M. Theodora

First trimester 3D volumetry. Association of the gestational volumes with the birth weight.

Objective. To evaluate the three dimensional ultrasound (3D) in the volume assessment of the gestational contents during the 1st trimester of pregnancy. Our aim was to correlate the embryo, gestational sac, and placenta volume with the birth weight. To monitor the increase of these volumes according to the gestational age. Method. Prospective study of 199 singleton low risk pregnant women undergoing the 1st trimester ultrasound for fetal anomalies. In these women, gestational volumetry was performed and it was compared with the crown-rump length (CRL). Regression models were computed in order to analyze the dependence of birth weight with the volumes. Results. The embryo volume reveals the strongest association with the birth weight at delivery (β = 0.24), followed by the CRL (β = 0.20) and the gestational sac volume (β = 0.20). The placenta volume appears the weakest association with fetal weight at delivery (β = 0.16). All volumes increased significantly from 11+0–11+6 to 13+0–13+6 weeks of gestation (p < 0.001). Ten cubic millimeter increase in embryo volume corresponds to a mean birth weight increase of 75 g, while 1 mm increase in the CRL corresponds to a birth weight increase of 113 g. Conclusion. Our results provide evidence that the embryo volume during the first trimester of pregnancy correlates better with birth weight than the CRL. This might assist in the identification of the high risk pregnancies caring macrosomic and low birth weight fetuses.

Prevalence of Trichomonas vaginalis infection in women attending a major gynaecological hospital in Greece: a cross-sectional study

Background The prevalence of Trichomonas vaginalis is not accurately estimated, since it is not a reportable disease. Aims To assess the prevalence of T vaginalis infection in women attending a Greek gynaecological hospital and to evaluate four diagnostic methods for T vaginalis infection. Methods 255 symptomatic and 247 asymptomatic women were included in the study during 2006–07; 372 were Greek and 130 were immigrants. T vaginalis was detected in vaginal samples, using wet mount, culture in modified Diamonds medium, antigen detection and two PCR assays, targeting different regions of T vaginalis genome. Specimens were considered positive for T vaginalis, when tested positive either by culture or by both PCRs. Results 23 women (4.6%) were positive for T vaginalis. Seven of the 23 positive samples (30.4%) were only PCR-positive. Infection was more prevalent in symptomatic women (6.7%) than in asymptomatic ones (2.4%). T vaginalis was more frequently detected in immigrants (7.9%) than in Greek women (3.3%). Gardnerella vaginalis infection was significantly more frequent in women infected with T vaginalis. PCR was the most sensitive method (100%), followed by culture (69.6%), wet mount (69.6%) and latex agglutination (54.6%). Agreement between PCR and culture as well as wet mount examination was very good (κ=0.79). Conclusions The study shows a relatively low percentage of trichomoniasis in the female population living in Athens. The infection was more prevalent among immigrants, and a proportion of the infected women was asymptomatic. The tested methods had good agreement and PCR was found to improve the diagnostic yield considerably.

Incidental discovery of two levonorgestrel-releasing intrauterine systems misplaced in the peritoneal cavity.

Objectives To present a rare case of the incidental discovery of two misplaced intrauterine devices in the same patient, and to discuss risk factors for uterine perforation and appropriate management. Case A 37-year-old woman complaining of chronic lower back pain presented with an X-ray of her abdomen showing two misplaced LNG-IUSs in the peritoneal cavity. More than two years before the patient had submitted within two months to two successive attempts at insertion of a Mirena® IUS. The threads of the first IUS were not seen at the follow-up visit and the IUS was not detected on ultrasound either. As it was assumed to have been expelled, insertion of a second IUS of the same type was attempted. Again, the threads were not seen at the control visit. This time, no further action was undertaken. Conclusions Radiography is helpful in confirming migration of an intrauterine contraceptive. Removal of the latter is recommended, due to the potential for serious complications.

Fetal loss following second trimester amniocentesis. Who is at greater risk? How to counsel pregnant women?

Abstract Objective: The purpose of this retrospective observational cohort study was to determine the impact of certain risk factors on fetal loss, after mid-trimester amniocentesis. Material and methods: Six thousand seven-hundred and fifty-two (6752) consecutive amniocenteses with known pregnancy outcome performed during a 7-year period (2004–2010) were included in this study. Different maternal-, fetal- and procedure-related factors were evaluated in this study. Results: During this 7-year period, 6752 cases who underwent amniocentesis, with complete data available were evaluated for the outcome and risk factors mentioned. Total fetal loss rate (FLR) up to the 24th week was 1.19%. Risk factors associated with increased risk of fetal loss after amniocentesis were maternal age (OR:2.0), vaginal spotting (OR:2.2) and serious bleeding (OR:3.5) during pregnancy, history of 2nd trimester termination of pregnancy (OR:4.0), history of more than three spontaneous (OR:3.0) or surgical first trimester abortions (OR:2.1), fibromas (OR:3.0) and stained amniotic fluid (OR:6.1). Conclusions: Amniocentesis is a safe-invasive procedure for prenatal diagnosis with total FLR of 1.19% in our institution during the study period. The present study has emphasized the significance of certain risk factors for adverse outcome and therefore the need to individualize the risk.

Assessment of nuchal translucency thickness and the fetal anatomy in the first trimester of pregnancy by two-and three-dimensional ultrasonography: a pilot study

Abstract Aim: To evaluate the use of three-dimensional ultrasonography (3D) as an alternative for examining fetal anatomy and nuchal translucency (NT) in the 1st trimester of pregnancy. Method: Prospective study of 199 low risk pregnant women undergoing 1st trimester ultrasound scan for fetal anomalies. The NT and fetal anatomy were evaluated by three-dimensional (3D) ultrasonography after the standard two-dimensional (2D) examination. The gold standard in this study was the 2D ultrasonography. Results: In some of the evaluated parameters the 3D method approaches the conventional 2D results. These parameters are the crown-rump length (CRL), the skull – brain anatomy (93.5%), the spine (85.4%), the upper (88.4%) and lower limbs (87.9%) and the examination of the fetal abdomen (98.5%). Some of the anatomic parameters under evaluation revealed a statistically significant difference in favor of the 2D examination. During the 3D examination the nasal bone was identified in 62.1% of the cases, the stomach in 85.9%, and the urinary bladder in 57.3% of the cases. The NT was assessed accurately in half of the cases compared to 2D examination. Conclusion: The 3D ultrasound is insufficient for the detailed fetal anatomy examination during the 1st trimester of pregnancy. Nevertheless, the method might be improved in order to be considered as a screening method.

Safety and efficacy of the cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth

Abstract Introduction: The aim of this study was to evaluate the safety and efficacy of the combined treatment of cervical pessary and endovaginal progesterone for the prevention of spontaneous preterm birth (SPB) in women with a short cervical length (CL) between 20 and 24 weeks of gestation. Materials and methods: This is a prospective study of women with a singleton pregnancy and a sonographically detected mid-trimester CL ≤25 mm. The primary outcome measure was spontaneous delivery before 34 weeks (238 days) of gestation. Results: The study sample consisted of 90 women with a mean CL of 14.2 mm (SD=6.5 mm). Of the women, 34.4% had at least one risk factor for SPB; 7.8% delivered preterm before 34 weeks of gestation, and 25.6%, before 37 weeks. Neonatal death occurred in two (2.2%) cases due to respiratory distress syndrome. Lower body mass index values, history of preterm delivery and number of second trimester miscarriages were independently associated with delivery before 34 weeks. Conclusion: The combination of vaginal progesterone and cervical pessary for the prevention of SPB in women with a short cervix is safe and well tolerated. This therapy was associated with pregnancy prolongation, reduced prematurity rate and a low rate of perinatal complications.

Risk for fetal loss and prematurity after 12,413 second trimester amniocenteses in a single center.

Abstract Objectives: The purpose of this retrospective controlled study is to estimate the risk for fetal loss and preterm delivery attributed to second trimester amniocentesis from a single tertiary center. Methods: The study group consists of 12,413 singleton pregnancies with consecutive amniocenteses, performed in a single tertiary center during a 15-year period (1996–2010) with known pregnancy outcome. The control group consisted of 6993 pregnancies with negative second trimester screening for aneuploidies during the same period who did not have any invasive test. The two groups were compared in terms of fetal loss rate up to 24 weeks and premature deliveries. Results: Total fetal loss up to 24 weeks in the study group, excluding terminations of pregnancy, was estimated at 1.25% (1.05%–1.45%, confidence interval [CI]: 95%). In the control group the loss rate was 0.65% giving a procedure related fetal loss rate of 0.6% which was not found to be a statistically significant difference. Delivery before the 28th, 32nd, 34th, and 37th week in the study group was reported in 0.2%, 0.8%, 1.2% and 8.1% respectively, and it was not statistically different from controls. Conclusion: The present study has shown that the risk of miscarriage that can be attributed to amniocentesis in our institution is 0.6%, and this is not statistically significant when compared with cases without any invasive procedure during pregnancy. Similarly, the risk for preterm labor was not statistically significant when compared with controls.

Reply to: Cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth: is evidence sufficient?

We would like to thank Madar et al. [1] for their comments referring our article “Safety and efficacy of the cervical pessary combined with vaginal progesterone for the prevention of spontaneous preterm birth” [2]. We agree with them that no definitive conclusions can be drawn out of randomized trials. Although the lack of a control group in our study is a major limitation, all women that took part in the study underwent frequent sonographic cervical screening and were treated following the same protocol, thus making the study more homogenous. Moreover, all doctors involved in this study were certified for both ultrasonograhic cervical assessment and pessary placement. As the authors of the letter have already mentioned, the daily clinical practice sometimes differs substantially from the results of randomized trials. In addition, randomized trials on the pessary use in women with short cervix had conflicting results, whereas the influence of the ethnicity on the results may be significant [3–6]. Therefore, we believe that the single center international experience in the management of rare events in pregnancy, such as a short cervix in the second trimester, should be appropriately reported. This management should be based on not only the good knowledge of the literature but also the logic and the operators experience, which represents what is called “reality-based medicine”. The current study reported our experience on the combined treatment of pessary and simultaneous vaginal progesterone administration, which had not been tested in any randomized trial to date. More importantly, we neither overinterpreted nor overemphasized our results. In fact, we concluded by saying, “.... the present study has shown that combined treatment with cervical pessary and vaginal progesterone is a safe and feasible option, which may be beneficial for the prolongation of the pregnancy and therefore could be an effective method for preventing SPB. This can only be confirmed in a large multicenter randomized study”.

A Spontaneous Pregnancy in a Patient with Turner Syndrome with 45,X/47,XXX Mosaicism: A Case Report and Review of the Literature

BACKGROUND Turner syndrome is a chromosomal abnormality, due to a total or partial loss of 1 of the X chromosomes and is mostly characterized clinically by short stature and primary ovarian insufficiency. Spontaneous pregnancies are rare (5%) and of relatively high risk. This is 1 of few reported cases of spontaneous conception and favorable prognosis in a patient with Turner syndrome and a 45,X/47,XXX karyotype. CASE A 21-year-old woman with Turner mosaicism (45,X/47,XXX) who had a full-term, uncomplicated pregnancy after spontaneous conception, gave birth to a healthy female (46,XX) infant. SUMMARY AND CONCLUSION Spontaneous pregnancies in women with Turner syndrome are a rarity. Fertility preservation methods are being discussed. Due to the high reported incidence of neonatal, obstetric, maternal, and especially cardiovascular complications in those pregnancies, close monitoring is essential.

Prenatal diagnosis of sirenomelia with anencephaly and craniorachischisis totalis: A case report study

Rationale: Sirenomelia and anencephaly are well-defined congenital malformations that usually occur independently. Patient concerns: We report a case of combined sirenomelia, anencephaly and complete rachischisis, diagnosed in the 16th week of gestation. Diagnoses: To our knowledge, this is the 7th case in the literature and the first that is diagnosed so early in pregnancy. Interventions: The final diagnosis is confirmed with radiological examination after the termination of pregnancy. Outcomes: Prenatal diagnosis of sirenomelia is difficult due to the presence of kidney agenesis and severe oligohydramnios. Lessons: The combination of sirenomelia and craniorachischisis totalis is extremely rare and prenatal ultrasound scan are a challenge, even for experts in the field.