Nadia Roncaglia

A randomised controlled trial of ursodeoxycholic acid and S-adenosyl-l-methionine in the treatment of gestational cholestasis

Objectiveu2003 To compare the efficacy of S‐adenosyl‐l‐methionine and ursodeoxycholic acid in improving serum biochemical abnormalities in gestational cholestasis.

Hepatitis C virus infection is associated with a higher incidence of cholestasis of pregnancy

To investigate a possible relationship between hepatitis C virus infection and cholestasis of pregnancy, we identified all cases of cholestasis of pregnancy (145/16,271) and hepatitis C virus infection (63/16,27 1) between January 1992 and December 1997. Serologic screening was performed universally. The rate of cholestasis of pregnancy was greater in women whose hepatitis C virus antibodies were positive rather than negative [15.9% (10/63) vs 0.8% (135/16,208), P < 0.0011. Among women with cholestasis of pregnancy, mean (standard deviation) gestational age at onset of symptoms and at delivery was significantly lower among women whose hepatitis C virus antibodies were positive compared with negative women: 28.9 (3.2) vs 34.3 (3–5) weeks, P < 0.001 and 36–3 (0.9) vs 37.0 (1–6) weeks, P= 0.03, respectively. These findings suggest that early Occurrence of cholestasis of pregnancy may be an indication for serologic testing for hepatitis C virus.

Doppler predictors of adverse neonatal outcome in the growth restricted fetus at 34 weeks' gestation or beyond

OBJECTIVEnThe study was undertaken to assess whether prenatal Doppler variables can identify cases of fetal growth restriction (FGR) approaching term who are at risk for adverse neonatal outcome.nnnSTUDY DESIGNnFrom a cohort of FGR cases delivered at >or=34 weeks, fetal biometry and pulsatility indices (PI) of fetal arteries obtained less than 2 weeks before delivery were related to adverse neonatal outcome, defined as admission to the neonatal intensive care unit (NICU) for indications other than low birth weight alone.nnnRESULTSnStepwise regression analysis showed that after controlling for gestational age at delivery and fetal biometry, only the last umbilical artery (UA) PI percentile was significantly predictive of adverse neonatal outcome (odds ratio=1.02, 95% CI 1.01-1.03, P=.02). Receiver operating characteristic curve analysis identified a UA PI at the 65th percentile as optimal predictor of adverse neonatal outcome (sensitivity=60%, false-positive rate=30%).nnnCONCLUSIONnIn FGR cases delivered at >/=34 weeks gestation, Doppler PI at the UA independently predicts the likelihood of admission to the NICU for reasons other than low birth weight alone.

Infants Weighing <1500 g: Better Born Too Small or Too Soon?

OBJECTIVEnTo evaluate the influence of intrauterine growth on intact neurological outcome at 12 to 24 months in a cohort of infants weighing <1500 g at birth.nnnSTUDY DESIGNnThis retrospective study was conducted in the Department of Obstetrics and Gynecology, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy. Perinatal variables were correlated with occurrence of composite adverse outcome, including neonatal death or adverse neurodevelopmental outcome (ANDO), at 12 to 24 months follow-up, in 240 consecutive very low-birth-weight (VLBW) neonates prenatally classified as growth restricted (IUGR; n = 100) or appropriate for gestational age (n = 140).nnnRESULTSnAmong the 214 surviving neonates, neurological follow-up was available in 163. ANDO was present in 46 children (28%). At multivariate analysis, only gestational age at delivery was independently related to the composite outcome (p < 0.001, odds ratio = 0.69, 95% confidence interval 0.59, 0.81), whereas diagnosis of IUGR was not.nnnCONCLUSIONnOnly gestational age at delivery was significantly associated with composite adverse outcome in VLBW preterm infants.

Selective IUGR in dichorionic twins: what can Doppler assessment and growth discordancy say about neonatal outcomes?

Abstract Objective: The aim of the present study was to assess, in a population of dichorionic twin pregnancies with selective growth restriction, the effect of inter-twin differences by use of Doppler velocimetry and fetal growth discordancy on perinatal outcomes. Methods: This was a retrospective study including dichorionic twin pregnancies from January 2008 to December 2015 at the Department of Obstetrics and Gynecology of Fondazione MBBM. Only dichorionic twin pregnancies affected by selective intrauterine growth restriction (IUGR) delivering at ≥24 weeks were included in the study. Results: We found that twin pregnancies with inter-twin estimated fetal weight (EFW) discordance ≥15% were significantly associated with a higher risk of preterm delivery before 32 (P=0.004) and 34 weeks (P=0.04). Similarly, twin pregnancies with inter-twin abdominal circumference (AC) discordance ≥30° centiles were associated with a higher rate of neonatal intensive care unit (NICU) admission (P=0.02), neonatal resuscitation (P=0.02) and adverse neonatal composite outcome (P=0.04). Of interest, when comparing twin pregnancies according to Doppler study, growth restricted twins had a higher rate of composite neonatal outcome and in multivariate analysis, an abnormal Doppler was an independent risk factor for this outcome. Conclusions: Our study associated growth discrepancy with specific pregnancy outcomes, according to defined cut-offs. In addition, we demonstrated that an abnormal umbilical artery Doppler is independently associated with a composite neonatal adverse outcome in growth restricted fetuses.

Obstetric cholestasis: Outcome with active management

OBJECTIVEnConservative management of intrahepatic obstetric cholestasis is associated with a high stillbirth rate despite monitoring of fetal well-being with non-stress test and amniotic fluid volume assessment. Most cases of stillbirth are associated with meconium passage. We prospectively evaluated the effect of a management protocol inclusive of surveillance for presence of meconium and induction of labor at 37 weeks.nnnSTUDY DESIGNnBetween January 1989 and December 1997, all women with obstetric cholestasis underwent transcervical amnioscopy after 36 weeks for assessment of amniotic fluid color, in addition to standard monitoring of fetal well-being (semi-weekly non-stress test and amniotic fluid volume determinations). Amniocentesis for fetal lung maturity and amniotic fluid color assessment was performed before 36 weeks in severe cases. Labor was induced at 37 weeks or earlier in the presence of non-reassuring fetal testing, meconium, or severe maternal symptoms unresponsive to therapy with mature fetal lungs. The obstetric outcome of the group with cholestasis was compared with that of the general obstetric population at our Institution during the study period. The rate of fetal death in the study group was compared with that of series published within the last 20 years, which used expectancy and conventional monitoring of fetal well-being. Statistical analysis utilized Fishers exact test, Chi-square, and Students t-test with P value <0.05 or an odds ratio (OR) with 95% confidence interval (CI) not inclusive of the unity considered significant.nnnRESULTSnObstetric cholestasis was diagnosed in 206/20,815 pregnant women (1%) at a median gestational age of 34 weeks (range 20-40). Delivery was prompted by non-reassuring fetal testing in four cases (2%). Meconium passage was documented in 33 cases (16%), in 11 of which before onset of labor and in 10 before 37 weeks. The rate of meconium passage before 37 weeks (17.9 versus 2.9%, OR=7.3; 95% CI 3.3, 16.0) was significantly higher in obstetric cholestasis than in the general obstetric population, whereas the cesarean section rate was similar in the two groups (15.1 versus 16.0%, OR=0.9; 95% CI 0.6, 1.4). The fetal death rate was significantly lower in the group managed with the current strategy than in the published series of obstetric cholestasis (0/218 versus 14/888, P=0.045).nnnCONCLUSIONnIn pregnancies complicated by obstetric cholestasis, a protocol inclusive of search for meconium and elective delivery at 37 weeks, in addition to standard monitoring of fetal well-being, can significantly reduce the stillbirth rate without increasing the cesarean delivery rate.