Katarzyna Kosinska-Kaczynska

IVF versus spontaneous twin pregnancies – which are at higher risk of complications?

Objective: To analyze the course of twin pregnancies, deliveries and neonatal outcome after in vitro fertilization (IVF) and compare them with spontaneous twins (ST). Methods: The studied material consisted of 131 women in twin pregnancies: 43 patients with IVF and 83 with ST, who delivered at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw in years 2005–2009. Results: Complications of pregnancy, especially imminent abortion and imminent preterm delivery, were significantly more often diagnosed in IVF versus ST. The rate of preterm delivery was similar in both groups. The vast majority of all analyzed twin pregnancies were delivered by cesarean section. The dominant indication was other than cephalic presentation of either one of the twins. Regardless of the group, all cases of neonatal mortality were a result of sepsis and extreme prematurity. The length of hospitalization and treatment period depended mostly on prematurity. It was also dependent on the method of conception – IVF was in favor of shorter treatment time. Conclusions: The method of conception seems not to have a negative impact on the course of pregnancy, risk of preterm delivery and obstetric outcome. Neonatal complications of IVF and spontaneous twins are mostly a result of prematurity.

Vaginal progesterone after tocolytic therapy in threatened preterm labor

Objective: The aim of this study was retrospective evaluation of progesterone efficacy in pregnant patients with preterm uterine contractions. Material: 190 women hospitalized at 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, in 2007–2010, with symptoms of threatened preterm labor were enrolled in the study. 94 women were treated with tocolytics and steroids (control group), while 96 women received additionally 200 mg of progesterone vaginally until delivery or 34th weeks of gestation (progesterone group). Results: The mean gestational age at admission was 27 weeks in progesterone group and 28 weeks in control group. Cervical length was similar in both groups. There were no significant differences in week of delivery between groups, but the progesterone group had significant increase in prolongation of pregnancy (7.6 versus 6.3 weeks, p = 0.039). Vaginal progesterone was associated with reduction of delivery before 34 weeks (9.8% versus 35.3%; p = 0.002) and neonatal birth weight <1500 g (3.2% versus 20.6%; p = 0.011) only in patients presenting with uterine contractions after 27 weeks. Conclusion: The administration of vaginal progesterone after tocolysis in threatened preterm labor is associated with prolongation of pregnancy. The reduction of deliveries before 34 weeks was observed in patients presenting with contractions after 27 weeks gestation.

Autonomous adrenocorticotropin reaction to stress stimuli in human fetus

The aim of the study was to determine whether human fetuses show ACTH response to stress stimuli, to define the gestational age from which these reactions may be present and to analyze the relationship between hormone concentrations and their changes, both in fetuses and in pregnant women. The study included 81 intrauterine transfusions carried out in 19 pregnant women. 52 procedures were performed directly into the umbilical vein, which is not innervated, so neutral for the fetus (the PCI group) and 29 transfusions into the intrahepatic vein -which puncture is stressful for the fetus (the IHV group). ACTH and cortisol concentrations in fetal and maternal plasma obtained during the procedures were assayed. The initial mean plasma ACTH concentration in the PCI group equaled 18.94pg/mL, but in the IHV group it was significantly higher and amounted 75.17pg/mL (p<0.001). There was no significant change in the hormone concentration during the transfusion both in the IHV group (95.8pg/mL, p>0.05) and in the PCI group (22.36pg/mL, p>0.05). The observed hormonal response in the IHV group proves the existence of fetal pituitary reaction to stress. The initial fetal ACTH concentration in the IHV group correlated with the number of transfusions performed on a single fetus (R=0.41; p=0.04). No correlation with parity, gestational weeks or the volume of transfused packed red blood cells was found. There was also no correlation between fetal and maternal ACTH concentrations in any group. Presented data suggest that the human fetus shows autonomous ACTH reaction to stress stimulation.

The usefulness of the universal culture-based screening and the efficacy of intrapartum prophylaxis of group B Streptococcus infection

Abstract Objective: To evaluate the usefulness of universal culture-based GBS screening at 35–37 weeks of gestation, assess the efficacy of intrapartum antibiotic administration (IAP) and investigate factors influencing the infection rate in neonates. Methods: Out of 1653 pregnant women 304 (18.4%) further analyzed were GBS positive directly before the delivery, among them 69 were false GBS negative on antenatal screening. Various variables regarding parturients’ and newborns’ characteristics were taken into account in order to achieve the objective of the study. Results: Out of 304 GBS-positive patients directly before the delivery, culture-based screening was positive in 72.4%, while 22.7% presented with GBS-negative screening and received no IAP. No single culture-confirmed early-onset GBS disease was observed. Conclusions: IAP is an effective way of early-onset GBS disease prevention, however prenatal screening would be most efficient if performed intrapartal.

Adjunctive Pessary Therapy after Emergency Cervical Cerclage for Cervical Insufficiency with Protruding Fetal Membranes in the Second Trimester of Pregnancy: A Novel Modification of Treatment

Aim. To evaluate the effectiveness of adjunctive pessary therapy after emergency cervical cerclage (ECC) in improving perinatal outcome in cervical insufficiency with fetal membranes protruding into the vagina. Material and Methods. A retrospective analysis of patients treated at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, between 2008 and 2013. The study group consisted of 15 women treated with ECC and a pessary and the control group consisted of 17 patients treated with cerclage only. Results. The mean gestational age at delivery was significantly higher in the study group (34.7 versus 29.7 weeks, p = 0.03). The period between cerclage insertion and delivery was significantly longer in the study group (82.9 versus 52.1 days, p = 0.045). The mean neonatal birthweight and neonatal “discharge alive” ratio were higher in the study group, although not statistically significant (2550 g versus 1883 g, p = 0.14, and 93.3% versus 70.5%, p = 0.18, resp.). NICU hospitalization rates were comparable (33.3% versus 35.3%, p = 0.9). Conclusions. Adjunctive pessary therapy allows delaying delivery in women treated with ECC due to cervical insufficiency with protruding fetal membranes. It also seems to improve neonatal outcome, although the differences are not statistically significant. Further prospective study is required to prove these findings.

Relation between time interval from antenatal corticosteroids administration to delivery and neonatal outcome in twins

The aim of this study was to evaluate the perinatal outcome in twins, who were administered one complete course of antenatal corticosteroids (ACS) depending on the time interval from corticosteroids to delivery.

Late Prematurity in Twins: A Polish Multicenter Study

The study aimed at investigating the impact of late prematurity (LPT) on neonatal outcome in twins and neonatal morbidity and mortality within LPT with regard to the completed weeks of gestation. The study was conducted in six tertiary obstetric departments from different provinces of Poland (Warsaw, Lublin, Poznan, Wroclaw, Bytom). It included 465 twin deliveries in the above centers in 2012. A comparative analysis of maternal factors, the course of pregnancy and delivery and neonatal outcome between LPT (34 + 0-36 + 6 weeks of gestation) and term groups (completed 37 weeks) was performed. The neonatal outcome included short-term morbidities. The analysis of neonatal complication rates according to completed gestational weeks was carried out. Out of 465 twin deliveries 213 (44.8%) were LPT and 156 (33.55%) were term. There were no neonatal deaths among LPT and term twins. One-third of LPT newborns suffered from respiratory disorders or required antibiotics, 40% had jaundice requiring phototherapy, and 30% were admitted to NICU. The analysis of neonatal morbidity with regard to each gestational week at delivery showed that most analyzed complications occurred less frequently with the advancing gestational age, especially respiratory disorders and NICU admissions. The only two factors with significant influence on neonatal morbidity rate were neonatal birth weight (OR = 0.43, 95% CI = 0.2-0.9, p = .02) and gestational age at delivery (OR = 0.62, 95% CI = 0.5-0.8, p < .01). LPT have a higher risk of neonatal morbidity than term twins. Gestational age and neonatal birth weight seem to play a crucial role in neonatal outcome in twins.

Sudden Fetal Hematologic Changes as a Complication of Amnioreduction in Twin-Twin Transfusion Syndrome

We present the first case of a monochorionic twin pregnancy in which sudden hematologic changes occurred as a complication of the amnioreduction procedure for twin-twin transfusion syndrome (TTTS). At 33 weeks of gestation, 4 days after the amnioreduction, the recipient developed severe anemia while the donor developed severe polycythemia. Postnatal placental examination revealed several arteriovenous and venoarterial anastomoses, a pale placental mass of the recipient and a congested and plethoric placental mass of the donor. We speculate on the pathophysiologic changes and potential deleterious effects provoked by the decompressive amnioreduction. Decompression of the placenta and anastomoses after the amnioreduction may have led to an acute blood shift from recipient to donor (thus also a reversal of feto-fetal transfusion), resulting in anemia in the recipient and polycythemia in the donor twin. In the past 15 years, 13 TTTS cases with late presentation were treated with amnioreduction. This is the first time we encountered this severe complication, yielding an incidence of 8%. Although the optimal treatment in TTTS with late presentation is not known, perinatologists should be aware that treatment with amnioreduction can lead to sudden hematologic changes.

The association of first trimester bleeding with preterm delivery.

Abstract Introduction: Preterm birth (PTB) is a predictor of perinatal morbidity and mortality, and prematurity continues to burden public healthcare with growing expenses. First trimester bleeding (FTB) has a well-known association with PTB; however, the relationship with severity of PTB is less obvious. Aim: The primary aim of the study was to analyze the influence of FTB on the risk and severity of PTB, as well as to assess the connection of FTB and other pregnancy complications. Methods: It was an observational case control study. The material consisted of medical records of patients who delivered between 2010 and 2013. Two groups were formed – 497 women with FTB and 500 women without bleeding. Results: Women with FTB were more likely to deliver preterm in general (OR=2.11; 95% CI 1.43–3.10). The risk of extremely PTB (<28 weeks) was almost four-fold (OR=3.76; 95% CI 0.97–17.06) and very PTB (28–31 weeks) more than three-fold (OR=3.41; 95% CI 0.86–15.69). FTB increased the risk of placenta previa (OR=4.81; 95% CI 1.29–20.53; P=0.007). Conclusion: FTB is a risk factor of PTB and is associated with greater risk of PTB-related pregnancy complications. Management of FTB pregnancies should include thorough screening for both preterm delivery and placental pathologies.

OC048: Comparison of conventional and three‐dimensional sonohysterography in the assessment of submucous uterine myomas before their hysteroscopic resection

Objectives: To evaluate to what extent removal of focal intracavity lesions results in cessation of abnormal uterine bleeding. Methods: Prospective observational study. From a cohort of 402 women presenting with abnormal uterine bleeding, 124 patients were referred for operative hysteroscopy after diagnosis of a focal intracavity lesion seen at hydrosonography and/or hysteroscopy. A telephone survey was conducted two years later asking patients about their bleeding pattern. The symptoms before and after surgery and the results of histology were compared. Results: There were 112 patients, with the mean age of treatment at 52.2 years, with 47% being premenopausal. In 14 patients (12.5%) the endometrial thickness at ultrasound was below 5 mm. The histology of the resected tissue were endometrial polyps in 60.7%, submucous myomas in 21.4%, with focal endometrial hyperplasia in 4.5%. For those women with endometrial polyps and intracavity myomas confirmed on histology, 97% and 83%, respectively reported an improvement in bleeding pattern. For those with polyps and myomas there was a definitive cure rate of 76% and 79%, and a transient improvement in 21% and 4%, respectively. Conclusions: The vast majority of women complaining of abnormal uterine bleeding and with a focal intracavity lesion will benefit from removal under hysteroscopic guidance.