Margherita Zanello

Screening models using multiple markers for early detection of late-onset preeclampsia in low-risk pregnancy

BackgroundOur primary objective was to establish a cutoff value for the soluble fms-like tyrosine kinase 1(sFlt-1)/placental growth factor (PlGF) ratio measured using the Elecsys assay to predict late-onset preeclampsia in low-risk pregnancies. Our secondary objective was to evaluate the ability of combination models using Elecsys data, second trimester uterine artery (UtA) Doppler ultrasonography measurements, and the serum fetoplacental protein levels used for Down’s syndrome screening, to predict preeclampsia.MethodsThis prospective cohort study included 262 pregnant women with a low risk of preeclampsia. Plasma levels of pregnancy-associated plasma protein-A (PAPP-A) and serum levels of alpha-fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin-A were measured, and sFlt-1/PlGF ratios were calculated. All women underwent UtA Doppler ultrasonography at 20 to 24 weeks of gestation.ResultsEight of the 262 women (3.0%) developed late-onset preeclampsia. Receiver operating characteristic curve analysis showed that the third trimester sFlt-1/PlGF ratio yielded the best detection rate (DR) for preeclampsia at a fixed false-positive rate (FPR) of 10%, followed by the second trimester sFlt-1/PlGF ratio, sFlt-1 level, and PlGF level. Binary logistic regression analysis was used to determine the five best combination models for early detection of late-onset preeclampsia. The combination of the PAPP-A level and the second trimester sFlt-1/PlGF ratio yielded a DR of 87.5% at a fixed FPR of 5%, the combination of second and third trimester sFlt-1/PlGF ratios yielded a DR of 87.5% at a fixed FPR of 10%, the combination of body mass index and the second trimester sFlt-1 level yielded a DR of 87.5% at a fixed FPR of 10%, the combination of the PAPP-A and inhibin-A levels yielded a DR of 50% at a fixed FPR of 10%, and the combination of the PAPP-A level and the third trimester sFlt-1/PlGF ratio yielded a DR of 62.5% at a fixed FPR of 10%.ConclusionsThe combination of the PAPP-A level and the second trimester sFlt-1/PlGF ratio, and the combination of the second trimester sFlt-1 level with body mass index, were better predictors of late-onset preeclampsia than any individual marker.

Circulating mRNA for epidermal growth factor‐like domain 7 (EGFL7) in maternal blood and early intrauterine growth restriction. A preliminary analysis

To evaluate the alteration in epidermal growth factor‐like domain 7 (EGFL7) mRNA expression in maternal blood from pregnancies affected by early‐onset intrauterine growth restriction (IUGR) at 20–24 weeks.

Multivariable evaluation of term birth weight: a comparison between ultrasound biometry and symphysis-fundal height

Abstract Objective: To derive a birth weight predictive equation and to compare its diagnostic value with that of ultrasound. Methods: A longitudinal observational cohort study, including singleton pregnancies at term, was performed at St. Orsola-Malpighi Hospital, University of Bologna (Italy). A birth weight prediction formula, including symphysis-fundal height (SFH), BMI, maternal abdominal circumference (mAC) and parity was derived from a general linear model (GLM) (retrospective study). Moreover, on a new series of patients, the fetal weight was estimated by using both GLM and ultrasound using Hadlock formula (prospective study). The residual analysis and the intraclass correlation coefficient (ICC) were used to test the accuracy of methods in predicting birth weight. Results: Between January and November 2012, 1034 patients were included in the retrospective study and 44 in the prospective one. The following GLM was derived: estimated birth weight (g) = 1485.61 + (SFH (cm) × 23.37) + (11.62 (cm) × mAC) + [BMI × (−6.81)] + (parity (0 = nulliparous, 1 = multiparous) × 72.25). When prospectively applied, the GLM and ultrasound provided a percentage of prediction within ±10% of the actual weight of 73% and 84%, respectively. Ultrasound estimation, as opposite of GLM one, was significantly associated with neonatal weight (R2 = 0.388, F = 26.607, p value <0.001, ICC = 0.767). Conclusions: Although ultrasound biometry has provided the best values in fetal weight estimation, the predictive performance of both methods is limited.

Severe ureteral endometriosis: frequency and risk factors

Abstract Ureteral endometriosis (UE) can be classified as severe when there is obstruction to urinary flow (ureteral compression (UC)). In this retrospective study on 205 patients, we evaluated intraoperatively the frequency of severe ureteral endometriosis (UE) in women with UE and, secondarily, risk factors associated with UC. We documented intraoperatively ureteral UC in 124 (60.5%) patients with UE. A significantly lower body mass index (BMI) was observed in women with UC than in women without UC (p = .02). A significant association was found between UC and parametrial endometriosis (p = .001). In multivariable analysis, these variables remained significantly associated with UC. Ureteral compression is common in patients with UE, especially in women with parametrial infiltration and a low BMI.

Laparoscopic vs transvaginal cuff closure after total laparoscopic hysterectomy: a randomized trial by the Italian Society of Gynecologic Endoscopy

BACKGROUND Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event. OBJECTIVE The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial. STUDY DESIGN Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password‐protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single‐layer running braided and coated 0‐polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow‐up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy. RESULTS After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16–6.63; P = .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43–3.37; P = .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence. CONCLUSION Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention.

Clinical use of endovenous indocyanine green during rectosigmoid segmental resection for endometriosis

OBJECTIVE To describe a new use of endovenous indocyanine green (ICG) to allow real-time visualization of bowel perfusion in women with recto-sigmoid endometriosis who may be candidates for segmental resection. DESIGN Step-by-step explanation of this method using descriptive text and educational video. SETTING Tertiary level referral academic center. PATIENT(S) A nulliparous 36-year-old woman affected by a large rectal endometriotic nodule was referred for severe dysmenorrhea, dyspareunia, hematochezia, and dyschezia, despite progestinic therapy. INTERVENTION(S) An intravenous injection of 1.5 mL solution containing 3.75 mg dose of ICG for intraoperative fluorescence imaging. MAIN OUTCOME MEASURE(S) Evaluation of blood perfusion of bowel and rectal endometriosis nodule. Evaluation of neoanastomosis vascularization after bowel resection. RESULT(S) The procedure of endometriosis removal was performed using the daVinciXi surgical platform (Intuitive Surgical, Sunnyvale, CA). After ovarian endometriosis removal and adhesiolysis, we identified the endometriosis nodule on the anterior surface of the rectum. Pararectal, rectovaginal, and retrorectal spaces were dissected with a nerve-sparing technique. Indocyanine green was administered through a peripheral line. A near-infrared camera head enabled vision of the colorant after latency of a few seconds. We observed the ischemic area around the rectal nodule and perfusion areas upstream and downstream from the lesion. We selected the transecting line for rectal resection, taking account of this objective evaluation, beyond the limits of macroscopic disease. After direct mechanical anastomosis, we checked the rectal vascularization with ICG. CONCLUSION(S) To the best of our knowledge, this is the first reported use of endovenous ICG during a bowel resection for deep endometriosis. Endovenous ICG is proposed during surgery for rectosigmoid endometriosis to assess the perfusion of the bowel and select the transecting line. With ICG fluorescence imaging, we can objectively evaluate whether blood supply to the anastomosis is adequate. Endovenous ICG for objective vascular assessment is simple and rapid to use, and no complications related to ICG use were recorded.

Uterine Suspension: A New Laparoscopic Technique

Laparoscopic surgery is a frequently performed surgical technique in a gynecological field. Total Laparoscopic Hysterectomy (TLH) for large uteri is a difficult procedure technically. In this study, We report our experience with large uteri and present a case of TLH performed on a uterus weighting 3550g. From 2012 to 2013, We performed TLH procedures for 962 cases, TLH in case of uteri weighing over one kilogram was 60 cases. The median uteri weight was 1050g (1000-4545g) The median operative time and blood loss were 119 minutes(62-315 minutes) and 334ml (10-1380ml). The convention to abdominal hysterectomy was only one case (1.7%). The experience and specialized techniques are necessary to performe TLH for large uteri safely and fast.

P01.03: Maternal primary cytomegalovirus infection and small for gestational age neonates

Two placentas in singleton pregnancy with fused umbilical cord which has its own placental insertion site forming 3-vessel cord at fetal end is an extremely rare case. This present case describes two placentas with fused umbilical cord with an episode of vanishing twin syndrome and there seems to be a strong relationship between these two events. Therefore, as far as we know, this is the first case in the world which describes two placentas with fused umbilical cord related to vanishing twin syndrome. A 37-year-old woman, gravid 0, para 0, visited ER with an episode of vaginal bleeding without pelvic cramps at 8 weeks and 5 days of gestation and repeated ultrasonic exams revealed reabsorption of vanishing twin and two separate placentas on anterior and posterior body of uterus. At 40 weeks and 4 days, the patient delivered a viable female infant weighing 3900 g via Cesarean section and postpartum examination of the placentas and membranes confirmed two placentas with fused umbilical cord. Two placentas were almost equal in size and main placental disc cord had 2 arteries with one vein (3 vessel-cord) whereas side placental disc cord had one artery with one vein (2 vessel-cord). Several hypothesis including placenta abnormalities after IVF-ET procedure, succenturiate lobes and fetus-in-fetu were proposed.