Graziano Clerici

B-Lynch suture, intrauterine balloon, and endouterine hemostatic suture for the management of postpartum hemorrhage due to placenta previa accreta

To report our experience with a new conservative management approach to treat postpartum hemorrhage (PPH) due to placenta previa accreta.

Cerebral blood flow autoregulation and congenital heart disease: possible causes of abnormal prenatal neurologic development.

Objective. To determine whether the major congenital heart diseases (CHDs) can modify the cerebrovascular flow dynamics and the biometrical parameters in fetuses at third trimester of pregnancy. Methods. We studied 60 fetuses with CHD. Data included prenatal versus postnatal cardiac diagnosis, cerebral and umbilical artery doppler, fetal biometrical parameters, fetal weight, and gestational age. The pulsatility index (PI) was used to determine blood flow velocities in the umbilical artery (UA) and middle cerebral artery (MCA), while the cerebro/placental ratio (CPR) was assessed as a measure of cerebral autoregulation. Fetuses with CHD were compared to normal controls and then analyzed after being divided into groups based on specific defects. Results. Compared with control fetuses, those with CHD showed a decrease of resistance blood flow in the middle cerebral artery (1.76 vs 1.92 PI) especially considering the CPR (1.66 vs 2.03 PI) (p  <  0.01). Furthermore, fetuses with CHD also had smaller head circumferences (30.6 cm vs 31.5 cm p  <  0.01) and head/abdominal (HC/AC) ratio (1 vs 1.05 p  <  0.01). When stratified for single cardiac diseases, fetuses with hypoplasic left heart syndrome showed a lower CPR and HC/AC ratio. Conclusions. Cerebrovascular resistance is significantly lower in fetuses with CHD, especially in cases of left side obstruction. The cerebro/placental hemodynamic changes are similar to that described in fetuses with placental insufficiency and may contribute to their abnormal neurologic development.

Atypical hemodynamic pattern in fetuses with hypercoiled umbilical cord and growth restriction.

Objectives: To describe fetal and uterine hemodynamics in intrauterine growth restriction (IUGR) fetuses with hypercoiled umbilical cord. Methods: 102 pregnant women with IUGR fetuses were enrolled in the study. In these cases, hemodynamic indices and Doppler waveform profiles were evaluated. Results: In seven of the enrolled cases of IUGR, we found an anomalous umbilical coiling. They showed normal impedance to flow in utero-placental district and abnormal venous umbilical cord pulsatility with flow velocity higher than the umbilical artery. The ductus venosus showed a reduction of the forward flow and/or a reverse flow during atrial contractions. Two of these seven patients had early onset IUGR and a particular deteriorating hemodynamic profile with “brain sparing”, severe reverse flow in the ductus venosus, increased reverse flow in the inferior vena cava during atrial contraction and absent flow during the diastole in the umbilical arteries. Five patients had late onset of IUGR and three of these did not demonstrate these worsening hemodynamic alterations until term. Conclusions: In patients with fetal IUGR and hypercoiling without signs of placental insufficiency, we observed an “atypical” feto-maternal hemodynamic pattern. These IUGR fetuses with hypercoiling and fetal venous system hemodynamic alteration can be at high hypoxic risk.

Placenta Previa Percreta: A Case Report of Successful Management via Conservative Surgery

Placenta percreta is one of the most serious complications of placenta previa and is frequently associated with severe obstetric hemorrhage usually necessitating hysterectomy. We present a case of placenta previa percreta diagnosed by ultrasound and magnetic resonance imaging techniques, in which we accomplished conservative management of postpartum hemorrhage. The management we propose includes the following steps: preventive catheterization of the descending aorta via transhumeral access; Stark cesarean delivery; uterotonics drugs; Affronti endouterine square hemostatic sutures; intrauterine application of Bakri balloon and partial filling with 100 mL of normal saline; B Lynch suture, hysterorrhaphy, and filling a Bakri balloon with up to 500 mL of normal saline; reversible radiological embolization; and/or surgical ligation of the uterine arteries. The bleeding stopped following placement of Affronti sutures combined with external (B-Lynch suture) and internal (Bakri balloon) uterine compression. Our experience indicates that this conservative method can be considered an option in the management of selected cases of pregnancy at high risk for intrapartum hemorrhage.

Atosiban versus betamimetics in the treatment of preterm labour in Italy: clinical and economic importance of side-effects

The aim of this study was to determine the cost effectiveness of atosiban compared to betamimetics in the treatment of preterm labour within the Italian setting. A systematic literature review identified randomised controlled trials (RCTs) comparing atosiban with betamimetics. Meta-analysis of nine RCTs determined that atosiban and betamimetics had similar efficacy in delaying preterm birth by at least 48 h (p=0.910). Use of atosiban was associated with significantly fewer adverse events (p<0.008). Results demonstrate that atosiban is cost-saving versus ritodrine or isoxuprine. Atosiban cost savings are €657 per patient from the National Health Service payers perspective; €299 at 18 h of tocolysis to €189 at 48 h from the hospitals perspective. The respective values versus isoxuprine were €303 and €199. From the combined perspective, using atosiban versus ritodrine saved from €425 to €316; and versus isoxuprine from €429 to €326. Owing to its superior safety profile, atosiban is cost-saving versus betamimetics in the treatment of preterm labour in Italy from the payers, hospitals and combined perspectives. With the approximate 40,000 annual preterm births in Italy the annual savings could be in excess of €13 million for the payer or €3.8-6.2 million for the hospitals.

Development of customized fetal growth charts in twins

BACKGROUND: Twin gestations are at significantly higher risk of fetal growth restriction in comparison with singletons. Using fetal biometric charts customized for obstetrical and parental characteristics may facilitate an accurate assessment of fetal growth. OBJECTIVE: The objective of the study was to construct reference charts for the gestation of fetal biometric parameters stratified by chorionicity and customized for obstetrical and parental characteristics. STUDY DESIGN: Fetal biometric measurements obtained from serial ultrasound examinations in uncomplicated twin pregnancies delivering after 36 weeks of gestation were collected by 19 Italian fetal medicine units under the auspices of the Società Italiana di Ecografia Ostetrica e Ginecologica. The measurements acquired in each fetus at each examination included biparietal diameter, head circumference, abdominal circumference, and femur length. Multilevel linear regression models were used to adjust for the serial ultrasonographic measurements obtained and the clustering of each fetus in twin pregnancy. The impact of maternal and paternal characteristics (height, weight, ethnicity), parity, fetal sex, and mode of conception was also considered. Models for each parameter were stratified by fetal chorionicity and compared with our previously constructed growth curves for singletons. RESULTS: The data set included 1781 twin pregnancies (dichorionic, n = 1289; monochorionic diamniotic, n = 492) with 8923 ultrasonographic examinations with a median of 5 (range, 2–8) observations per pregnancy in dichorionic and 6 in (range, 2–11) monochorionic pregnancies. Growth curves of twin pregnancies differed from those of singletons, and differences were more marked in monochorionic twins and during the third trimester. A significant influence of parental characteristics was found. CONCLUSION: Curves of fetal biometric measurements in twins are influenced by parental characteristics. There is a reduction in the growth rate during the third trimester. The reference limits for gestation constructed in this study may provide a useful tool for a more accurate assessment of fetal growth in twin pregnancies.

Progesterone in normal and pathological pregnancy.

Abstract Progesterone is an essential hormone in the process of reproduction. It is involved in the menstrual cycle, implantation and is essential for pregnancy maintenance. It has been proposed and extensively used in the treatment of different gynecological pathologies as well as in assisted reproductive technologies and in the maintenance of pregnancy. Called “the pregnancy hormone”, natural progesterone is essential before pregnancy and has a crucial role in its maintenance based on different mechanisms such as: modulation of maternal immune response and suppression of inflammatory response (the presence of progesterone and its interaction with progesterone receptors at the decidua level appears to play a major role in the maternal defense strategy), reduction of uterine contractility (adequate progesterone concentrations in myometrium are able to counteract prostaglandin stimulatory activity as well as oxytocin), improvement of utero-placental circulation and luteal phase support (it has been demonstrated that progesterone may promote the invasion of extravillous trophoblasts to the decidua by inhibiting apoptosis of extravillous trophoblasts). Once the therapeutic need of progesterone is established, the key factor is the decision of the best route to administer the hormone and the optimal dosage determination. Progesterone can be administered by many different routes, but the most utilized are oral, the vaginal and intramuscular administration. The main uses of progesterone are represented by: threatened miscarriage, recurrent miscarriage and preterm birth (in the prevention strategy, as a tocolytic agent and also in the maintenance of uterine quiescence).

Is there a sex of the placenta

The placenta has traditionally been considered as an asexual organ. Thus, most of the studies focusing on the placenta have not taken the sex of the embryo into account. However, as trophoblast cells originate from the embryo, they reflect fetal sex as either XX or XY, allowing for possible sex differences in placental biochemistry, function, and signaling. The placenta is a temporary organ performing the functions of many adult organs for the growing fetus. The placenta plays a key role in fetal growth and development, it is designed for exchange of oxygen, nutrients, antibodies, hormonal compounds and waste products between the mother and fetus and may carry significant information about the pregnancy. The placenta is considered also a major endocrine organ being responsible for synthesizing vast quantities of hormones and cytokines that have important effects on both maternal and fetal physiology. The investigation of placenta and its functions helps to identify molecular mechanisms that have both early- and long-term effects on health of the fetus. Gender differences were observed in the placenta at multiple levels: epigenetic modifications of DNA, gene expression, protein expression and immune function. Proceedings of the 11 th International Workshop on Neonatology and Satellite Meetings · Cagliari (Italy) · October 26 th -31 st , 2015 · From the womb to the adult Guest Editors: Vassilios Fanos (Cagliari, Italy), Michele Mussap (Genoa, Italy), Antonio Del Vecchio (Bari, Italy), Bo Sun (Shanghai, China), Dorret I. Boomsma (Amsterdam, the Netherlands), Gavino Faa (Cagliari, Italy), Antonio Giordano (Philadelphia, USA)

Bovine aortic arch: clinical significance and hemodynamic evaluation

Abstract Objective: The most common aortic arch branching variation described in literature is the common origin of the brachiocephalic trunk and left common carotid artery (“bovine arch” / type II aortic arch), with an incidence of 7.2–21.1%. The first aim of this study was to investigate the prevalence of bovine arch in the fetuses. The second aim was the hemodynamic evaluation of the epiaortic vessels. Methods: In two years we examined 742 pregnant women and it was possible to obtain a good hemodynamic evaluation in 39 patients. Among the 39 fetuses, we found 6 with bovine arch. The blood flow of all epiaortic vessels and of MCA was evaluated. Results: Among the 742 fetuses examined, the bovine aortic arch was identified in 45 patients (6.06%). The hemodynamic evaluation of the epiaortic vessels showed statistically significant differences between the bovine arch and normal aortic arch. Conclusion: The presence of bovine aortic arch in the fetus is characterized by some hemodynamical differences. They could have a possible relationship with the incidence of some pathologies in adult life. Prenatal knowledge of anatomic variants of the aortic arch can bring benefits to the individuals health for future possible cardiovascular investigations.

Progestogens in Preterm Labour

Pre-term birth (PTB) is a major health challenge to-day. Perinatal mortality is increased more than three times and PTB is the leading cause of short and long-term neonatal/infant morbidity. Many are the risk factors, previous PTB, cervical effacement or dilatation on clinical vaginal examination or shortening of the length of the cervical canal on ultrasound are major predisposing factors.