Vincenzo D'Addario

The Efficacy of Quintero Staging System to Assess Severity of Twin–Twin Transfusion Syndrome Treated with Laser Therapy: A Systematic Review with Meta-Analysis

Severity of twin-twin transfusion syndrome (TTTS) is classified in five stages according to Quintero staging. However, the efficacy of such staging was recently debated. We reviewed the efficacy of Quintero staging to predict survival rate in TTTS treated with laser therapy. Articles reporting survival rate for each stage in TTTS treated with laser therapy were reviewed. Number of twins alive per pregnancy (NAP) was compared between early (I + II) and advanced (III + IV) stages and within stages. Meta-analysis was performed according to Meta-analysis Of Observational Studies in Epidemiology guidelines. Heterogeneity was tested with chi-square for heterogeneity at a significance level of P < 0.10, and random or fixed models were generated as appropriate. A P value < 0.05 was considered statistically significant. NAP was similar between early (zero survivors: 34/228, 15%; one survivor: 49/228, 21%; two survivors: 145/228, 63%) and advanced stages (zero survivors: 38/214, 18%; one survivor: 64/214, 30%; two survivors: 112/214, 52%; P > 0.05) except for one survivor ( P < 0.05). A trend for increased NAP was observed in all stages. Because clinically relevant differences were not observed, laser therapy is the optimal treatment for all stages. As Quintero staging does not provide information about prognosis, a new staging system is proposed.

Comparison of six sonographic signs in the prenatal diagnosis of spina bifida.

Abstract Aims: To compare the diagnostic accuracy of sonographic signs that may be looked for in fetuses with spina bifida. Methods: Forty-nine fetuses affected by spina bifida were enrolled, at a gestational age of 18–28 weeks. The following sonographic signs were looked for: “lemon” sign, small cerebellum, effaced cisterna magna, small posterior fossa, ventriculomegaly and direct visualization of a spinal defect. Results: The “lemon” sign was present in 53%, a small cerebellum in 96%, an effaced cisterna magna in 93%, a small posterior fossa in 96%. Ventriculomegaly was present in 40/49 (81%) cases and was severe in 20 fetuses and borderline in the remaining 20. The spinal defect was missed in one fetus presenting the cerebellar and posterior fossa signs. In two fetusus, the myelomeningocele was present without cranial signs of Chiari II malformation and in both cases the defect was covered by intact skin. Conclusions: Our results confirm the usefulness of evaluation of the posterior fossa in the diagnosis of spina bifida, particularly in cases of small spinal defects that may be missed at ultrasound. Conversely, myelomeningocele covered by intact skin was not associated with the cranial signs of Chiari II malformation.

Neonatal outcomes of assisted and naturally conceived twins: systematic review and meta-analysis.

Abstract Objective: To review the neonatal outcomes of assisted reproductive technique (ART) vs. naturally conceived (NC) twins. Methods: A search in PubMed, Medline, EMBASE, and Cochrane library was performed (January 2000–September 2010). Articles reporting outcomes of ART vs. NC twins were classified in controlled and non-controlled studies. A sub-group was limited to unlike sex twins (UST). The MOOSE guidelines were followed. A randomized model was generated if inter-studies heterogeneity was >25%. Inter-group comparison was significant if P<0.05. Results: Thirteen articles were reviewed. In non-controlled studies, outcomes were equal between groups, except for cesarean section rates (ART: 71.8%; NC: 49.6%; P<0.0001; OR: 2.34; 95% CI: 1.55–3.54). Similar results were obtained in controlled studies, except for higher rates of preterm delivery in ART (55%) than in NC (53%) twins (P=0.03; OR: 1.30; 95% CI: 1.03–1.65). UST differed with regard to preterm delivery (ART: 58.6%; NC: 49.5%; P<0.0001; OR: 1.51; 95% CI: 1.25–1.83), and perinatal death (ART: 3.6%; NC: 1.8%; P<0.0001; OR: 1.95; 95% CI: 1.41–2.71). Birth weight differed between groups. Conclusion: ART twins carry increased risk of adverse outcomes. UST are at higher risk of perinatal death, although further studies are needed to assess whether chorionicity impacts on neonatal outcomes after ART.

Comparison of donor and recipient outcomes following laser therapy performed for twin-twin transfusion syndrome: a meta-analysis and review of literature.

We reviewed current literature about donor and recipient outcomes after laser therapy performed for twin-twin transfusion syndrome (TTTS). Study inclusion criteria were monochorionic diamniotic pregnancies, TTTS diagnosed with standard criteria, survival, and cerebral anomalies rates defined individually for donors and recipients. Exclusion criteria were studies including triplets and monoamniotic pregnancies, therapeutic techniques different from laser therapy, data reported in graphs or percentage, and non-English language publications. Meta-analysis was performed by random effects model whenever heterogeneity across studies was > 25%. Fifteen articles were reviewed. Survival rate was 60% in donors and 70% in recipients ( P = 0.0002; odds ratio: 0.66; 95% confidence interval: 0.53 to 0.82). Neurological morbidity did not differ between twins (donors: 9% versus recipients: 10%; P = 0.66). This review shows that recipients are more likely to survive as compared with donors, whereas no differences are noted with regard to neurological morbidity. It may be hypothesized that a lethal injury (to which donors appear to be more sensitive) or a cerebral damage (with which donors and recipients are equally affected) occurs before the timing of surgery. Therefore, a study protocol to assess whether diagnosis of TTTS may be anticipated in the first trimester is proposed.

Gastrointestinal stromal tumors mimicking gynecological masses on ultrasound: a report of two cases

Gastrointestinal stromal tumors (GISTs) are among the most common mesenchymal tumors of the gastrointestinal tract. Diagnosis of GIST on ultrasound examination can be difficult because of their similarity in appearance to gynecological neoplasms. We present two cases of GIST originating from the small bowel and the stomach, which were preoperatively misdiagnosed as a uterine leiomyoma and an ovarian tumor, respectively. The ultrasonographic differential diagnosis of these pelvic masses is discussed. Copyright

Survival Outcomes of Twin–Twin Transfusion Syndrome Stage I: A Systematic Review of Literature

OBJECTIVE To review literature about treatment of twin-twin transfusion syndrome (TTTS) stage I. MATERIALS A search in PubMed, EMBASE, Medline, and reference lists was performed. Inclusion criteria were TTTS diagnosed with standard criteria and classified with Quintero staging and survival rates (SR) stratified for stage and first-choice treatment. Outcomes were SR and progression to advanced stages. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. RESULTS Seven articles pooled 262 twin sets treated with amnioreduction (16%), conservative management (22%), and laser therapy (62%). The overall SR was 77% after amnioreduction, 86% in the conservative management group, and 85% in the laser therapy group. Progression rate occurred in 30%, 15%, and 0%, respectively. Outcomes were similar between laser therapy as first- versus second-choice treatment. Because most studies were observational and not comparative, a meta-analysis was not performed. CONCLUSION Conservative management of TTTS stage I is a reasonable option until randomized clinical trials are presented.

ULTRASONIC DIAGNOSIS AND PERINATAL MANAGEMENT OF COMPLICATED AND UNCOMPLICATED FETAL OVARIAN CYSTS : A COLLABORATIVE STUDY

Ovarian cysts can be demonstrated in the ovaries of fetuses and full term infants at birth. Small cysts involute spontaneously during fetal life or within the first few months of life. Large cysts may cause mechanical complications or respiratory distress. Sonographic detection of fetal ovarian cysts has been reported, as well as intrauterine surgical treatment. The sonographic findings and the outcome of the smaller and the complicated cysts were studied in 25 pregnant women. Uncomplicated fetal ovarian cysts should be monitored by weekly examination until delivery. Huge ovarian cysts may be an indication for cesarean section; or, intrauterine aspiration may be the alternative. Complicated fetal ovarian cysts represent an indication for neonatal surgery.

Laparoscopic Diagnosis and Treatment of Pelvic Benign Multicystic Mesothelioma Associated with High CA19.9 Serum Concentration

We report a case of benign multicystic mesothelioma in a 20-year-old woman referred because of amenorrhea. She underwent pelvic transabdominal ultrasound, which disclosed a micropolycystic appearance of the ovaries and a fluid collection in the pouch of Douglas. Tumor serum markers revealed an increase in CA19.9. Abdominal and pelvic computed tomography scans confirmed the presence of ascites. Laparoscopy disclosed small, thin-walled, translucent cysts in the Douglas cavity. The cysts were free-floating in a yellowish, sticky, gelatinous material. Microscopically, cystic lesions showed mesothelium-lined cystic spaces surrounded by a delicate thin fibrovascular wall. With immunohistochemistry, the tumor cells were strongly positive for cytokeratin and calretinin. These aspects were suggestive of benign multicystic mesothelioma. Electron microscopy confirmed the mesothelial nature of this tumor. Serial evaluation of the CA19.9 concentration showed a progressive decrease in the serum marker in the normal range. The patient is now well and symptom-free with no recurrence 24 months after surgery. The association between benign multicystic mesothelioma and increased CA19.9 serum concentration has been described only once, in a man. To our knowledge, this is the second case of benign multicystic mesothelioma associated with increased CA19.9 serum concentration and the first diagnosed in a woman. In the present case, a minimally invasive laparoscopic approach enabled not only histologic diagnosis of benign multicystic mesothelioma but also its surgical treatment. Although benign multicystic mesothelioma is a rare pathologic entity, it is important that sonologists include it in the differential diagnosis of diseases that manifest with ascites. Furthermore, all surgeons should be aware of the macroscopic and laparoscopic appearance of the lesion, and its generally benign course.

Pivotal points to prevent iatrogenic infections triggered by hysteroscopy

Gianluca Raffaello DAMIANI, Stefano LANDI, Vincenzo D’ADDARIO, Domenico SPELLECCHIA, Giuseppe LOVERRO and Antonio PELLEGRINO Department of Obstetric and Gynecology, Sondrio Hospital, Sondrio, Department of Obstetric and Gynecology, Chiavenna Hospital, Chiavenna, Department of Obstetric and Gynecology, University of Bari, Policlinico of Bari, Department of Obstetric and Gynecology, Alessandro Manzoni Hospital, Lecco, Italy E-mail: damiani14@alice.it

WS17‐10Sonographic evaluation of the umbilical cord throughout gestation

Traditionally, the prenatal assessment of the umbilical cord (UC) is limited to the assessment of the number of vessels and to the evaluation of umbilical artery blood flow parameters. Morphologic aspects of the UC have usually been studied by pathologists and retrospectively correlated with the perinatal outcome. The introduction of more sophisticated imaging techniques have offered the possibility to investigate the UC characteristics during fetal life from early to late gestation. A number of investigations have demonstrated that an altered structure of the UC can be associated with pathologic conditions (i.e. preeclampsia, fetal growth restriction, diabetes, fetal demise). Nomograms of the various UC components have been generated and allow the identification of lean or large umbilical cords, entities frequently associated with fetal growth abnormalities and diabetes, respectively. Of note, lean UC in the second and third trimester differs from normal UC not only from a structural point of view but also in the umbilical vein blood flow characteristics. On the other hand a thin UC in the first trimester seems to be a marker for identifying a subset of fetuses at risk for spontaneous abortion and pre‐eclampsia. A Whartons jelly reduction has also been invoked as a possible cause of fetal death in the presence of single umbilical artery. Prenatal morphometric and morphologic UC characteristics as well as UC arterial and venous blood flow parameters in normal and pathologic conditions will be presented and discussed.