S. Mesogitis

Screening for pre‐eclampsia and fetal growth restriction by uterine artery Doppler and PAPP‐A at 11–14 weeks' gestation

To assess the role of maternal demographic characteristics, uterine artery Doppler velocimetry, maternal serum pregnancy‐associated plasma protein‐A (PAPP‐A) and their combination in screening for pre‐eclampsia and small‐for‐gestational age (SGA) fetuses at 11–14 weeks.

Emergency obstetric hysterectomy

Background. All cases of obstetric hysterectomies that were performed in our hospital during a seven‐year study period were reviewed in order to evaluate the incidence, indications, risk factors, and complications associated with emergency obstetric hysterectomy. Methods. Medical records of 45 patients who had undergone emergency hysterectomy were scrutinized and evaluated retrospectively. Maternal age, parity, gestational age, indication for hysterectomy, the type of operation performed, estimated blood loss, amount of blood transfused, complications, and hospitalization period were noted and evaluated. The main outcome measures were the factors associated with obstetric hysterectomy as well as the indications for the procedure. Results. During the study period there were 32,338 deliveries and 9,601 of them (29.7%) were by cesarean section. In this period, 45 emergency hysterectomies were performed, with an incidence of 1 in 2,526 vaginal deliveries and 1 in 267 cesarean sections. All of them were due to massive postpartum hemorrhage. The most common underlying pathologies was placenta accreta (51.1%) and placenta previa (26.7%). There was no maternal mortality. Conclusions. Obstetric hysterectomy is a necessary life‐saving procedure. Abnormal placentation is the leading cause of emergency hysterectomy when obstetric practice is characterized by a high cesarean section rate. Therefore, every attempt should be made to reduce the cesarean section rate by performing this procedure only for valid clinical indications.

Misoprostol for second trimester pregnancy termination in women with prior caesarean section

Objective  To examine whether a previous caesarean section increases the risk for complications in women undergoing a mid‐trimester pregnancy termination by labour induction.

Screening for pre‐eclampsia and small for gestational age fetuses at the 11–14 weeks scan by uterine artery Dopplers

Objective. To assess the role of uterine artery Doppler studies at 11‐14 weeks in screening for pre‐eclampsia (PET), small for gestational age (SGA) fetuses, and placental abruption. Methods. Prospective study on 1,123 women presenting for routine ultrasound examination at 11–14 weeks for nuchal translucency measurement. Uterine artery blood flow was studied by transvaginal colour Doppler, the mean pulsatility index (PI) was calculated, and the presence of a diastolic notch was recorded. Results. The mean, median and 95th centile of uterine artery PI were 1.71, 1.64 and 2.54, respectively. Bilateral notches were observed in 63.4%, and a unilateral notch in 18.4% of cases. The sensitivity of mean uterine artery PI ≥95th centile for PET, early onset severe PET necessitating delivery before 34 weeks, SGA ≤5th centile, SGA necessitating delivery before 34 weeks, SGA ≤10th centile and placental abruption were 21.4, 33.3, 17.8, 100, 9.6 and 44.4%, respectively. One in 6 women with increased resistance in the uterine arteries at 11–14 weeks will develop a complication related to utero‐placental insufficiency. Conclusions. Abnormal uterine Dopplers at 11–14 weeks identified one‐third of women with severe early onset pre‐eclampsia, all fetuses with SGA ≤5th centile that were delivered at ≤34 weeks, and 40% of cases with placental abruption. Uterine artery Doppler examination at the 11–14 weeks scan can identify a high risk population in which preventive or therapeutic interventions might be effective.

Risk factors predisposing to fetal loss following a second trimester amniocentesis

Objective To examine the influence of possible risk factors on fetal loss rate following amniocentesis.

Genetic amniocentesis in women 20-34 years old: associated risks

The aim of this retrospective controlled study is to evaluate the impact of predisposing factors on amniocentesis‐related fetal loss. It comprises 3910 consecutive cases of women, aged 20–34 years, who had genetic amniocentesis during the years 1992–97 (study group). The control group comprised 5324 women under 35, at low risk for Down syndrome, during the same period. The fetal losses in both groups were analysed, in respect of: (a) maternal historical conditions; and/or (b) bleeding during current pregnancy. The leading indication for amniocentesis in women 20–34 years was maternal anxiety, mainly for marginal age (33–34 years), which accounted for a remarkable 34.4% of the study group. Total fetal loss rate up to the 28th week was 2.1% in the study group versus 1.5% in controls. A history of previous spontaneous or induced abortions, as well as bleeding during the current pregnancy, was associated with a substantial rise of fetal loss in both groups. In cases with no predisposing factors, the added fetal loss rate was 0.03%. Previous abortions and bleeding during the current pregnancy are associated with the most fetal losses after amniocentesis. In the absence of these, the added fetal loss rate (0.03%) is non‐significant. Copyright

Sonographic Cervical Length Measurement before Labor Induction in Term Nulliparous Women

Objective: The purpose of the study was to determine if transvaginal sonographic measurement of the cervical length is a useful method to predict successful labor induction in nulliparas. Methods: 137 women who were scheduled for medically indicated induction of labor had a transvaginal sonographic measurement of the cervical length before labor induction. Inclusion criteria were: (1) singleton pregnancy; (2) gestational age between 37–42 weeks; (3) live fetus in cephalic presentation; (4) intact membranes; (5) no vaginal bleeding; (6) no previous history of uterine surgery; (7) nulliparous women, and (8) no allergy or asthma in response to prostaglandins. Induction of labor was performed within 6 h of the ultrasonographic examination, by inserting 2 mg of dinoprostone in the posterior vaginal fornix, repeated if needed every 6 h for up to three doses. When the cervix became favorable and no regular contractions were observed, amniotomy and oxytocin augmentation, starting at 1 mIU/min and increasing 1 mIU every 30 min as necessary, was performed. Results: All women were Caucasians and the mean age was 24.3 years (range 19–37 years). The mean cervical length was 28 mm (range 11–39 mm). The Bishop score was ≤5 in 101 women and >5 in the 36 others. Vaginal delivery occurred in 92 women (67.1%), and the vast majority of them (89 women; 96.7%) gave birth within 24 h of induction. Forty-five women (32.8%) had a cesarean section. The Bishop score was not predictive of the mode of delivery. Thirty-six of 101 women (35.6%) with a Bishop score ≤5 delivered by cesarean section, compared to 9 of 36 women with a Bishop score >5 (25%) (p = NS). Women with a cervical length <27 mm were more likely to deliver vaginally. Using this cutoff value the sensitivity of a successful labor induction was 76% and the specificity was 75.5%. Conclusions: Transvaginal sonographic measurement of cervical length is a good predictor of a successful labor induction at term in nulliparas.

Combined ultrasonographically guided drainage and methotrexate administration for treatment of endometriotic cysts

We report an effective alternative for the management of endometriotic cysts with transabdominal drainage under ultrasonographic control, followed by injection of 30 mg of methotrexate.

Embryo reduction versus expectant management in triplet pregnancies

OBJECTIVE In triplet pregnancies, to compare pregnancy outcome of expectant management with that after embryo reduction to twins. METHODS Retrospective study of 255 trichorionic triplet pregnancies, of which 185 had embryo reduction to twins (reduced group) and 70 were managed expectantly (non-reduced group). RESULTS Median birth weight was higher by about 500 g and gestation prolonged by about 3 weeks in the reduced pregnancies compared with the expectantly managed pregnancies (2300 vs. 1760 g; 36 vs. 33 weeks). The rates of preterm delivery were significantly lower in the reduced group (11.17 vs. 36.76% for delivery at < or = 32 weeks and 40.58 vs. 83.82% for delivery at < or = 35 weeks, reduced vs. non-reduced group). The percentage of infants born with low birth weight was significantly higher in the expectantly managed triplets (10.98 vs. 28.44% for birth weight < or = 1500 g and 68.55 vs. 92.89% for birth weight < or = 2500 g, reduced vs. non-reduced group). Total fetal loss was significantly higher in the reduced group than in the non-reduced group (15.41 and 4.76%, respectively) and the difference was mainly due to the higher miscarriage rate in the reduced group (8.11 vs. 2.86% in the non-reduced group). With the expected rates of handicap in preterm infants, we would anticipate 0.63% of severely handicapped children due to extreme prematurity in the reduced group and 1.64% in the non-reduced group. CONCLUSION In triplet pregnancies, embryo reduction to twins significantly reduces the risk of severe preterm delivery and very low birth weight by about one-third, at the expense of a significant increase in total fetal loss, by about one-quarter. The procedure is likely to reduce the risk of having a severely handicapped child due to extreme prematurity.

USE OF MISOPROSTOL FOR THE TERMINATION OF SECOND TRIMESTER PREGNANCIES

Abstract Surgical termination of pregnancy is of high risk for the woman’s health and safe medical ways are required. The use of prostaglandins may substantially reduce this risk. The efficacy and safety of misoprostol as a medication for the termination of the second trimester pregnancies were studied. During a 15-month period ninety-eight healthy pregnant women (13–24 weeks) wishing to terminate their pregnancy due to medical reasons participated voluntarily in this study. Misoprostol was administered 400 µg per os and 400 µg vaginally. Dose was repeated every 6 hours until adequate contractions and cervical ripening were achieved. Outcome measures included successful termination rates, mean expulsion time and side effects of the medication. The efficacy of the method was as high as 91.8% (90/98 cases 95%, CI 86–97%). Mean expulsion time was 10.2 h (range 3–23.4 h) for primigravida and 9.2 h (range 2.5–22.2 h) for multigravida. In 9 cases (9.2%) placenta remnants and in 8 (8.2%) placenta retention were found. Most common side effect was shivering in 17.3% of cases, vomiting and nausea (10.2%), headache and dizziness (7.1%), abdominal pain (79.6%), while diarrhea was noticed in 4.1%. The high efficacy and low incidence of side effects make misoprostol a useful alternative method for medical termination of second trimester pregnancies.