tasa relativa de cesárea y en aumento significativo.(AU)

Introduction: The need to rationalise and optimise the use of caesarean sections is an international public health challenge. To this end, the WHO recommends the use of the Robson classification, which allows comparison of caesarean section rates according to the maternal-fetal profile. The aim of this study is to evaluate the rate of caesarean section in the Hospital Universitario Materno-Infantil La Paz in Madrid between 2010 and 2018 using the Robson classification. Material and methods: The population analysed corresponds to data from the 41,037 deliveries registered in the Obstetrics programme of the Hospital Universitario Materno-Infantil La Paz of Madrid from 2010 to 2018. Using SPSS software, the temporal change in (a) the percentage of deliveries (vaginal and caesarean) with respect to total births, (b) the caesarean rate with respect to vaginal deliveries and (c) the relative contribution to the overall caesarean rate is evaluated. Results: The highest partial contributions to the overall caesarean section rate were made by nulliparous women with induced labour, previous caesarean section, nulliparous women with spontaneous labour and multiple gestations. The group of nulliparous with induced labour was the only one with a significant increase in its contribution to the overall caesarean section rate (30.4% in 2018). Conclusions: The results of this work indicate that the challenge in public health is to further assess the relationship between induction of labour and risk of intrapartum caesarean section, particularly in nulliparous women, the group with the highest and significantly increasing relative caesarean section rate.(AU)

Malformación arteriovenosa uterina. Un reto diagnóstico y terapéutico / Uterine arteriovenous malformation: A diagnostic and therapeutic challenge

Introducción: Las malformaciones arteriovenosas uterinas (MAVU) generalmente se presentan como sangrado vaginal en mujeres en edad fértil. Los antecedentes obstétricos o quirúrgicos uterinos y la ecografía son clave para la sospecha de esta dolencia. Existen múltiples tratamientos disponibles tanto médicos como quirúrgicos, con efectividad diversa. Material y métodos: Analizamos el proceso diagnóstico y terapéutico de 3 pacientes con episodios de metrorragias y antecedentes obstétricos o cirugías uterinas que presentaban MAVU. Resultados: En los 3 casos analizados, se realizó tratamiento médico como primera elección. Tras el fracaso del tratamiento médico mediante gestágenos orales, metilergometrina o ácido tranexámico, se realizó embolización transarterial con oclusión del nido o punto de la fístula. Conclusiones: Con base en nuestra experiencia, debido a la demora entre el diagnóstico y la amplia variedad de tratamientos de las MAVU, la embolización supraselectiva podría valorarse como uno de los tratamientos con mayor tasa de eficacia en un perfil de paciente que habitualmente no ha completado su deseo genésico. Aunque los resultados a corto plazo parece que no afectan a la fertilidad, sería importante realizar un seguimiento prospectivo de estas pacientes en lo que respecta a la consecución de nueva gestación o recidiva de MAVU.(AU)

Introduction: Uterine arteriovenous malformations (UAVM) usually present as vaginal bleeding in women of childbearing age. Obstetric or uterine surgical history and ultrasound are key when suspecting this pathology. There are multiple treatments available, including medical surgery or interventional radiology with different effectiveness. Material and methods: We analysed the diagnosis and management of three patients with episodes of vaginal bleeding and obstetric history, or uterine surgeries with a MAVU diagnosis. Results: In the three cases analysed, medical treatment was provided as first line treatment. After the failure of medical treatment with oral gestagens, methylergometrine, or tranexamic acid, transarterial embolization was performed with occlusion of the nidus or fistula point. Conclusions: Based on our experience, due to the delay between diagnosis and the wide variety of MAVU treatments, supraselective embolization could be assessed as one of the treatments with the highest rate of efficacy in a patient profile that has usually not fulfilled their reproductive desire. Although the short-term results do not seem to affect fertility, it is important to prospectively follow-up these patients regarding achievement of a new pregnancy or recurrence of MAVU.(AU)

Obstetric perinatal and maternal outcomes of monochorionic diamniotic twins following assisted reproductive techniques. Retrospective observational study / Resultados obstétricos perinatales y maternales en gemelos monocoriales diamnióticos conseguidos mediante técnicas de reproducción asistida. Estudio observacional retrospectivo

Introduction: Multiple and specifically monochorionic diamniotic (MCDA) pregnancies are related to maternal and foetal complications. The aim of this study is to evaluate obstetric and perinatal outcomes of MCDA after assisted reproductive techniques (ART). Methods: This is a case-control study comparing 23 MCDA twin pregnancies after ART (ART-MCDA) and 75 spontaneous MCDA (sMCDA). Maternal, obstetric, foetal, and perinatal outcomes variables including maternal age, prematurity, TTTS, sIUGR, TAPS, PROM, and neonatal weight were compared. Results: mean maternal age is higher in the ART-MCDA pregnancies, 38.0±.6 (OR=1.32(1.13–1.53)). Neonates weighing between 1500 and 2500g are more frequent in the sMCDA group and those weighing >2500g in the ART group (OR=0.47(0.22–0.97)). Foetuses born at between 32 and 37 weeks are more frequent in sMCDA pregnancies and those born >37 in the TRA group (OR=0.27(0.09–0.80)). These differences are lost when we adjust the results by maternal age. There were no differences in maternal, obstetric, or foetal complications. Conclusions: ART-MCDA are not associated with a higher number of maternal, obstetric or foetal complications if they are adjusted by maternal age. When they are not adjusted by maternal age, there would be better outcomes such as premature and neonatal weight in the ART group.(AU)

Antecedentes: El incremento de las técnicas de reproducción asistida (TRA) ha supuesto un aumento de las gestaciones gemelares en general, pero también de las monocoriales biamnióticas (MCBA), que se asocian a diversas complicaciones maternofetales. Estas complicaciones están bien estudiadas en gestaciones espontáneas, pero no en aquellas conseguidas mediante una TRA. Objetivo: Comparar la incidencia de complicaciones maternas, fetales, obstétricas y perinatales en gestaciones MCBA conseguidas de forma espontánea frente a aquellas conseguidas mediante TRA. Materiales y métodos: Estudio de casos-controles retrospectivo. Se han analizado 98 gestaciones gemelares MCBA controladas en la Unidad de Medicina Materno-Fetal del Servicio de Obstetricia del Hospital La Paz de Madrid entre los años 2015 y 2020. Resultados: La media de edad de las madres de las gestaciones MCBA conseguidas mediante TRA es mayor (OR=1,32 [1,13-1,53]). Los recién nacidos de peso entre 1.500-2.500g son más frecuentes en las gestaciones MCBA conseguidas de forma espontánea y los de >2.500g en las de TRA (OR=0,47 [0,22–0,97]). Los recién nacidos entre las 32-37 semanas son más frecuentes en las gestaciones gemelares MCBA espontáneas y los recién nacidos de >37 semanas en las de TRA (OR=0,27 [0,09-0,80]). Cuando estos resultados se ajustan por la edad materna dejan de ser estadísticamente significativos. Conclusiones: Las TRA no conllevan un aumento de las complicaciones en las gestaciones MCBA cuando se ajustan los resultados por la edad materna. Si no se ajustasen por la edad materna, las gestaciones MCBA conseguidas mediante TRA tendrían mejores resultados, con menos prematuridad y mayor peso del neonato.(AU)

Influence of introducing a maneuverable vacuum extractor cup on maternal hospital stay after instrumental birth. Retrospective cohort study / Repercusión de la introducción de la ventosa obstétrica maniobrable en un centro hospitalario sobre la estancia materna tras parto instrumental. Estudio de cohortes retrospectivo

Objectives: The aim of our study is to evaluate the impact of the introduction of a maneuverable vacuum extractor cup on the length of hospital stay after assisted vaginal birth in nulliparous women in a hospital where no vacuum devices were used. Methods: This single center retrospective analytical study included two groups of nulliparous women who had undergone an assisted vaginal birth. The 2 groups differ according to the availability or not of a maneuverable vacuum extractor cup. The first group includes the last 54 instrumental births until May 2017, when only obstetric forceps and Thierry's spatulas were available in our center; the second group includes the first 54 instrumental births since May 2018 in our center, when obstetric forceps, Thierry's spatulas and maneuverable vacuum extractor cup were available. Maneuverable vacuum extractor cups had been available for 12 months in the second group. Results: In the no vacuum cup group, Kjelland forceps and Thierry's spatulas were used in 29 (53.7%) and 25 (46.3%) of the 54 assisted vaginal births, respectively. In the vacuum available group, a vacuum cup was chosen in 30 (55.6%), Kjelland forceps were used in 18 (33.3%) and Thierry's spatulas in 6 (11.1%) of the assisted vaginal births. 22 women (40.7%) had a postpartum hospital stay longer than 3 days in the group with no maneuverable vacuum extractor cup availability, versus 3 women (5.6%) in the group with availability of a maneuverable vacuum extractor cup, p<0.001. Average postpartum hospital stay length was 3.17±0.803 days versus 2.81±0.585, p<0.001. There was also a significant reduction in the number of episiotomies. Conclusion: The introduction of a maneuverable vacuum extractor cup in a center where only forceps and Thierry's spatulas had been used resulted in a decrease in postpartum hospital stay in nulliparous women.(AU)

Objetivos: El objetivo de nuestro estudio es evaluar el impacto de la introducción de una ventosa obstétrica con cazoleta maniobrable en la duración de la estancia hospitalaria tras parto instrumental en mujeres nulíparas en un hospital donde no se utilizaban ventosas obstétricas. Métodos: Este estudio de cohortes retrospectivo unicéntrico incluyó 2 grupos de mujeres nulíparas sometidas a parto instrumental. Los 2 grupos se diferencian según la disponibilidad o no de ventosa obstétrica en el centro. El primer grupo se compone de las últimas 54 mujeres a las que se les asistió un parto instrumental hasta mayo del 2017, cuando solo había disponibilidad de fórceps obstétricos y espátulas de Thierry en nuestro centro; el segundo grupo se compone de las primeras 54 mujeres a las que se les asistió un parto instrumental desde mayo del 2018 en nuestro centro, cuando había disponibilidad de fórceps obstétricos, de espátulas de Thierry y de ventosa obstétrica con cazoleta maniobrable (esta última desde hacía 12 meses). Resultados: En el grupo sin disponibilidad de ventosa obstétrica, se utilizaron fórceps de Kjelland y espátulas de Thierry en 29 (53,7%) y 25 (46,3%) de los 54 partos instrumentales, respectivamente. En el grupo con disponibilidad de ventosa, se usó la ventosa en 30 (55,6%), fórceps de Kjelland en 18 (33,3%) y espátulas de Thierry en 6 (11,1%) de los partos instrumentales; 22 mujeres (40,7%) tuvieron una estancia hospitalaria tras el parto mayor de 3 días en el grupo sin disponibilidad de ventosa, frente a 3 mujeres (5,6%) en el grupo con disponibilidad de ventosa, p<0,001. La duración media de la estancia hospitalaria tras el parto fue de 3,17±0,803 días frente a 2,81±0,585, p<0,001. También hubo una reducción significativa en el número de episiotomías.(AU)

Complicaciones obstétricas relacionadas con la terapia antirretroviral en gestantes infectadas por el VIH / Obstetric complications related to antiretroviral therapy in pregnant women with HIV infection

IntroducciónEl porcentaje de gestantes infectadas por VIH que demandan embarazo ha aumentado en los países desarrollados debido a la estabilidad de la infección y la disminución de la transmisión vertical por los tratamientos antirretrovirales (TAR) y las medidas preventivas. Sin embargo, existe poca información respecto al efecto del TAR sobre el embarazo.MétodosEstudio retrospectivo de las gestantes infectadas por VIH con TAR controladas en el Hospital La Paz entre los años 2000-2017. Se estudiaron las complicaciones maternofetales.ResultadosSe recogieron 141 gestaciones en 112 mujeres infectadas por VIH. El TAR más utilizado fue la combinación de 2 inhibidores de la transcriptasa inversa análogos nucleosídicos+1 inhibidor de la proteasa (58,1%), con diferencias significativas entre los distintos tratamientos en cuanto a la carga viral plasmática, siendo indetectable en mayor medida con 2 inhibidores de la transcriptasa inversa análogos nucleosídicos +1 inhibidor de la transcriptasa inversa no nucleosídico, segunda pauta más utilizada. Las tasas de neonatos a término de bajo peso (<2.500g) (11,3%), partos pretérmino (11,1%) y rotura prematura de membranas pretérmino (5,6%) fueron mayores que en la población general. Aunque no hubo asociación, estas complicaciones fueron más frecuentes en gestantes con un inhibidor de la proteasa/ritonavir. No se relacionaron con la carga viral plasmática. No se encontró aumento en la tasa de interrupciones gestacionales, malformaciones ni diabetes gestacional.ConclusiónEn las gestantes infectadas por VIH con TAR está aumentada la tasa de neonatos a término de bajo peso, prematuridad y rotura prematura de membranas pretérmino en comparación con la población general, relacionándose especialmente con el tratamiento con un inhibidor de la proteasa, aunque sin asociación significativa.

IntroductionThe percentage of HIV-infected pregnant women seeking pregnancy has increased in developed countries due to the stability of the infection and the decrease in vertical transmission due to antiretroviral treatment (ART) and preventive measures. However, there is little information regarding the effect of ART on pregnancy.MethodsRetrospective study of HIV-infected pregnant women on ART monitored at Hospital La Paz between 2000-2017. Maternal-foetal complications were studied.ResultsOne hundred and forty-one gestations were collected in 112 HIV-infected women. The most commonly used ART was the combination of 2 nucleoside reverse transcriptase inhibitor analogues+1 protease inhibitor (58.1%), with significant differences between the different treatments in terms of plasma viral load being undetectable to a greater extent with 2 nucleoside reverse transcriptase inhibitor analogues+1 non-nucleoside reverse transcriptase inhibitor, the second most used regimen. The rates of low birth weight (<2,500g) term neonates (11.3%), preterm delivery (11.1%) and preterm premature rupture of membranes (5.6%) were higher than in the general population. Although there was no association, these complications were more frequent in pregnant women with a protease inhibitor/ritonavir. They were not related to plasma viral load. No increase in the rate of gestational terminations, malformations or gestational diabetes was found.ConclusionHIV-infected pregnant women on ART have an increased rate of low birth weight, prematurity, and preterm premature rupture of membranes at term compared to the general population, especially related to treatment with protease inhibitor, although without significant association.

Hernia diafragmática congénita en la gestación gemelar / Congenital diaphragmatic hernia in twin gestation

La hernia diafragmática congénita (HDC) en un feto de una gestación gemelar es una situación extremadamente infrecuente y de difícil manejo. La cirugía fetal no parece una opción válida debido al alto riesgo de rotura prematura de membranas y/o parto prematuro. La interrupción fetal selectiva debe hacerse antes de la semana 22, y tampoco está exenta de riesgos. El manejo expectante se asocia a la prematuridad y a fetos de bajo peso característicos de una gestación gemelar. Por tanto, el asesoramiento a los padres por parte de un equipo multidisciplinar es crucial en la toma de decisiones. La cesárea programada a término parece ser la vía más razonable en estos casos, sobre todo si es el segundo gemelo el afecto por HDC. Se presentan 6 casos de gestaciones gemelares bicoriales con uno de los fetos afecto de HDC con diferentes manejos y evoluciones obstétricas.(AU)

Congenital diaphragmatic hernia (CDH) in a twin gestation foetus is an extremely infrequent and difficult situation to manage. Foetal surgery does not seem to be an option due to the high risk of premature rupture of membranes and/or preterm delivery. Selective foetal termination must be done before 22 weeks and is also not without risk. Expectant management is associated with prematurity and low weight foetuses characteristic of twin gestation. Therefore, parental counselling by a multidisciplinary team is crucial in decision making. Programmed caesarean section at term seems to be the most reasonable route in these cases, especially if the second twin is affected by CDH. Six cases of bicornuate twin gestations with one of the foetuses affected by CDH are presented, with different management and obstetric outcomes.(AU)

Diagnosis of amyopathic dermatomyositis after two intrauterine fetal deaths.

Chronic histiocytic intervillositis (CHIV) is an uncommon condition, characterized by an infiltrate of mononuclear cells of maternal origin in the intervillous space that has been related to placenta insufficiency and poor perinatal outcomes. The aetiology is unclear, although maternal immunological aggression toward fetal tissues has been proposed. Dermatomyositis (DM) is a multisystem autoimmune inflammatory myopathy. Different autoantibodies have been associated with particular clinical phenotypes; presence of anti-melanoma differentiation-associated gen 5 (MDA5) antibody has been associated with rapidly progressive interstitial lung disease and severe skin lesions, none of which the woman had. Described here is a case of a woman diagnosed with amyopathic DM with positive anti-MDA5 antibodies after two intrauterine fetal deaths. Pathological examination of the placenta in both pregnancies showed CHIV. The presence of a potential relationship between both processes is discussed.

Safety profile of treatments administered in COVID 19 infection in pregnant women.

SARS-CoV-2 infection has unexpectedly arrived in our society. In pregnant women, the situation has been similar to general population. Some drugs have been used empirically, and obstetricians have to consider whether the same treatments used in the general population were valid for pregnant women with severe disease, according to their safety profile for both the mother and the fetus. There has been a wide experience with the use of hydroxychloroquine and lopinavir/ritonavir in pregnant women. Tocilizumab and interferon beta could be used if benefits exceed risks. There is no experience using remdesivir in pregnancy.

La infección por SARS-CoV-2 ha llegado a nuestra sociedad de forma inesperada. En las mujeres embarazadas, la situación ha sido similar a la de la población general. Algunos fármacos se han utilizado de forma empírica y los obstetras deben considerar si los mismos tratamientos utilizados en la población general son válidos para mujeres embarazadas con enfermedad grave, de acuerdo con su perfil de seguridad tanto para la madre como para el feto. Existe una amplia experiencia con el uso de hidroxicloroquina y lopinavir/ritonavir en mujeres embarazadas. Se podrían usar tocilizumab e interferón beta si los beneficios superan los riesgos. No hay experiencia en el embarazo con remdesivir.

First trimester combined screening test for aneuploidies in anti-Ro carriers pregnant women.

INTRODUCTION: Anti-Ro/SSA and anti-La/SSB antibodies are associated with neonatal lupus and congenital heart block. Controversial results regarding perinatal outcomes are found and less is known about aneuploidy screening. The hypothesis is that the presence of anti-Ro and/or anti-La antibodies influences the levels of PAPP-A and ß-HCG, thus interfering in the calculation of risk of aneuploidies. MATERIAL AND METHODS: Fifty-five anti-Ro/SSA positive pregnant women were included. The demographic characteristics and laboratory variables were studied. Data concerning chromosomopaties screening were also recorded. RESULTS: PAPP-A and ß-HCG levels were calculated (as well as NT and CRL) and compared with a healthy cohort of 12971 pregnant women. PAPP-A levels in mg/mL were lower significatively. In anti-La/SS-B cohort, significant differences were found in PAPP-A in mg/mL and in MoM. Combined risks for Down syndrome (DS) in both groups were higher but the differences were due to age. CONCLUSIONS: Serum levels of PAPP-A were significative lower but not confirmed when adjusted to MoM. This will have to be confirmed in studies with a larger number of patients and to check whether there is an impact in the calculation of DS risk or not. They could represent a group of pregnant women with significantly a higher risk of adverse perinatal outcome. Key Points • Pregnant patients with anti-Ro/SS-A ant/or anti-La/SS-B antibodies have low PAPP-A levels compared with pregnant women without antibodies. • PAPP-A levels are used in obstetrics for aneuploidies screening in the first trimester, so in these patients, there could be more false positive screening. • In these findings are verified in trials with a larger number of patients, a correction variable would have to be applied for the aneuploidies screening calculation. • Also, low PAPP-A levels are correlated with poor placentation, that is to say, more risk of miscarriages, small fetus for gestational age, and preeclampsia. This is another topic to take into consideration in this population.

[How to organize a Fetal Medicine Unit in the context of COVID-19 pandemic. Safe measures for obstetric scans and equipment cleaning]. / Cómo reestructurar una Sección de Medicina Fetal en tiempos de pandemia COVID-19. Medidas de seguridad y limpieza de los equipos ecográficos.

During a pandemic, the three basic principles are. to prioritize medical resources, ensure patients' lockdown in order to avoid community transmission and prevent healthcare collapse, and keep the number of visits to an absolute minimum to avoid patient exposure and safeguard healthcare workers. Antenatal care must be maintained during a health crisis, regardless of the COVID-19 state of alert. Routine and specialist obstetric ultrasound scans are essential for clinical decision-making during pregnancy, as it has a direct impact on the management of mothers and fetuses and on the perinatal outcome. In an attempt to minimize in-person visits, these will be organized according to the established ultrasound schedule. Based on scientific evidence, and on existing main national and international guidelines, this document has been prepared, in which proposals and options are provided for managing pregnant women in the context of the SARS-CoV-2 pandemic. It includes how a Fetal Medicine Unit facing this health crisis should be restructured, what safety measures should be followed in the performance of obstetric scans and invasive procedures, and how ultrasound rooms, equipment and transducers should be cleaned and disinfected. These recommendations should be adapted to different units based on their resources and infrastructure.

Successful treatment of intrauterine cytomegalovirus infection with an intraventricular cyst in a dichorionic diamniotic twin gestation using cytomegalovirus immunoglobulin.

Congenital cytomegalovirus (CMV) infection is the leading cause of severe congenital abnormalities. CMV immunoglobulin (CMVIG) may lower risk for symptomatic disease in congenital CMV infection. In a twin pregnancy, only one fetus shows CMV infection, raising a dilemma about intervention since the uninfected fetus would be exposed to treatment unnecessarily. CMVIG (2 × 200 U/kg) was given due to high viral load and development of an intraventricular cyst. The cyst growth plateaued, no other brain damage developed, and at 8 months, the infant was symptom-free. CMVIG appears appropriate to treat intrauterine CMV infection in this setting.

[Intestinal complications in twin-to-twin transfusion syndrome (TTTS) treated by laser coagulation (LC)]. / Complicaciones intestinales en el síndrome de trasfusión feto fetal (STFF).

AIM OF THE STUDY: The hemodynamic imbalance due to placental vascular anastomoses in TTTS but also vascular changes generated after intrauterine treatment may lead to hypoxic-ischemic complications. Different intestinal complications in TTTS are reviewed in this paper. METHODS: Retrospective review of TTTS cases treated by laser coagulation (LC) from 2012-2015. Demographic data, fetal therapy, prenatal diagnosis (US, MRI) and perinatal outcome were recorded. We describe cases with intestinal complications and their postnatal management. Results are expressed by median and range. RESULTS: 29 monochorionic pregnancies with TTTS were treated (23 LC, 4 cord occlusions and 2 cord occlusions after LC). The diagnosis was made at 19 (16-26) weeks and 86% presented stage of Quintero ≥ II. In 70% of mothers survived at least one fetus with a median of 31 (24-37) weeks at birth. Four patients had intestinal complications (1 jejunal atresia, 2 ileal atresia, 1 perforated necrotizing enterocolitis), half of them had prenatal diagnosis. Postnatal resections of the affected segments and ostomies were performed. Intestinal transit was restored and there were no severe digestive sequelae after 21 (8-38) months of follow up. CONCLUSIONS: Different types of intestinal complications were associated with TTTS and LC. US and MRI enable prenatal diagnosis of these complications and this allows prompt decisions after birth.

INTRODUCCION: El desequilibrio hemodinámico secundario a la presencia de anastomosis vasculares placentarias en el STFF así como los cambios hemodinámicos generados durante y tras su tratamiento mediante fotocoagulación con láser (FC) puede dar lugar a complicaciones hipóxico-isquémicas en distintos sistemas. Revisamos nuestra experiencia en el tratamiento del STFF con FC y presentamos las complicaciones intestinales encontradas. MATERIAL Y METODOS: Estudio retrospectivo de casos tratados intraútero entre 2012 y 2015. Recogimos datos sociodemográficos, terapia fetal, pruebas diagnósticas prenatales (ecografía, RM) y resultados perinatales. Expresamos las medidas en medianas y rangos. RESULTADOS: Se procedió al tratamiento intraútero de 29 gestaciones monocoriales complicadas con STFF (23 FC, 4 oclusiones de cordón y 2 FC seguidas de oclusión). La edad gestacional en el procedimiento fue 19 (16-26) semanas y en el 86% de los casos se trataba de un estadio de Quintero ≥ II. El 70% de las madres tuvieron al menos 1 recién nacido vivo, con mediana de edad gestacional al parto de 31 (24-37) semanas. Presentaron problemas intestinales 4 pacientes (1 atresia yeyunal, 2 atresias ileales, 1 enterocolitis necrotizante con perforación), con sospecha prenatal diagnóstica en 2 de ellos. Postnatalmente se realizó resección del segmento afecto y ostomía. Actualmente se ha restablecido el tránsito intestinal en todos sin secuelas digestivas graves tras 21(8-38) meses de seguimiento. CONCLUSIONES: Hemos descrito distintos tipos de complicaciones intestinales asociadas al STFF y/o su tratamiento con FC. Es posible hacer el diagnóstico prenatal de dichas complicaciones mediante ecografía y RM. Su conocimiento pone al cirujano en alerta y es importante en la toma de decisiones postnatales.

Vaginal progesterone as maintenance treatment after an episode of preterm labour (PROMISE) study: a multicentre, double-blind, randomised, placebo-controlled trial.

OBJECTIVE: To evaluate whether maintenance treatment with vaginal progesterone after an arrested preterm labour reduces the incidence of preterm delivery. DESIGN: Multicentre, randomised, double-blind, placebo-controlled trial. SETTING: Twelve tertiary care centres in Spain. POPULATION: A total of 265 women with singleton pregnancy, preterm labour successfully arrested with tocolytic treatment, and cervical length of <25 mm. METHODS: Randomisation was stratified by gestational age (from 24.0 to <31.0 weeks of gestation and from 31.0 to <34.0 weeks of gestation) and centre. Patients were randomly assigned, in a 1 : 1 ratio, to either daily vaginal capsules of 200 mg progesterone or placebo until delivery or 36.6 weeks of gestation, whichever occurred first. MAIN OUTCOME MEASURES: Primary outcome was delivery before 34.0 and 37.0 weeks of gestation. Secondary outcomes were discharge-to-delivery time, readmissions because of preterm labour, emergency service use, and neonatal morbidity and mortality. RESULTS: From June 2008 through June 2012, 1419 women were screened: 472 met the inclusion criteria and 265 were randomised. The final analysis included 258 women: 126 in the progesterone group and 132 in the placebo group. There were no significant differences between the progesterone and placebo groups in terms of delivery at <34 weeks of gestation [9/126 (7.1%) versus 10/132 (7.6%), P = 0.91] or <37 weeks of gestation [36/126 (28.6%) versus 29/132 (22.0%), P = 0.22]. There were no differences observed between groups when considering the two strata of gestational age at inclusion. CONCLUSIONS: A maintenance treatment of 200 mg of daily vaginal progesterone capsules in women discharged home after an episode of arrested preterm labour did not significantly reduce the rate of preterm delivery. TWEETABLE ABSTRACT: Maintenance progesterone in 258 women after arrested PTL showed no benefit.