Maddalena Morlando

Placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section

Placenta accreta is a rare and potentially life‐threatening complication of pregnancy characterized by abnormal adherence of the placenta to the uterine wall. A previously scarred uterus or an abnormal site of placentation in the lower segment is a major risk factor. The aim of this study was to investigate the change in the incidence of placenta accreta and associated risk factors along four decades, from the 1970s to 2000s, in a tertiary south Italian center. We analyzed all cases of placenta accreta in a sample triennium for each decade. The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.

Risk Factors for Coarctation of the Aorta on Prenatal Ultrasound: A Systematic Review and Meta-Analysis

Background: Prenatal diagnosis of coarctation of the aorta (CoA) is still challenging and affected by high rates of false-positive diagnoses. The aim of this study was to ascertain the strength of association and to quantify the diagnostic accuracy of different ultrasound signs in predicting CoA prenatally. Methods: Medline, Embase, CINAHL, and Cochrane databases were searched. Random-effects and hierarchical summary receiver operating characteristic model meta-analyses were used to analyze the data. Results: Seven hundred ninety-four articles were identified, and 12 (922 fetuses at risk for CoA) articles were included. Mean mitral valve diameter z score was lower ( P <0.001) and the mean tricuspid valve diameter z score was higher in fetuses with CoA than in those without CoA ( P =0.01). Mean aortic valve diameter z score was lower in fetuses with CoA than in healthy fetuses ( P ≤0.001), but the ascending aorta diameter, expressed as z score or millimeters, was similar between groups ( P =0.07 and 0.47, respectively). Mean aortic isthmus diameter z scores measured either in sagittal ( P =0.02) or in 3-vessel trachea view ( P <0.001) were lower in fetuses with CoA. Conversely, the mean pulmonary artery diameter z score, the right/left ventricular and pulmonary artery/ascending aorta diameter ratios were higher ( P <0.001, P =0.02, and P =0.02, respectively) in fetuses with CoA in comparison with controls, although aortic isthmus/arterial duct diameter ratio was lower in fetuses with CoA than in those without CoA ( P <0.001). The presence of coarctation shelf and aortic arch hypoplasia were more common in fetuses with CoA than in controls (odds ratio, 26.0; 95% confidence interval, 4.42–153; P <0.001 and odds ratio, 38.2; 95% confidence interval, 3.01–486; P =0.005), whereas persistent left superior vena cava ( P =0.85), ventricular septal defect ( P =0.12), and bicuspid aortic valve ( P =0.14) did not carry an increased risk for this anomaly. Multiparametric diagnostic models integrating different ultrasound signs for the detection of CoA were associated with an increased detection rate. Conclusions: The detection rate of CoA may improve when a multiple-criteria prediction model is adopted. Further large multicenter studies sharing the same imaging protocols are needed to develop objective models for risk assessment in these fetuses. # Clinical Perspective {#article-title-31}Background: Prenatal diagnosis of coarctation of the aorta (CoA) is still challenging and affected by high rates of false-positive diagnoses. The aim of this study was to ascertain the strength of association and to quantify the diagnostic accuracy of different ultrasound signs in predicting CoA prenatally. Methods: Medline, Embase, CINAHL, and Cochrane databases were searched. Random-effects and hierarchical summary receiver operating characteristic model meta-analyses were used to analyze the data. Results: Seven hundred ninety-four articles were identified, and 12 (922 fetuses at risk for CoA) articles were included. Mean mitral valve diameter z score was lower (P<0.001) and the mean tricuspid valve diameter z score was higher in fetuses with CoA than in those without CoA (P=0.01). Mean aortic valve diameter z score was lower in fetuses with CoA than in healthy fetuses (P⩽0.001), but the ascending aorta diameter, expressed as z score or millimeters, was similar between groups (P=0.07 and 0.47, respectively). Mean aortic isthmus diameter z scores measured either in sagittal (P=0.02) or in 3-vessel trachea view (P<0.001) were lower in fetuses with CoA. Conversely, the mean pulmonary artery diameter z score, the right/left ventricular and pulmonary artery/ascending aorta diameter ratios were higher (P<0.001, P=0.02, and P=0.02, respectively) in fetuses with CoA in comparison with controls, although aortic isthmus/arterial duct diameter ratio was lower in fetuses with CoA than in those without CoA (P<0.001). The presence of coarctation shelf and aortic arch hypoplasia were more common in fetuses with CoA than in controls (odds ratio, 26.0; 95% confidence interval, 4.42–153; P<0.001 and odds ratio, 38.2; 95% confidence interval, 3.01–486; P=0.005), whereas persistent left superior vena cava (P=0.85), ventricular septal defect (P=0.12), and bicuspid aortic valve (P=0.14) did not carry an increased risk for this anomaly. Multiparametric diagnostic models integrating different ultrasound signs for the detection of CoA were associated with an increased detection rate. Conclusions: The detection rate of CoA may improve when a multiple-criteria prediction model is adopted. Further large multicenter studies sharing the same imaging protocols are needed to develop objective models for risk assessment in these fetuses.

Diagnostic accuracy of intracranial translucency in detecting spina bifida: a systematic review and meta‐analysis

To evaluate the diagnostic accuracy of intracranial translucency (IT) in the detection of spina bifida (SB) in the first trimester of pregnancy.

Doppler reference values of the fetal vertebral and middle cerebral arteries, at 19–41 weeks gestation

Abstract Objectives: Blood flow to the fetal brain is supplied by two vascular systems: the vertebral artery (VA) and the internal carotid artery with its anatomical continuation, the middle cerebral artery (ICA/MCA). In this work, our aim was to establish consistent reference values for the comparative study of both arterial systems. Methods: The study group consisted of 2323 Doppler examinations of the VA, MCA and UA performed on 2323 single pregnancies between 19 and 41 weeks. These values were afterwards used to calculate the pulsatility index (PI), peak systolic velocity (PSV) and cerebro-placental ratio (CPR) percentiles. Results: The VA and MCA PI reached maximum values at the end of the second trimester and decreased afterwards due to an increase in the diastolic flow. Conversely, the VA and MCA PSV increased progressively until the end of pregnancy. Regarding the VA and MCA CPR values, they were higher in the middle of the third trimester and decreased afterwards. Conclusions: In both arterial systems, Doppler reference values have been calculated for the PI, PSV and CPR, being available for future comparative studies.

Maternal body mass index influences umbilical artery Doppler velocimetry in physiologic pregnancies

The aim of our study was to assess whether there is a relationship between maternal body mass index (BMI) and umbilical artery Doppler velocimetry in physiologic pregnancies.

First-trimester ultrasound determination of chorionicity in twin gestations using the lambda sign: a systematic review and meta-analysis

OBJECTIVE To evaluate the accuracy of first-trimester sonographic determination of chorionicity in twin gestations using the lambda sign. STUDY DESIGN Electronic databases (MEDLINE, PROSPERO, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect) were searched from their inception until April 2016. We included only study assessing the accuracy lambda sign in prediction of monochorionicity in the first trimester. Forest plots for pooled sensitivity and specificity with 95% confidence intervals (CI) were generated. In addition, symmetric summary receiver-operating characteristic curves were plotted. The area under the curve (AUC) was also computed to evaluate the overall accuracy of the diagnostic test. RESULTS Nine studies, including 2292 twins, were analysed. In all of these studies, identification of the lambda sign was used to diagnose chorionicity on real-time B-mode imaging. Twins were classified as monochorionic if there was a single placental mass in the absence of the lambda sign, and dichorionic if there was a single placental mass but the lambda sign was present or the placentas were not adjacent to each other. In all nine studies, placental histology or discordant fetal sex were used to confirm chorionicity. Pooled results from the meta-analysis showed that sensitivity of the presence of the lambda sign in the prediction of dichorionicity was 99% (95% CI 98-100%), and specificity was 95% (95% CI 92-97%). Pooled sensitivity of the absence of the lambda sign in the prediction of monochorionicity was 96% (95% CI 92-98%) and pooled specificity was 99% (95% CI 98-99%). The AUC for diagnostic accuracy was 0.99, and suggested very high diagnostic accuracy. CONCLUSION The lambda sign predicts chorionicity with a high degree of accuracy before 14 weeks of gestation. Presence of the lambda sign indicates dichorionicity, and absence of the lambda sign indicates monochorionicity. All hospitals should encourage departments providing ultrasound services to determine chorionicity when examining women with twin pregnancies in the first trimester. As determination of chorionicity is most accurate before 14 weeks when the amnion and chorion have not yet fused, the first-trimester scan in twin pregnancy is paramount.

Neonatal Acid-Base Status in Term Fetuses: Mathematical Models Investigating Cerebroplacental Ratio and Birth Weight.

Objective: Cerebroplacental ratio (CPR) is emerging as a marker of fetal hypoxia at term. The aim of this study was to demonstrate graphically the interrelationships among CPR, birthweight (BW), and neonatal pH, and construct 2D and 3D representations of the areas with potential low pH. Methods: This was a retrospective study of 2,927 term fetuses evaluated according to BW and CPR. The outcome was the acid-base status at birth. Multivariate relationships among CPR, BW, and arterial and venous pH were depicted in 3D scattergrams. Subsequently, trend surfaces were calculated and represented in 2D contour graphs. Finally, 3D representations were constructed by smothering pH data using moving average filters. Results: The trend surfaces and the 2D and 3D contour graphs showed the complex association among the three variables. Although pH changed with CPR and BW, the influence of the BW was smaller than the influence of the CPR, with this effect being more evident in the venous than in the arterial pH. Conclusions: Two scenarios threaten fetal well-being at term: a very low birth weight and a very low fetal CPR. Our findings suggest that the importance of fetal hemodynamics in determining the acid-base status at birth surpasses that of fetal weight.

Predictive accuracy of second‐trimester uterine artery Doppler indices for stillbirth: a systematic review and meta‐analysis

To assess the predictive accuracy for stillbirth of second‐trimester uterine artery Doppler.

Anesthetic management of a parturient with spinal muscular atrophy type II

In the past, pregnancy was contraindicated in patients with spinal muscular atrophy. Recently, more cases are occurring because of improvement in survival and functional status. The goals for anesthetic management of these patients include satisfactory anesthesia during surgery and excellent postoperative analgesia with minimal compromise of respiratory function. Spinal anesthesia may be considered contraindicated due to spinal deformities, but successful spinal anesthesia was performed in a 37 year old parturient following magnetic resonance imaging of the spine.

GRK2 Levels in Umbilical Arteries of Pregnancies Complicated by Gestational Hypertension and Preeclampsia

BACKGROUND G-Protein coupled receptor kinase 2 (GRK2) represents a regulator of cell function in different cardiovascular conditions, including high blood pressure. The relationship between elevated GRK2 levels and impaired vasorelaxant responses is causative of hypertension through the increase in vascular resistances. The aim of this study is to ascertain if this feature is present in the fetal placental vasculature of pregnancies complicated by hypertensive disorders. METHODS We have assessed GRK2 levels in the umbilical arteries (UA) of 21 preeclamptic or gestational hypertensive and 23 normotensive women at time of delivery. RESULTS GRK2 levels were increased in the hypertensive group (0.83 ± 0.14 vs. 0.48 ± 0.06 densitometry units; P < 0.05). GRK2 levels were in correlation and in linear regression with systolic, diastolic, and mean arterial pressure (P < 0.05, r(2) = 0.12, r(2) = 0.11, r(2) = 0.12). Correlations did not reach a significant value for other clinical parameters such as gestational age at birth, umbilical artery pulsatility index, maternal proteinuria, and neonatal birth weight. Out of the 21 hypertensive women, 7 who developed a preeclampsia associated with early preterm delivery (before 34 weeks) had a significantly lower GRK2 levels compared to the remaining 14 (0.51 ± 0.12 vs. 1.08 ± 0.20 densitometry units, P < 0.05). CONCLUSIONS We conclude that elevated GRK2 levels in the umbilical vasculature is correlated to elevated blood pressure levels, with a likely compensatory rather than causative role since the lack of protective effect of elevated GRK2 levels may negatively affect the outcome of the hypertensive state.