Paola Algeri

Bedside diagnosis of two major clinical phenotypes of hypertensive disorders of pregnancy

To investigate the hypothesis that fetal abdominal circumference (AC) and uterine artery (UtA) Doppler pulsatility index (PI) could be used to select two homogeneous subgroups of women affected by hypertensive disorders of pregnancy (HDP), characterized by the coexistence of maternal hypertension with and without intrauterine growth restriction (IUGR).

Expectant management in di-chorionic pregnancies complicated by discordant anomalous twin

Abstract Fetal malformations are more frequent in twins than in singletons. The aim of our study was to define the influence of a malformed twin on di-chorionic pregnancy outcomes. We performed a retrospective cohort study of di-chorionic pregnancies delivered between 2000 and 2015. Exclusion criteria were: both twins affected by fetal malformations, double intra-uterine fetal death in pregnancies without fetal malformation, selective feticide and therapeutic pregnancy termination. We compared maternal and fetal outcomes of di-chorionic pregnancies not complicated by fetal malformations with pregnancies affected by a single malformed fetus with conservative management. We included 642 di-chorionic pregnancies: 56 (case group, 8.7%) with one twin affected by a malformation (20 minor, 36 major ones), 586 (control group, 91.3%) without fetal malformation. No differences were found on maternal and not malformed co-twin outcomes when compared to pregnancies with no malformation; case vs control group presented similar rates of preeclampsia (8.9% vs. 10.8%, respectively), intrauterine growth restriction (7.1% vs. 9.4%) and composite adverse neonatal outcomes (19.6% vs. 15.1%). No case of fetal death in not malformed co-twin was reported. Expectant management could be a safe option for both mother and co-twin in case of di-chorionic twin pregnancy complicated by only one malformed fetus.

Re: Comparison of management regimens following ultrasound diagnosis of nontubal ectopic pregnancies: a retrospective cohort study

Sir, We largely appreciated the paper by Ramkrishna et al., in particular for the effort in providing an evidencebased, standardised and noninvasive treatment for nontubal ectopic pregnancies. In our routine clinical practice, we frequently deal with first-trimester pregnancies with no previous evaluation coming to the emergency room for bleeding and abdominal pain. In these women, a prompt diagnosis of the site of implantation is mandatory, but frequently challenging for the early gestational age and for the technical limitations related to ultrasound. In particular, in our experience, we have found more difficulties in diagnosing and consequently correctly treating ectopic pregnancies located in the cornual position. The main effort is to distinguish them from an intrauterine pregnancy in eccentric position and from tubal isthmic pregnancies. Recently some papers highlighted the potential role of threedimensional (3D) ultrasound as a tool to determine the site of implantation and evolution of the pregnancy, but data are not univocal. Moreover, 3D probes are probably not available for many clinicians in the emergency room, as in our setting. In the last 5 years, we diagnosed three cases of interstitial pregnancies. Considering the absence of a specific protocol and a univocal consensus on their treatment, we have managed each one differently, based on b-human chorionic gonadotrophin (b-hCG), imaging and clinical conditions. A first case occurred in a 35-year-old multipara at 6 weeks, who came to our unit for vaginal bleeding and resolved spontaneously with a progressive decrease in b-hCG levels without any specific therapy. The second one occurred in a 27-year-old multipara at 10 weeks, in which a uterine septum was suspected and a gestational sac with only yolk sac was visible in the cornual portion of the right fallopian tube. Three days after the diagnosis she had spontaneous vaginal bleeding with incomplete miscarriage that needed curettage. The third case presented in a 36-year-old multipara with a medical history of caesarean section for breech presentation and a right salpingectomy for tubal ectopic pregnancy. At the admission, a left isthmic tubal pregnancy was suspected and laparoscopic access was performed, but no extrauterine pregnancy was found. The following scan detected a gestational sac in the angular left portion of the uterus, but curettage was performed unsuccessfully. Finally, magnetic resonance imaging demonstrated a left interstitial pregnancy. Eight days after surgery the b-hCG value was still increasing, so systemic methotrexate was planned. Three administrations were necessary to reach a significant decrease in b-hCG. This case was particularly challenging for diagnosis and treatment. In the paper by Ramkrishna et al., interstitial pregnancies represent the largest part of the series. We read with interest the therapeutic options proposed, in particular the possibility of ultrasoundguided intra-sac injection, which was performed as treatment of choice in 17 of 41 interstitial pregnancies, with a success rate of 100%, which was significantly higher than in systemic methotrexate cases. Although the limitations in the diagnosis persist, we will take into account in our clinical practice the management suggestions proposed in this paper.&

What is the effect of intertwin delivery interval on the outcome of the second twin delivered vaginally

Abstract Objective: Optimal management of twin deliveries is controversial. We aimed to assess if intertwin delivery interval, after vaginal delivery of the first twin, may have an influence on adverse neonatal outcomes of the second twin Study design: This is a retrospective observational study including diamniotic twin pregnancies with vaginal delivery of the first twin, between January 2000 and July 2017. Inclusion criteria were diamniotic pregnancies and vaginal delivery of the first twin. We excluded higher twin order, monoamniotic pregnancies, cesarean delivery of the first twin and patients with missing data. Results: A number of 400 diamniotic twin pregnancies met the inclusion criteria and were divided, considering intertwin delivery interval into (1) ≤30 minutes (n = 365); and (2) >30 minutes (n = 35). Considering the two study groups, maternal and first twin characteristics and outcomes were similar. Second twin reported higher incidence of cesarean section and vacuum delivery, but similar incidence of neonatal adverse outcomes, in case of intertwin interval >30 minutes. At multivariate analysis, a difference between second and first twin weight ≥25% was correlated to neonatal adverse outcome, while we did not found this correlation with a cut-off of 30 minutes. Conclusions: In our study, growth discrepancy between twins was significantly correlated to adverse neonatal outcomes, while intertwin delivery time was not an influencing factor. So, in line with this result, in our clinical practice, we do not use a fixed time in which both twins should be delivered, neither in monochorionic nor in dichorionic pregnancies, when fetal wellbeing was demonstrated during labor.

A uterus didelphys with a spontaneous labor at term of pregnancy: a rare case and a review of the literature

Abstract Uterus didelphys accounts for 13% of uterine anomalies and has been correlated with preterm delivery and fetal malpresentation at delivery. A 37-year-old pregnant woman reported a spontaneous pregnancy in the right horn of a uterus didelphys. The course of the pregnancy was complicated by gestational diabetes, but no miscarriage threat or preterm delivery threat was reported during this pregnancy. She arrived at our division, in labor, at 39.2 gestational weeks’. She delivered by cesarean section due to failure to progress at 5 cm. Her post-operative course was uneventful. Vaginal delivery could be a safe option and the induction of labor or the use of oxytocin could be helpful in such cases, but recommended doses and labor time should be evaluated, so cesarean section is to date the most frequent delivery route in uterus didelphys at term.

Comment on “Contemporary epidemiology and novel predictors of uterine rupture: a nationwide population-based study”

We appreciate the paper by Vilchez et al. “Contemporary epidemiology and novel predictors of uterine rupture: a nationwide population-based study” [1]. Uterine rupture remains one of the most important obstetrical emergency, correlated to life-threatening consequences for both the mother and the fetus. In the paper by Vilchez et al., the authors identify some risk factors for the uterine rupture, which could be helpful in clinical management. In particular, they associate not only chorionamnionitis, history of previous caesarean, pre-gestational diabetes, induction or augmentation of labor, but also maternal age, ethnicity, socioeconomic status, high-old gestation, little interval since last birth, high body mass index, high number of prior caesarean section to higher risk of uterine rupture. Surely, a previous caesarean section is one of the most important condition correlating to uterine rupture, and the story of previous pregnancy (kind of caesarean section, insurgence of complications intraoperatively or post-partum) could give important information for a subsequent pregnancy [2, 3]. In our institution, we admit patients to trial of labor after vaginal delivery, excluding short interval between pregnancy and longitudinal uterine incision. We experience a vaginal delivery after caesarean section in 80% of the cases, with an incidence of uterine rupture of 0.4%, which remains, frequently, not predictable, even considering all these helpful risk factors. Not only a meticulous examination during pregnancy to discriminate the women admitted to trial of labor, but also a continuous and careful evaluation at the time of the arrival in emergency room for contractions is required. A one-to-one assistance during labor is recommended; moreover, in case of unusual pain or dyskinetic contractions, also in cases of absence of risk factors. We recently reported a case in which no risk factors were underlined, with the exclusion of the availability of little information about the previous caesarean section, executed in another country. The patient was a Gravida 2 Para 0 for a previous caesarean section, which have been performed before the onset of labour due to suspected macrosomia, 4 years before. The current pregnancy has been regular and the woman, who required vaginal delivery, after an adequate counselling, was admitted to trial of labor. No abnormalities at the uterine scan were described by the routine ultrasounds performed during pregnancy. She came to obstetrical emergency room at 41 weeks and 3 days for uterine contractions. At admission, she was immediately evaluated: fetal cardiotocography, lasting 30 min, was normal with fetal heart frequence of 130 heart beats for minute, variability was conserved and she presented rhythmic uterine contractions. During the pause between contractions, the uterus was tender and no pain nor vaginal bleeding were referred. Obstetrical evaluation found a central, 0.5 cm long cervix, tender, dilated 1 cm. An obstetrical abdominal scan was performed, to confirm fetal wellness and amniotic fluid quantity; an echogenic rounded area, of about 6 cm, with an iperechogenic contour, suspected for amniocele, was detected in the lower left abdominal quadrant, starting from a continuous solution of the myometrium, and lying out of the uterus in the abdomen. The fetus was cephalic with normal heart frequency and regular biophysical score. Only mild abdominal pain was referred when the area doubt for uterine rupture was touched. The patient was informed about the necessity to perform an emergency cesarean section, due to the high suspicion of uterine rupture. During her preparation for surgery, she complained a sudden, fix and strong pain at the lower left abdominal quadrant. Contractions vanished and cardiotocography lost its variability. Caesarean section started within 15 min. In the surgery room, at the celiotomy, after the exposition of * P. Algeri p.algeri@campus.unimib.it

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.

O4. Predisposing factors for early- and late-onset preclampsia.

Objectives: Early (34.0 wks) and late (>34.0 wks) onset preeclampsia (EO–LO PE) are supposed to have different etiologies, vascular and inflammatory disfunction respectively. The aim of our study is to evaluate general characteristics of women affected by either EO or LO PE, to identify risk factors for the two forms of disease. Study design: Retrospective cohort study of 197 consecutive singleton women diagnosed as preeclamptic at 22.4– 41.4 wks, from 1/2005 to 9/2009, evaluating demographic, clinical, and ultrasonographic (US) variables on hospital admission, in relation to EO vs LO PE. HELLP syndrome and stillbirth cases, and fetus with congenital anomalies were excluded. Obesity was defined as a BMI 30 kg/m2. First abnormal uterine arteries (UtA) Doppler, evaluated in women with history of APO (previous PE/IUGR/SGA), was defined as mean RI > 0.58 or bilateral Notch within 26.0 wks. IUGR was considered as an US AC 35 yrs and UtA Doppler related to EO PE (Table 2), whereas WG > 12 kg to LO PE (p = 0.04; OR = 4.6, CI (95%) = 2.39–8.87). Conclusions: Age > 35 yrs and UtA Doppler appeared risk factors for EO PE, whereas WG > 12 kg for the late form, supporting the hypothesis of a different pathogenesis.