Antonella Vimercati

Estimation of Birth Weight by Two-Dimensional Ultrasonography : A Critical Appraisal of Its Accuracy

OBJECTIVE: To assess the accuracy and characterize two-dimensional ultrasonographic formulas for the estimation of birth weight according to the type of fetal biometric parameters these formulas rely on to make fetal weight predictions. METHODS: A prospective recruitment of 589 pregnant women was carried out for this cross-sectional study. Different biometric parameters were taken ultrasonographically to estimate birth weight using 35 different formulas. Only those patients who delivered within 48 hours were considered for the analysis (n=441). Differences between the estimated and actual birth weight were assessed by percentage error, accuracy in predictions within ±10% and ±15% of error, and use of the Bland-Altman method. All formulas were assessed individually and clustered on the basis of the type of fetal biometric information that they incorporate. RESULTS: Twenty-nine formulas provided an overall mean absolute percentage error less than or equal to 10%, with overall predictions within ±10% and ±15% of the actual birth weight (69.2% and 86.5%, respectively). Twenty formulas showed a good accuracy (bias 0.50 or less) and low variability (mean standard deviation 1.2). Among the categorized algorithms, formulas based on head-abdomen-femur measurements showed the lowest mean absolute percentage error. Upon stratification for birth weight, the group of formulas that rely on abdomen and femur measurements performed best for fetuses weighing more than 3,500 g (P<.01). CONCLUSION: Our findings show that most formulas are relatively accurate at predicting birth weight up to 3,500 g, and all algorithms tend to underestimate large fetuses. LEVEL OF EVIDENCE: III

Indications and outcome for intensive care unit admission during puerperium.

Abstract Background: A significant decrease of maternal mortality related to improvement in diagnosis and prevention of disorders in pregnancy has been observed without a similar reduction of puerperal morbidity. Objective of this study was to identify risk factors and outcome of patients, which required intensive care during puerperium. Methods: During the period 1987–1998 all pregnant patients, which were transferred from Department of Obstetrics and Gynecology to Intensive Care Unit (ICU) of University of Bari, were retrospectively included into the study. Several risk factors (age, preexisting diseases, gestational age, medical complication of pregnancy, mode of delivery, surgical additional procedure, fetal outcome, intrapartum transfusions, and puerperal complications) and the indications for transfer were evaluated. Results: The overall incidence of admission into Intensive Care Unit was 0.17% (41/23.694) of deliveries. Indications for admission into ICU were: worsening of preeclampsia in 75.6% of cases, severe bleeding in 14.7% of cases, maternal cardiac disease stage III AHA in 4.9% of cases, pulmonary embolism and acute pulmonary oedema respectively in 2.4% of cases. Conclusions: Transfer of patients to ICU due to hypovolemic postraumatic shock seems progressively declining thanks to modern criteria of obstetric management; on the contrary we assist to a prevalence of serious intrinsic maternal diseases often preexisting pregnancy or late consequence of preeclampsia, pulmonary embolism and sequelae of abnormal insertion of placenta.

Fetal blood-brain barrier P-glycoprotein contributes to brain protection during human development.

During brain development and blood-brain barrier (BBB) differentiation the expression of P-glycoprotein (P-gp) may complement the protective function of the placental barrier against xenobiotic substances. To establish an immunohistochemical procedure for P-gp detection, different anti-P-gp monoclonal antibodies were first tested on a fibrosarcoma cell line and colonic carcinoma tissue. The protocol was then tested on adult human brains as a BBB-P-gp tissue-specific control and for double labeling with anti-P-gp and the astroglia marker glial fibrillary acidic protein (GFAP). The protocol was then used to analyze the expression and localization of P-gp in human fetuses during cerebral cortex formation. At the earliest examined stage, 12 weeks of gestation (wg), P-gp was detectable as diffuse cytoplasmic labeling of the endothelial cells lining the primary cortex microvessels. At 18 wg, a punctate P-gp staining pattern was detected on cortex and subcortical vessels and on their side branches. At 22 wg, P-gp staining was linear and concentrated on endothelial cell membranes. In all examined ages, GFAP-positive radial glial cells and astrocytes did not stain for P-gp, even at their perivascular processes, whereas faint P-gp labeling was seen on vimentin-reactive radial glia at the earliest examined fetal age. At midgestation, P-gp colocalized with caveolin-pY14 on the abluminal endothelial cell membrane. These results demonstrate that P-gp is expressed early during human cerebral cortical microvessel development, and suggest that at midgestation there may be efflux activity that is regulated by interactions with the caveolar endothelial cell compartment.

Diagnosis of HIV infection in pregnancy: data from a national cohort of pregnant women with HIV in Italy

We analysed the characteristics of the pregnancies with a previously undetected HIV infection in a national observational study of pregnant women with HIV in Italy. In a total of 443 pregnancies with available date of HIV diagnosis, 118 were characterized by a previously undetected HIV infection (26.6%, 95% CI 22.5-30.8). The following factors were independently associated with this occurrence in a multivariate analysis (adjusted odds ratios; 95% CIs): foreign nationality (5.1, 2.8-9.3); no pre-conception counselling (35.9, 4.8-266.1); first pregnancy (2.1, 1.2-4.0); asymptomatic status (6.8, 1.5-30.6). Women with previously undetected infection started antiretroviral treatment significantly later during pregnancy (P < 0.001). Missed diagnosis was responsible for one case of transmission. A high rate of previously undetected HIV infection was observed. This suggests a good HIV detection during pregnancy, but also the need to reinforce HIV testing strategies among women of childbearing age. We identified some determinants which may be considered for intervention measures.

Accuracy of transvaginal sonography and contrast‐enhanced magnetic resonance‐colonography for the presurgical staging of deep infiltrating endometriosis

To investigate the accuracy of transvaginal sonography (TVS) and contrast‐enhanced magnetic resonance‐colonography (CE‐MR‐C) for the presurgical assessment of deep infiltrating endometriosis (DIE).

The effects of a soy rich diet on serum lipids: the Menfis randomized trial.

OBJECTIVE To assess beneficial effects of a soy rich diet on the main biomarkers of cardiovascular health in menopause, compared with the effects of the hormone replacement therapy (HRT). METHODS 187 healthy asymptomatic postmenopausal women, aged 39-60, were recruited and randomized into three groups: a soy rich diet group, a HRT group, and a control group. Lipid profile, body mass index, blood pressure, endometrial thickness, uterine artery resistance index (RI), were evaluated in all the participants at the baseline, after 6 months, and at the end of the study. RESULTS After a 6-month intervention period, the lipid profile in the soy rich diet group showed a favourable outcome, similar to that observed in the HRT group, but compliance to the diet was low. CONCLUSION Soy products may be used in the prevention of cardiovascular risk in postmenopausal women because of their efficacy in contrasting the negative effects of menopause on the cardiovascular system, but our findings should be confirmed; moreover, suitable strategies to improve the compliance have to be considered.

Maternal complications after caesarean section in HIV infected women

OBJECTIVE To assess the intervention related risk in HIV-infected women, undergoing caesarean section (CS). SETTING Tertiary care center for high risk obstetrics and infectious diseases in pregnancy. PATIENTS AND METHODS Thirty-three HIV-positive women and one hundred and sixty-eight controls, cross matched for age, weight, parity, obstetrical characteristics at delivery and indication for CS, were prospectively recruited for the study. Infection related characteristics, as mode of acquisition, drug abuse, immune status and stage of disease were also recorded. Complications of the intervention were evaluated according to infectious status and risk factors. RESULTS Post-operative complications were significantly more frequent among HIV-infected mothers. More advanced disease and maternal age were the risk factors statistically related to complications. DISCUSSION According to our data, CS carries a higher chance of post-operative complications in HIV-infected women, these complications being also related with the severity of infection (stage and duration of the disease). Given the characteristics of the population in the study (mode of acquisition, prevalence of early stage of the disease), the rate of complication is still relatively low compared to non-western, malnourished, drug-abusers groups.

Uterine cavity assessment in infertile women: comparison of transvaginal sonography and hysteroscopy

OBJECTIVES To evaluate the diagnostic accuracy of transvaginal sonography (TVS) in detecting uterine cavity abnormalities in infertile patients, with reference to hysteroscopy as the gold standard method. STUDY DESIGN At the Institute of Obstetrics and Gynaecology, University of Bari, 134 infertile women were investigated with both TVS and hysteroscopy. In all cases endometrial biopsy was performed. Sensitivity, specificity, and positive and negative predictive values were calculated for TVS, considering hysteroscopic diagnosis as the gold standard. Statistical analysis was performed by using McNemar test. RESULTS There was one failed insertion of hysteroscope. Hysteroscopy diagnosed pathological findings in 58 out of 133 cases (44%). TVS was in agreement with 50 of the 58 (86%) of the pathological findings diagnosed at hysteroscopy. As a test for the detection of uterine cavity abnormalities, TVS in comparison with hysteroscopy had 84.5% sensitivity and 98.7% specificity, 98.0% positive predictive value and 89.2% negative predictive value. CONCLUSIONS TVS is able to diagnose polyps, septum and submucous fibroids with quite significant accuracy, while hysteroscopy is indicated for their confirmation and removal. Thus, hysteroscopy provides both diagnostic and therapeutic capabilities, but TVS permits to proceed directly to operative hysteroscopy avoiding the need for a separate diagnostic procedure.

Estimation of fetal weight by measurement of fetal thigh soft-tissue thickness in the late third trimester

The accuracy of current formulae for the sonographic estimation of fetal weight (EFW) is compromised by significant intra‐ and interobserver variability of biometrical measurements, particularly circumferences. The aim of this study was to assess the reliability of the linear measurement of mid‐thigh soft‐tissue thickness (STT) and to derive a novel formula for EFW.

Polycystic ovary syndrome: relationship between insulin sensitivity ,sex hormone levels and ovarian stromal blood flow

Polycystic ovary syndrome (PCOS) is the most common cause of menstrual disorders ,and is characterized by chronic anovulation ,hyperandrogenism and infertility. In recent years ,it has become apparent that PCOS is also associated with hyperinsulinemia that is probably central to the pathogenesis of PCOS. As a peculiar vascular pattern has been reported to be present in PCOS ,the aim of this study was to investigate intraovarian stromal vascularization in PCOS patients and its possible correlation with sex hormones ,gonadotropins and insulin levels. Twenty-eight oligomenorrheic or amenorrheic patients with PCOS and 14 eumenorrheic women with a PCOS-like ovarian pattern undergoing endocrine screening and ultrasound color Doppler intraovarian blood flow were recruited to the study. Ten healthy women with regular menses represented the control group. Hormonal assays (follicle-stimulating hormone (FSH) ,luteinizing hormone (LH) ,androstenedione ,testosterone ,sex hormone-binding globulin (SHBG) and estradiol), oral glucose tolerance test (OGTT) ,baseline and glucose-induced insulin levels ,and transvaginal ultrasonographic and color Doppler analysis (pulsatility index (PI) ,resistance index (RI) and velocity (Vmax) of ovarian stromal flow) were performed in all participants in the early proliferative phase. Endocrine values showed significant differences in PCOS patients compared with PCOS-like women and controls ,while PI and RI indices were significantly higher in controls. PCOS patients were divided into hyperinsulinemic (n = 16) and normoinsulinemic (n = 12). Androstenedione was significantly higher (p < 0.01) in the hyperinsulinemic than in the normoinsulinemic patients and controls ,while SHBG was significantly (p < 0.01) lower in the hyperinsulinemic group. Analysis of color Doppler intraovarian vascularization showed a significantly lower RI and a higher Vmax in the hyperinsulinemic subjects than in the normoinsulinemic PCOS patients and controls. An increased stromal blood flow was observed in the PCOS and PCOS-like patients by transvaginal color Doppler evaluation ,but this technique is not able to differentiate these two similar ovarian patterns. However, hyperinsulinemic PCOS patients had an increased vascularity of the ovarian stroma. A strong correlation between hyperinsulinemia ,hyperandrogenism and low SHBG levels was evidenced ,and a hyperinsulinemia-induced mechanism for ovarian stromal angiogenesis is discussed.