Marina Pekar-Zlotin

Prediction of morbidly adherent placenta using a scoring system

To evaluate the accuracy of an ultrasound‐based scoring system for diagnosing morbidly adherent placenta (MAP).

Predicting of morbidly adherent placenta using a scoring system: A prospective study

To evaluate the accuracy of an ultrasound‐based scoring system for diagnosing morbidly adherent placenta (MAP).

Impact of targeted scanning protocols on perinatal outcomes in pregnancies at risk of placenta accreta spectrum or vasa previa

BACKGROUND: Placenta accreta spectrum and vasa previa (VP) are congenital disorders of placentation associated with high morbidity and mortality for both mothers and newborns when undiagnosed before delivery. Prenatal diagnosis of these conditions is essential to allow multidisciplinary management and thus improve perinatal outcomes. OBJECTIVE: The objective of the study was to compare perinatal outcome in women with placenta accreta spectrum or vasa previa before and after implementation of targeted scanning protocols. STUDY DESIGN: This retrospective study included 2 nonconcurrent cohorts for each condition before and after implementation of the corresponding protocols (2004–1012 vs 2013–2016 for placenta accreta spectrum and 1988–2007 vs 2008–2016 for vasa previa). Clinical reports of women diagnosed with placenta accreta spectrum and vasa previa during the study periods were reviewed and outcomes were compared. RESULTS: In total, there were 97 cases of placenta accreta spectrum and 51 cases with vasa previa, all confirmed at delivery. In both cohorts, the prenatal detection rate increased after implementation of the scanning protocols (28 of 65 cases [43.1%] vs 31 of 32 cases [96.9%], P < .001, for placenta accreta spectrum and 9 of 18 cases [50%] vs 29 of 33 cases [87.9%], 87.9%, P < .01 for vasa previa). The perinatal outcome improved also significantly in both cohorts after implementation of the protocols. In the placenta accreta spectrum cohort, the estimated blood loss and the postoperative hospitalization stay decreased between periods (1520 ± 845 vs 1168 ± 707 mL, P < .01, and 10.9 ± 14.1 vs 5.7 ± 2.2 days, P < .05, respectively). In the vasa previa cohort, the number of 5 minute Apgar score ≤5 and umbilical cord pH <7 decreased between periods (5 of 18 cases [27.8%] vs 1 of 33 cases [3%]; P < .05, and 4 of 18 cases [22.2%] vs 1 of 33 cases [3%], P < .05, respectively). CONCLUSION: The implementation of standardized prenatal targeted scanning protocols for pregnant women with risk factors for placenta accreta spectrum and vasa previa was associated with improved maternal and neonatal outcomes. The continuous increases in the rates of caesarean deliveries and use of assisted reproductive technology highlights the need to develop training programs and introduce targeted scanning protocols at the national and international levels.

The Rate of Cervical Length Shortening in the Management of Vasa Previa

There is no consensus about the optimal surveillance strategy in women with a diagnosis of vasa previa. The aim of this study was to evaluate the role of the rate of change in cervical length measurements in the management of singleton pregnancies with a diagnosis of vasa previa.

Clinical and sonographic predictors of adnexal torsion in pediatric and adolescent patients

OBJECTIVE To investigate the accuracy of torsion diagnosis in the pediatric and adolescent population. METHODS This retrospective study included 87 patients <18years who presented with acute pelvic pain and were operated for suspected adnexal torsion from January 2009 to September 2016. RESULTS Adnexal torsion was found in 53 of 87 (60.9%) cases operated for suspected torsion. The rate of accurate torsion diagnosis was significantly higher among pre-menarchal (21/21, 100%) compared with post-menarchal girls (32/66, 48.5%) (p<0.001). Patients with torsion were more likely to report nausea or vomiting (73.6% compared with 32.3%, p<0.001) and had higher rates of peritoneal irritation signs on exam (15.1% compared with 0.0%, p=0.02). On the pre-operative ultrasound, patients with torsion were characterized by higher rates of enlarged ovary showing signs of edema (49.1% compared with 8.8%, p<0.001) and free pelvic fluid (45.3% compared with 17.6%, p<0.001). In post-menarchal girls without adnexal torsion, the leading diagnosis was hemorrhagic corpus luteum cyst (found in 18/33, 78.3%) cases. CONCLUSIONS Various clinical and ultrasound findings may point to the correct diagnosis of torsion in the pediatric and adolescent population. However, none of the clinical and ultrasound characteristics are sufficient to confirm or disprove the pre-operative diagnosis, and young patients with the clinical suspicion of adnexal torsion should undergo laparoscopy. LEVEL OF EVIDENCE Level II. TYPE OF STUDY Clinical retrospective study.

The "honeycomb" appearance of fetal myofibromatosis

Infantile myofibromatosis (IM) is a benign neoplasm of infancy with an incidence of 1:150,000, presenting in 90% of the cases before two years of age and is rarely encountered in newborns. The mortality rate is 15%, most being with generalized visceral multicentric disease1-4 . Prenatal diagnosis may lead to termination of pregnancy being an option for the parents and the communities who accept such a choice. This article is protected by copyright. All rights reserved.

The mid-gestation triple test profile among women diagnosed with vasa previa

Abstract Purpose: To assess the mid-trimester triple test biomarkers among women diagnosed with vasa previa (VP). Methods: The study included 43 singleton pregnancies diagnosed with vasa previa between the years 1988 and 2011. The mid-gestation screening test for Down syndrome was calculated from the combination of triple serum markers and maternal age, and expressed as a multiple of the gestation specific normal mean (MoM). Reference MoM values were calculated from the local population. The levels of mid-gestation maternal serum alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) of patients with VP were compared with control reference group. Results: The mean hCG and αFP levels of women diagnosed with VP was significantly higher compared to control reference group (1.42 versus 0.99 MoM; p < .002 and 1.24 versus1.01 MoM; p < .001, respectively). In contrast, there was no significant difference in uE3 levels between these two groups (0.99 versus 0.98 MoM; p = .71). Conclusions: Our findings suggest that increased mid-gestation hCG and AFP were found among pregnancies complicated with VP. Clinicians should consider targeted scanning of pregnant women with risk factors for VP, including unexplained high maternal levels of hCG and αFP of the triple test, while conducting mid-gestation anomaly scan.

Second‐trimester levels of fetoplacental hormones among women with placenta accreta spectrum disorders

Human chorionic gonadotropin (hCG) and its free β-subunit (β-hCG) are exclusively synthesized by the villous trophoblast. α-Fetoprotein (AFP) is synthesized by the secondary yolk sac and fetal liver. Levels of both hormones differ between women with placenta accreta spectrum (PAS) disorders and those with non-accreta previa.1,2 Second-trimester maternal serum levels of AFP are increased,1 and first-trimester serum β-hCG is decreased in women with PAS,2 compared with those with non-accreta placenta previa. An increased level of cell-free β-hCG mRNA has also been found in the plasma of women with PAS disorder.3 The aim of the present study was to further assess the association between levels of serum markers measured as part of the triple test in the second trimester (hCG, AFP, and estriol) and the prenatal diagnosis of PAS disorders. This article is protected by copyright. All rights reserved.

Comment to the letter by Drs. Safiri and Ashrafi-Asgarabad

We thank Drs. Safiri and Ashrafi-Asgarabad for their questions and comments. We agree with Drs. Safiri and Ashrafi-Asgarabad that relatively rare signs and symptoms, such as peritoneal irritation signs in women presenting with adnexal torsion, may be problematic for statistical interpretation and that more sophisticated statistical methods suggested by Drs. Safiri and Ashrafi-Asgarabad could be more appropriate. However, the finding of positive peritoneal irritation signs in women with suspected adnexal torsion is only one of several clinical, laboratory and ultrasound parameters described in our study, and by no means the most important one. Because the diagnosis of adnexal torsion is often difficult, we emphasize in our study that all of these parameters should be assessed in women with suspected torsion, rather than relying on a single finding on the physical examination.

Evaluation of the impact of vasa previa on feto-placental hormonal synthesis and fetal growth

INTRODUCTION A vasa previa (VP) refers to aberrant chorionic vessels which can either connect the chorionic plate to a velamentous cord (type I) or a succenturiate or accessory lobe to the main placental mass (type II). METHODS We performed retrospective cohort study of 32 singleton pregnancies diagnosed with VP. The levels of maternal serum alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG) and unconjugated estriol (uE3) were measured at 15-18 weeks as part of the triple test screening for Trisomy 21. The data were subdivided according to the type of VP and compared with those of a control group with central cord insertion and no succenturiate or accessory placental lobe. RESULTS Twenty one (65.6%) parturient women presented with VP type I and 11 (34.4%) with VP type II. The mean birthweight and placental weight was significantly higher in pregnancies with VP type II than in pregnancies with VP with VP type I (3037.3±400.9 gr vs 2493.5±491.6 gr; p=0.004 and 511.0±47.2 gr vs 367.1±64.3 gr; p<0.0001; respectively). The mean hCG level in VP type II was significantly (p<0.001) higher than those with type I (2.38MoM vs 1.17MoM) and compared to controls (2.38MoM vs 0.99MoM). CONCLUSIONS There is no obvious impact on both placental and fetal growth in VP type II. By contrast, VP type I is associated with slower feto-placental growth secondary to impaired development and biological functions of the placenta during the first half of pregnancy.