Associated perinatal determinants of vanishing twin pregnancies achieved by in vitro fertilization vs. spontaneous conception.

PURPOSE: To evaluate whether vanishing twin (VT) pregnancies following spontaneous conception have a more adverse perinatal outcome than those conceived after assisted reproduction techniques. METHODS: The retrospective cohort study consisted of 316 VT pregnancies derived from a hospital database between January 1994 and January 2016 (81 after IVF/ICSI and 235 after spontaneous conception). RESULTS: VT was significantly more prevalent after spontaneous conception (in 22.0% of twins) than after IVF/ICSI (in 14.5% of twins). VT pregnancies were significantly more associated with pre-gestational and gestational diabetes mellitus (GDM) in IVF/ICSI pregnancies compared to those spontaneously conceived [adjusted odds ratio (AOR): 4.12 and 11.1, respectively]. IVF-related placental insertion abnormalities were significantly higher in VT pregnancies. A high risk for VT was recorded in the spontaneous group for those who had previously undergone an induced abortion (AOR 0.56) or second-trimester fetal loss (AOR 0.67). The VT phenomenon was a major prognosticator of intrauterine growth retardation (IUGR) for the remaining fetus in IVF pregnancies (AOR 5.12). After controlling for covariates conjointly, advanced age (AOR 1.3), GDM (AOR 2.1), hypertensive disorders (AOR 3.5), primiparity (AOR 3.8), and placentation anomalies all represented independent risk factors for VT in IVF pregnancies. CONCLUSIONS: IVF/ICSI poses a higher risk for an adverse perinatal outcome following VT pregnancies as compared with those spontaneously conceived.

Evaluation of the relation between placental weight and placental weight to foetal weight ratio and the causes of stillbirth: a retrospective comparative study.

The aim of the present study was to evaluate the clinical importance of placental weight (PW) and placental weight to foetal weight (PW/FW) ratio according to maternal characteristics, pathological conditions in obstetrics and the causes of foetal death by category in stillbirths. The results of autopsies and placental histopathological examinations for 145 singleton stillbirths were reviewed retrospectively. Pathological features of the placenta were significantly associated with lower PW compared to the group with no pathological placental parameters (230 grams versus 295 grams, p = .045). Foetal growth restriction (FGR) with pre-eclampsia (PE) was accompanied by significantly lower FW, PW and PW/FW compared to FGR cases without PE (1045 grams versus 1405 grams, p = .026, 200 grams versus 390 grams, p = .006 and .19 versus .24, p = .037, respectively), whereas a similar trend was not observed in the non-FGR pregnancies complicated by PE. Oligohydramnios was accompanied by lower foetal weight compared to those who had normal amount of amniotic fluid (650 grams versus 1400 grams, p = .006). Among the clinical factors, only PE and oligohydramnios contributed to disproportionate fetoplacental growth in stillbirth, while none of the categories of stillbirth was related to unequal fetoplacental growth. Impact statement What is already known on this subject: In 27% of stillbirths, pathological features of the placenta or placental vascular bed are recorded. Underlying placental pathology contributes to foetal growth restriction (FGR) in approximately 50%. Although placental weight relative to foetal weight (PW/FW ratio) is an indicator of foetal as well as placental growth, data on PW/FW in stillbirth has not yet been published. What the results of this study add: Causes of death do not show any correlation with PW/FW ratio. Placentas derived from pregnancies complicated by pre-eclampsia (PE) and concomitant FGR are smaller and PW/FW is also diminished. Oligohydramnios is associated with an enhanced risk of restricted placental growth. FGR is not correlated with any categories of causes of death. What the implications are of these findings for clinical practice and/or further research: Sonographic follow-up of placental volume and FW can predict the stillbirth in PE complicated by FGR and oligohydramnios.

Non-medical determinants of cesarean section in a medically dominated maternity system.

OBJECTIVE: To assess the contribution of non-medical factors to actual mode of delivery in a setting with high cesarean rates. DESIGN: Follow-up survey. SETTING: University department of obstetrics and gynecology. SAMPLE: Women with singleton pregnancies (n = 453) where there was no awareness of medical contradictions to vaginal delivery, attending for routine mid-pregnancy ultrasound examination in November 2011 to March 2012, and delivering between March and August 2012. METHODS: Structured questionnaire completed in gestational weeks 18-22. Information on subsequent delivery was obtained from patient files and through personal contact. MAIN OUTCOME MEASURES: Contribution of childbirth preference, Wijma Delivery Expectancy/Experience Questionnaire A score, socio-demographic characteristics, attitudes toward birth issues and circumstances of pregnancy/delivery to mode of delivery. RESULTS: The majority of respondents (410/453; 90.5%) preferred vaginal delivery; nevertheless, one-third (two-fifths of nulliparas) had a cesarean delivery. Among nulliparous respondents, a longer perceived interval from decision for pregnancy to conception, lower importance assigned to personal control, and the presence of an obstetrician with power to decide about cesarean delivery, were independent contributors to the binary logistic regression model explaining higher maternal cesarean risks. For parous respondents, corresponding factors were younger maternal age, perceived environmental influence towards cesarean section, the respondent's belief that cesarean is more beneficial than vaginal delivery and an older obstetrician attending the delivery. CONCLUSIONS: The results of this questionnaire survey contribute to the already existing evidence that against the background of high cesarean rates, non-medical factors, as much related to the obstetricians as to pregnant women's attitudes, play an important role.

Identification of causes of stillbirth through autopsy and placental examination reports.

The autopsy and placental histopathological examination results following fetal deaths were analyzed retrospectively in an attempt to explain the stillbirths that occurred from 1996 to 2010 at the Department of Obstetrics and Gynecology, University of Szeged. One hundred and forty fetal deaths were recorded in that period, i.e. a rate of 4.69 stillbirths per 1000 deliveries. The postmortem examination provided the exact cause of the fetal death in 57.9% of the cases. The most common causes were a placental insufficiency (46.9%) and an umbilical cord complication (25.9%). In the first half of the third trimester, a placental insufficiency predominated as the cause of stillbirth, whereas mainly umbilical cord complications occurred around term. In spite of the availability of the autopsy and histopathological examination results, the proportion of unexplained stillbirths in our sample was relatively high. A considerable proportion of stillbirth cases could probably be prevented by more effective screening of a placental insufficiency.

Magnetic resonance vs. sonographic imaging: diagnostics of a large congenital pulmonary airway malformation.

Sonographic scan revealed a homogenously hyperechogenic lesion in the right fetal lung with microcystic pattern by a primigravid women at 22nd weeks of gestation. A large congenital pulmonary airway malformation (CPAM) was suspected with a lesion-to-lung ratio over 90%. The microcystic image of this thoracic anomaly was moderately visible on magnetic resonance imaging (MRI) at that early stage of the pregnancy. Fetopsy confirmed the diagnosis as a pure microcystic CPAM following termination of pregnancy. A controlled prospective study could be performed to compare ultrasound as a diagnostic modality to the MRI, focusing on volumetry, signal characteristics, and follow-up/regression of fetal pulmonary malformations.

Therapy-resistant hypertension in pregnancy after live donor kidney transplantation / Élo donoros vesetranszplantációt követo terhességben kialakult terápiarezisztens hypertonia.

Összefoglaló. A veseátültetés a legnagyobb reményt nyújtja a végstádiumú vesebetegségben szenvedo nok számára, akik teherbe kívánnak esni. A veseátültetett beteg terhessége továbbra is kihívást jelent az immunszuppresszív gyógyszerek mellékhatásai, az allograftfunkció romlásának kockázata, a praeeclampsia és a magas vérnyomás káros anyai szövodményeinek rizikója, valamint a koraszülés, az alacsony születési súly kockázata miatt. A terhesség alatt nagy a magas vérnyomás kialakulásának kockázata, a szérum-kretaininszint emelkedik, és a terhesség végére proteinuria is kialakulhat. Az ajánlott fenntartó immunszuppresszió terhes noknél a kalcineurininhibitorok (takrolimusz/ciklosporin) és alacsony dózisú szteroid adása, melyek biztonságosnak tekinthetok. Fontos, hogy a gyermekvállalási tanácsadás már a vesetranszplantáció elott megkezdodjön, és a transzplantációt követoen minden klinikai kontroll megtörténjen. Orv Hetil. 2021; 162(23): 924-926. Summary. Kidney transplantation offers the best hope to women with end-stage renal disease who wish to become pregnant. Pregnancy in a kidney transplant recipient continues to remain challenging due to side effects of immunosuppressive medication, risk of deterioration of allograft function, risk of adverse maternal complications of preeclampsia and hypertension, and risk of adverse fetal outcomes of premature birth, low birth weight, and small for gestational age infants. The factors associated with poor pregnancy outcomes include the presence of hypertension, serum creatinine greater than normal range and proteinuria. The recommended maintenance immunosuppression in pregnant women is calcineurin inhibitors (tacrolimus/cyclosporine) and low-dose steroid which are considered safe. It is important that counseling for childbearing should start as early as prior to getting a kidney transplant and should be done at every clinic visit after transplant. Orv Hetil. 2021; 162(23): 924-926.

Comparison of vaginal and sublingual misoprostol for second trimester abortion: randomized controlled equivalence trial.

BACKGROUND: To identify an effective misoprostol-only regimen for the termination of second trimester pregnancy, we compared sublingual and vaginal administration of multiple doses of misoprostol in a randomized, placebo-controlled equivalence trial. METHODS: Six hundred and eighty-one healthy pregnant women requesting medical abortion at 13-20 weeks' gestation were randomly assigned within 11 gynaecological centres in seven countries into two treatment groups: 400 microg of misoprostol administered either sublingually or vaginally every 3 h up to five doses, followed by sublingual administration of 400 microg misoprostol every 3 h up to five doses if abortion had not occurred at 24 h after the start of treatment. We chose 10% as the margin of equivalence. The primary end-point was the efficacy of the treatments to terminate pregnancy in 24 h. Successful abortion within 48 h was also considered as an outcome along with the induction-to-abortion-interval, side effects and women's perceptions on these treatments. RESULTS: At 24 h, the success (complete or incomplete abortion) rate was 85.9% in the vaginal administration group and 79.8% in the sublingual group (difference: 6.1%, 95% CI: 0.5 to 11.8). Thus, equivalence could not be concluded overall; the difference, however, was driven by the nulliparous women, among whom vaginal administration was clearly superior to sublingual administration (87.3% versus 68.5%), whereas no significant difference was observed between vaginal and sublingual treatments among parous women (84.7% versus 88.5%). The rates of side effects were similar in both groups except for fever, which was more common in the vaginal group. About 70% of women in both groups preferred sublingual administration. CONCLUSIONS: Equivalence between vaginal and sublingual administration could not be demonstrated overall. Vaginal administration showed a higher effectiveness than sublingual administration in terminating second trimester pregnancies, but this result was mainly driven by nulliparous women. Fever was more prevalent with vaginal administration. Registered with International Standard Randomized Controlled Trial number ISRCTN72965671.

[What does fetal renal echogenicity mean in intrauterine growth retardation?]. / Mit jelent a vese hiperechogenitása intrauterin növekedési retardációban?

AIMS: The object of this study was to investigate the fetal renal and middle cerebral arterial blood flows in patients with normal and hyperechogenic kidneys during the fetal period. MATERIAL AND METHODS: Study group consisted of 82 pregnancies with intrauterine growth retardation. Group included pregnant women from the third trimester. Hyperechogenic medullae were detected in 17 out of 82 pregnancies with intrauterine growth retardation. RESULTS: Fetal renal hyperechogenicity appears to be an indicator of fetal arterial circulatory depression, correlated with pathological changes in the pulsatility index for the fetal renal arteries. The fetal renal arterial blood flow pulsatility index was significantly lower in hyperechogenic cases, while in the middle cerebral artery flow was in the normal range. This may also be an indication of subsequent intrauterine and neonatal complications, such as cesarean section because of fetal distress (47%), treatment in a neonatal intensive care unit (71%) or increased perinatal mortality (12%) in our cases. CONCLUSIONS: Detailed ultrasound of renal parenchyma and Doppler examination of renal and middle cerebral arteries appear to be an useful method in the prenatal diagnosis of reduced renal perfusion and of intrauterine hypoxia so as to detect possible pathological fetal conditions in utero.

Prevalences and pregnancy outcome of vanishing twin pregnancies achieved by in vitro fertilization versus natural conception.

OBJECTIVE: To evaluate whether vanishing twin (VT) pregnancies achieved by in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI) had a more adverse perinatal outcome than those after natural conception. DESIGN: Longitudinal, retrospective cohort study. SETTING: Tertiary university hospital. PATIENT(S): Three hundred and six (78 after IVF-ICSI and 228 after natural conception) VT pregnancies over a 22-year period, with VT cases matched to primarily singleton controls. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Obstetric and neonatal outcome data. RESULT(S): The incidence of VT was statistically significantly higher after natural conception (18.2% of twins) than after IVF-ICSI (12.6% of twins). The odds of VT in pregnancies complicated with pregestational or gestational diabetes were disproportionally higher in IVF-ICSI cases than in spontaneously conceived VT pregnancies (adjusted odds ratio [AOR]: 0.80 vs. 3.10 and 1.00 vs. 1.07, respectively). Previous induced abortion (AOR 1.34) or second-trimester fetal loss (AOR 3.3) increased the risk of VT pregnancies after spontaneous conception. Gestational diabetes mellitus in both the previous (AOR 5.41) and the present (AOR 2.3) pregnancy as well as chronic maternal diseases (AOR 3.5) and placentation anomalies all represented independent risk factors for VT after IVF-ICSI. CONCLUSION(S): Vanishing twin pregnancies had a lower prevalence and a worse perinatal outcome after IVF-ICSI as compared with those of their spontaneously conceived counterparts.

[Biparietal diameter/kidney length ratio in cases with chronic hypoxic state]. / A biparietalis átméro/vesehossz hányados mérése krónikus hypoxias státusú terhességekben.

AIMS: The object of this study was to investigate the fetal biparietal diameter/kidney length ratio in normal and hyperechogenic kidneys during the third trimester of gestation. MATERIAL AND METHODS: The selected cases were characterized by pregnancy-associated hypertension and/or proteinuria, which was associated with fetal hypoxia due to the depression of placental blood flow. Depending on the renal manifestation of intrauterine chronic hypoxia, cases were divided into two study groups. Group I was composed of 21 fetuses with pregnancy-associated hypertension and/or proteinuria and hyperechogenic renal medullae. Group II consisted of 162 fetuses with pregnancy-associated hypertension and/or proteinuria and normal echoic kidney. Both study groups included pregnant women from the third trimester. RESULTS: Fetal renal hyperechogenicity correlated with the pathological growth of fetal kidney. The fetal biparietal diameter/kidney length ratio was significantly lower in cases of hyperechogenicity. CONCLUSIONS: The fetal renal hyperechogenicity is a relevant indicator of diminution of fetal renal perfusion. This can lead to abnormal development of the affected kidney and can result in a pathological reduction of biparietal diameter/kidney length ratio, which may also be an in utero indicator of subsequent intrauterine and neonatal complications. Detailed ultrasound examinations of renal parenchyma and kidney length seem to be a useful method in the prenatal diagnosis of decreased renal perfusion and of intrauterine hypoxia and serve to detect pathological conditions in utero.

Pregnancy Rate after Controlled Ovarian Hyperstimulation and Intrauterine Insemination for the Treatment of Endometriosis following Surgery.

OBJECTIVE: To compare pregnancy rate after controlled ovarian hyperstimulation and intrauterine insemination (COH-IUI) with no treatment in patients with endometriosis-associated infertility treated with laparoscopy. DESIGN: A clinical cohort study. SETTING: University-level tertiary care center. PATIENTS: 238 women with various stages of endometriosis after laparoscopic treatment. INTERVENTIONS: Either COH-IUI or follow-up for 12 months. MAIN OUTCOME MEASURES: The primary outcome measures were clinical pregnancy and live birth rate. Predictive factors evaluated were female age, maternal BMI, and duration of infertility. RESULTS: The pregnancy rate attained after the integrated laparoscopy-COH-IUI approach was 53.4%, while it was significantly lower (38.5%) in the control group. Similarly, a significant difference was observed in live births (48.3% versus 34.2%). Patients with severe endometriosis were less likely to achieve pregnancy (38%) and live birth (35%) than their counterparts with milder forms (57% and 53%). CONCLUSIONS: In patients with endometriosis-based infertility, surgery followed by COH-IUI is more effective than surgery alone.

[Comparative study of the efficiency of gonadotrope releasing hormone (GnRH) analogs for the treatment of endometriosis]. / Endometriosis kezelésére alkalmazott gonadotrop releasing hormon (GnRH) analógok hatékonyságának összehasonlítása.

INTRODUCTION: Endometriosis is one of the most common gynaecological conditions in women of reproductive age. The aim of the authors' study was to compare the relative safety, efficacy and side effects of nafarelin and triptorelin. PATIENTS AND METHODS: They treated 133 patients for six months and followed up for at least an additional 6 months. In the diagnosis of the endometriosis they use the gold standard, the laparoscopy. RESULTS: During the 6-month therapy with analogues, there was a noticeable decline in the symptoms of the disease, there was no significant change in the efficacy and was no difference in main side effects of the two drugs. CONCLUSION: These treatments represent favourable approaches in the management of endometriosis.

Validation of the Edinburgh Postnatal Depression Scale as a screening tool for postpartum depression in a clinical sample in Hungary.

BACKGROUND: the purpose of the study was to assess the validity of the 10-item Edinburgh Postnatal Depression Scale (EPDS) in screening for postnatal depression (PND) in Hungary. METHODS: between July 2010 and March 2011, a sample of 266 women attending a routine check-up at six weeks post partum completed the newly translated Hungarian version of the EPDS at the Department of Obstetrics and Gynecology, University of Szeged, Hungary, and underwent clinical assessments based on the Structured Clinical Interview for DSM-IV disorders (SCID-I). FINDINGS: eight (3.0%) of the mothers were diagnosed with major postnatal depression, and 36 (13.5%) with minor depression on the basis of the SCID. Internal consistency of the Hungarian version of the EPDS was satisfactory (Cronbach α coefficients ≥0.727). The best cut-off for major depression was 12/13, with a sensitivity of 100.0%, and a specificity of 97.7%. The area under the ROC curve was found significant for combined (major+minor) depression as well and at a cut-off of 7/8 indicated a sensitivity of 72.7% and a specificity of 86.0%. A factor analysis suggested multidimensionality with two factors (anxiety and depression). CONCLUSIONS: the EPDS showed good validity in the postnatal period in a clinical sample in Hungary.

The Edinburgh Postnatal Depression Scale: translation and antepartum validation for a Hungarian sample.

OBJECTIVE: the Edinburgh Postnatal Depression Scale (EPDS) is an important screening instrument routinely used during the peripartum period for the identification of depression. The purpose of the study was to assess the validity of the 10-item EPDS in screening for antepartum depression (APD) in Hungary. DESIGN: validation study carried out between July and December 2010. SETTING: Department of Obstetrics and Gynecology, University of Szeged, Hungary. PARTICIPANTS: 219 women attending a routine check-up at 12 weeks antepartum. INTERVENTIONS: participants completed the newly translated Hungarian version of the EPDS and underwent a clinical assessment with the Structured Clinical Interview for DSM-IV disorders (SCID-I). MEASUREMENT AND FINDINGS: seven (3.2%) of the mothers were diagnosed with major antepartum depression and 15 persons (6.85%) with minor depression on the basis of the SCID. Internal consistency of the EPDS was satisfactory (Cronbach α coefficients ≥0.728). The best cut-off on the Hungarian version of the EPDS for major depression was 8/9, with a sensitivity of 71.4%, and a specificity of 91.5%. The area under the ROC curve was found significant for combined depression as well and at a cut-off of 6/7 indicated a sensitivity of 81.8% and a specificity of 83.2%. KEY CONCLUSIONS: the EPDS showed acceptable validity despite a considerable scatter in the total scores in our sample. IMPLICATION FOR PRACTICE: the EPDS is a reliable instrument for the screening of depressive disorders, especially major depressive disorder in early pregnancy among Hungarian women.