Paolo Cavoretto

Isolated tubal torsion in pregnancy

Adnexal torsion is an uncommon cause of acute abdomen in pregnancy and isolated fallopian tube twisting accounts for a very small number of these cases. These conditions, either in pregnancy or in non-gestational circumstances, are known to be due to both genital and non-genital causes and, in most cases, predisposing factors can be identified. We reviewed the literature and retrieved only 19 cases of isolated fallopian tube torsion in pregnancy treated surgically from 1936 to today, including one recently published case from our experience. The clinical presentation was lower quadrant abdominal pain in all cases. The right side was involved in 90% of the cases. Tenderness was usually present but peritoneal irritation with guarding or rebound was exceptional. Symptoms were nausea and vomiting, scanty vaginal bleeding and dysuria. Signs suggestive of necrosis such as leucocytosis, increased CRP and mild hyperpyrexia were uncommon. Preoperative ultrasound evaluation was performed in eight patients and in all cases an adnexal cyst was detected on the ipsilateral side of the abdominal pain. The case we recently published was carefully investigated preoperatively by Doppler flow ultrasound techniques which allowed for a precise differential diagnosis with total adnexal torsion. This aspect has never been previously considered. The surgical approach showed acute isolated fallopian tube torsion in all the cases and a predisposing factor was identified in 75% of the patients. Foetal and maternal outcome were always excellent. In cases of acute abdomen in pregnancy, with detailed Doppler flow ultrasound evidence of normal ovaries and of a pelvic cyst, an isolated tubal-paratubal cyst torsion should be considered and appropriate ovary-sparing surgical treatment foreseen.

Evaluation of a panel of circulating DNA, RNA and protein potential markers for pathologies of pregnancy.

Abstract Background: Among markers of pregnancy complications, corticotropin-releasing hormone (CRH) mRNA, long pentraxin 3 (PTX3) protein and fetal and total DNA had been reported to be increased in the plasma of women with overt preeclampsia (PE). We developed an optimized protocol to evaluate whether concentrations of CRH mRNA, PTX3 mRNA and protein, fetal and/or total DNA are increased in fetal growth restriction (FGR), and whether they predict complications of pregnancy. Methods: The protocol included a preamplification step to enrich rare mRNA species. CRH and PTX3 mRNA, DNA and PTX3 protein were measured in the plasma of women with PE or FGR, in women at risk of developing these pathologies and in healthy women matched for gestational age. Results: CRH mRNA, fetal and/or total DNA and PTX3 protein were significantly increased in women with overt PE when compared to controls. Pregnant women who later developed PE or FGR during pregnancy showed total DNA levels that were significantly increased before the onset of both pathologies, while RNA markers were increased only in women who later developed PE. Conclusions: Our protocol for plasma RNA quantification may allow for the extension of a panel of predictive markers to be investigated in larger patient cohorts. Clin Chem Lab Med 2010;48:791–4.

Aberrant right subclavian artery in fetuses with Down syndrome: a systematic review and meta‐analysis

The primary objective was to estimate the prevalence of aberrant right subclavian artery (ARSA) in fetuses with Down syndrome. Secondary objectives were to assess the prevalence of ARSA in euploid fetuses, the feasibility of ultrasound evaluation of the right subclavian artery (RSA) in the first and second trimesters of pregnancy, the performance of ARSA in screening for trisomy 21 and its association with other abnormalities.

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).

Early diagnosis, follow-up, and prenatal treatment of a case of TRAP sequence occurring in a dichorionic triamniotic triplet pregnancy

We are reporting a case of twin reversed arterial perfusion (TRAP) sequence occurring in a dichorionic triamniotic triplet pregnancy with successful percutaneous prenatal treatment and excellent neonatal outcome. TRAP sequence was diagnosed at 11 weeks in a spontaneous dichorionic‐triamniotic triplet. Sonographic assessment showed persistent arterial flow and development of hydrops in the acardiac twin. Percutaneous cord interstitial laser coagulation was performed, and the co‐twin subsequently developed growth restriction. The 9‐month‐old twins have a normal developmental course. This report confirms that fetal intervention is indicated in cases of TRAP sequence in which the acardiac twin presents a significant enlargement on follow‐up sonographic examinations.

Ultrasound imaging after evacuation as an adjunct to β-hCG monitoring in posthydatidiform molar gestational trophoblastic neoplasia

OBJECTIVE The purpose of this study was to identify prognostic factors associated with development of gestational trophoblastic neoplasia (GTN) after hydatidiform mole (HM). STUDY DESIGN A retrospective analysis of 189 patients with HM was performed. We recorded features such as maternal age, HM history, blood group, gestational age, uterine volume at evacuation, presence of theca lutein cysts, vaginal bleeding, and transvaginal ultrasonography with color Doppler imaging. We considered risk predictors to be the presence of nodules and hypervascularization within the myometrium or endometrium (positive ultrasound imaging). An univariate and multivariate analysis, with the COX nominal logistic model, was performed. RESULTS Fourteen patients experienced GTN (7.4%). After univariate analysis, uterine size (P = .0139) and positive ultrasound results (P < .0001) were associated significantly with GTN development. At multivariate analysis, only positive ultrasound results maintained significance (likelihood ratio test: chi(2) = 0.0000). CONCLUSION The risk of GTN is increased in patients with uterine involvement that is assessed by ultrasound imaging. None of the other prognostic factors that were evaluated was predictive of GTN development.

Prediction of pulmonary hypoplasia in mid‐trimester preterm prelabor rupture of membranes: research or clinical practice?

The pathophysiological basis of secondary pulmonary hypoplasia (PH) can include: extrinsic compression of the fetal lungs impairing growth and development; decreased vascular perfusion; severe fluid loss within lungs and airways, due either to extrinsic compression of the fetal thorax or to a decrease in intra-amniotic pressure and increase in the alveolar–amniotic pressure gradient;1 absence or cessation of fetal breathing movements2. Normal lung growth is impaired in the presence of thoracic masses (mainly congenital diaphragmatic hernia (CDH) and echogenic lung lesions), pleural effusions, significant cardiomegaly and thoracic wall hypoplasia (due to, for example, asphyxiating thoracic dystrophy or achondroplasia). PH is rarely associated with primary lung lesions in the absence of fetal hydrops or significant pleural effusions and the outcome in fetuses with lung masses and no associated hydrops is good in more than 95% of cases, irrespective of their volume3. Reduced pulmonary perfusion is a feature of major chromosomal abnormalities (trisomies 21, 18 and 13), scimitar syndrome, pulmonary arterial stenosis/atresia, Ebstein anomaly and tricuspid atresia, all of which potentially lead to persistent pulmonary hypertension of the newborn and PH. Extrathoracic causes of PH are neuromuscular disorders (congenital myotonic dystrophy, fetal akinesia deformation sequence), central nervous system malformations (anencephaly) and severe oligohydramnios (due to renal agenesis, obstructive uropathy or amniotic fluid leak) occurring before completion of the canalicular phase of lung development (at 16–28 weeks).

Risk of spontaneous preterm birth in singleton pregnancies conceived after IVF/ICSI treatment: meta‐analysis of cohort studies

Preterm birth (PTB) is more common in pregnancies conceived by in‐vitro fertilization (IVF) as compared with those conceived naturally. However, the extent to which this is attributed to spontaneous labor or to iatrogenic indications has not been determined. The aim of this study was to quantify the risk of spontaneous PTB (sPTB) in singleton pregnancies resulting from IVF or intracytoplasmic sperm injection (ICSI) treatment as compared with that in spontaneously conceived pregnancies.

Nuchal translucency measurement, free β-hCG and PAPP-A concentrations in IVF/ICSI pregnancies: systematic review and meta-analysis.

So far, data on the effect of assisted reproductive technologies (ART) on the components of first trimester combined screening for Down syndrome are still controversial. A systematic search of the literature was performed in order to identify the effect of ART, particularly in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) with fresh embryo transfer, on the nuchal translucency, free beta‐human chorionic gonadotrophin and pregnancy‐associated plasma protein‐A measurements. Moreover, a meta‐analysis and a descriptive graphical representation of the ratios between ART and spontaneous pregnancies (controls) values of median of the multiple of median (m0MoM) were performed. Free beta‐human chorionic gonadotrophin test showed slightly higher values in the ICSI group than controls (RR = 1.09, 95%CI: 1.03–1.16) but not in the IVF group (RR = 1.03, 95%CI: 0.94–1.12). Pregnancy‐associated plasma protein‐A values for IVF/ICSI, IVF and ICSI showed lower values in comparison with controls (RR, 95%CI 0.85, 0.80–0.90; 0.82, 0.74–0.89 and 0.83, 0.79–0.86, respectively). The nuchal translucency measurement did not show any statistical differences between study groups (IVF and ICSI) and controls (RR = 1.00, 95%CI: 0.94–1.08 and RR = 1.01, 95%CI: 0.97–1.05, respectively). These results may be due to alterations in the placentation of ART pregnancies. Differentiating further subgroups of ART pregnancies may explain the differences in biomarker concentrations, in prenatal behavior and in obstetric outcomes between ART and spontaneous pregnancies.

The risk of preeclampsia beyond the first pregnancy among women with type 1 diabetes parity and preeclampsia in type 1 diabetes

AIM To estimate the incidence of preeclampsia (PE) among nulliparous and multiparous patients with type 1 diabetes and to study predictors of PE. METHODS We prospectively collected data on all pregnancies of patients with pregestational type 1 diabetes, followed at our Prenatal Medicine Unit between 1993 and 2008. Medical records were prospectively reviewed by two obstetricians for maternal demographics, pregnancy data, maternal and fetal outcomes. Data were analyzed according to the development of PE and parity. RESULTS We identified and collected data on 291 eligible pregnancies (195 among nulliparae and 96 among multiparae). The incidence of PE was 9.2% (95% CI: 5.6-14.2) among nulliparae and 9.4% (95% CI: 4.4-17.0) among multiparae. Patients who developed PE had higher HbA1c during pregnancy compared to patients who did not (p=0.026 among nulliparae and p=0.032 among multiparae). Chronic hypertension [OR 17.12 (3.22, 91.00)], microalbuminuria at the beginning of the pregnancy [OR 3.77 (1.22, 11.61)], weight gain during pregnancy [OR 1.13 (1.04, 1.23)] and HbA1c in the first trimester [2.81 (1.12, 7.05)], but not parity, were significant predictors of PE. CONCLUSIONS Among patients with type 1 diabetes the incidence of PE was similar among nulliparae and multiparae, unlikely in the general population where PE is a disease of the first pregnancy. An increased risk of PE should be assumed for both nulliparous and multiparous women with pregestational diabetes.