Prediction of delivery after 40 weeks by antepartum ultrasound in singleton nulliparous women: a prospective cohort study

Background: Induction of labor at 39 weeks of gestation is associated with better maternal and perinatal outcomes than expectant management. However, a policy of induction of labor implies the identification of women who will deliver after 40 weeks, who are at higher risk of adverse outcome. Objective: This study primarily aimed to elucidate the role of antepartum ultrasound in predicting the onset of spontaneous labor in a cohort of low-risk singleton pregnancies, and secondarily to compare its diagnostic performance with that of other ultrasonographic and clinical parameters. Study design: This was a prospective study including singleton nulliparous women undergoing a dedicated ultrasound assessment at 36 to 38 weeks of gestation. The primary outcome was delivery ≥40 weeks of gestation. The ultrasound parameters explored were cervical length, posterior cervical angle, angle of progression, and head-perineum distance. Multivariate logistic regression, Kaplan-Meier, and area under the curve analyses were used to test the strength of association and diagnostic performance of variables considered in predicting delivery ≥40 weeks. Results: A total of 457 women were included, and 49.2% delivered ≥40 weeks. Cervical length was longer (30 vs 19 mm; P≤.0001) and posterior cervical angle wider (105° vs 98°, P≤.0001) in women delivering ≥40 weeks than those delivering 24 mm at 36 to 37 weeks of gestation shows the optimal combination of sensitivity and specificity in predicting delivery ≥40 weeks. The findings from this study can help in identifying those women for whom elective induction of labor at 39 weeks of gestation would be beneficial in reducing the risk of adverse pregnancy outcome

Thrombotic storm, hemostasis disorders and thromboinflammation in COVID-19

The rate of thrombosis and disseminated intravascular coagulation (DIC) has been increasing in COVID-19 patients. Key features related to such condition include minimal or no risk of bleeding, moderate thrombocytopenia, high plasma fibrinogen as well as complement components level in the areas of thrombotic microangiopathy. The clinical picture is not typical for classic DIC. This review systematizes the pathogenetic mechanisms of hypercoagulation in sepsis and its extreme forms in patients with COVID-19. The latter consist of the thrombosis-related immune mechanisms, the complement activation, the macrophage activation syndrome, the formation of antiphospholipid antibodies, the hyperferritinemia, and the dysregulation of the renin-angiotensin system. Taking into consideration the pathogenetic mechanisms, the biomarkers had been identified related to the prognosis of the disease development. Patients with pre-existing cardiovascular disease and other risk factors, including obesity, diabetes, hypertension, and aging pose the peak risk of dying from COVID-19. We also summarize new data on platelet and endothelial dysfunction, immunothrombosis, and, as a result, thrombotic storm as essential components of COVID-19 severe features

Outcome of fetal echogenic bowel: a systematic review and meta-analysis

The main aim of this systematic review was to explore the outcome of fetuses with isolated echogenic bowel (EB) on antenatal ultrasound. Inclusion criteria were singleton pregnancies with isolated EB no associated major structural anomalies at the time of diagnosis. The outcomes observed were: chromosomal anomalies, cystic fibrosis, associated structural anomalies detected only at follow-up scans and at birth, regression during pregnancy, congenital infections, intra-uterine (IUD), neonatal (NND) and perinatal (PND) death. Twenty-five studies (12971 fetuses) were included. Chromosomal anomalies occurred in 3.3% of the fetuses, mainly Trisomy 21 and aneuploidies involving the sex chromosomes. Cystic fibrosis occurred in 2.2%. Congenital infections affected 2.2%, mainly congenital CMV infection. The majority of fetuses with EB experienced regression or disappearance of the EB at follow-up scans. Associated anomalies were detected at a follow-up scan in 1.8%. Associated anomalies were detected at birth and missed at ultrasound in 2.1% of cases. IUD occurred in 3.2% of cases while the corresponding figures for NND and PND were 0.4% and 3.1%. Fetuses with EB are at increased risk of adverse perinatal outcome, highlighting the need for a thorough antenatal management and post-natal follow-up. Assessment during pregnancy and after birth should be performed in order to look for signs of fetal aneuploidy, congenital infections and associated structural anomalies. This article is protected by copyright. All rights reserved

The pathogenic role of circulating Hashimoto's Thyroiditis-derived TPO-positive IgG on fetal loss in naïve mice

Problem: Antibody-mediated autoimmune diseases, such as autoimmune thyroid diseases (ATD), systemic lupus erythematosus (SLE), and antiphospholipid syndrome (APS), often are associated with recurrent fetal loss. One of the ATD is Hashimoto's thyroiditis which recently showed association with complications of pregnancy with increased levels of circulating autoantibodies reactive with epitopes on thyroid tissue such as thyroid peroxidase (anti-TPO). In retrospective study of sera analyses in patients with Hashimoto's thyroiditis, all patients had mainly elevated circulating anti-TPO autoantibodies. Aim: We assessed the potential of human anti-TPO highly positive IgG, derived from patients with Hashimoto's thyroiditis sera associated with complications of pregnancy, to cause directly complications of pregnancy in murine model. Method of study: Naïve ICR female mice, infused intravenously with 100 μg of anti-TPO-positive IgG, showed increased fetal loss and embryo small for date (P <.001) in comparison with mice passively transferred with commercial IgG or PBS. Moreover, we observed embryos small for date in the mice passively transferred with anti-TPO-positive IgG, exemplified by reduced weight of embryos and placentae (P =.001). Histopathological examination revealed delay in fetal development in 50% cases of anti-TPO-positive IgG-treated mice. Importantly, pathological changes in the transition zone, state of glycogen cells, and significant structural changes in the labyrinth part of placenta were observed in all anti-TPO-positive IgG samples. Conclusion: The current study shows in the first time, a direct proof of concept, on the association of human TPO-positive IgG from Hashimoto's thyroiditis patients on fetal loss induction in murine model

Prenatal imaging features and postnatal outcomes of isolated fetal duplex renal collecting system: a systematic review and meta-analysis.

OBJECTIVES: To perform a systematic review of studies reporting the outcome of fetuses with a prenatal diagnosis of isolated duplex collecting system (DCS). METHODS: Inclusion criteria were studies reporting the outcome of fetuses with a prenatal diagnosis of isolated DCS, defined as DCS not associated with other major structural anomalies at the time of diagnosis. The outcomes observed were: imaging features of DCS on prenatal ultrasound, associated anomalies detected exclusively at prenatal follow-up ultrasound and at birth, abnormal karyotype, symptoms at birth [including vesicoureteral reflux (VUR), urinary tract infections (UTI)], need for and type of surgical approach, complications after surgery and accuracy of prenatal ultrasound in correctly identifying this anomaly. RESULTS: Eleven studies (284 fetuses with a prenatal diagnosis of DCS) were included. On ultrasound, DCS was associated with ureterocele in 70.7% and with megaureter in 36.6% of cases. Worsening of pelvic/ureteric dilatation was reported to occur in 41.3% of fetuses. At birth, 4.3% of fetuses affected by DCS showed associated renal anomalies. After birth, VUR and UTI presented in 51.3% and 21.7% of children respectively, while 33.6% required surgery. Prenatal diagnosis of DCS was confirmed in 90.9% of included cases. CONCLUSION: DCS diagnosed prenatally is associated with a generally good outcome. Prenatal ultrasound has a good diagnostic accuracy, while detailed post-natal assessment is required in order to identify associated renal anomalies. This article is protected by copyright. All rights reserved

First trimester prenatal screening in multiple pregnancies. Part II: serum proteins PAPP-A and β-hCG as markers of adverse pregnancy outcomes

Aim: to evaluate the ability of serum biochemical markers in pregnant woman - PAPP-A (pregnancy-associated plasma protein-A) and β-hCG (the в-subunit of human chorionic gonadotropin) studied in the first trimester (11+0-13+6) during combined prenatal screening to predict adverse perinatal outcomes of multiple pregnancy that occurred spontaneously and as a result of in vitro fertilization (IVF).Materials and methods. The main group consisted from 65 women with pregnancy occurred as a result of IVF; comparison group included 56 women with spontaneous pregnancy. All pregnancies were multiple and their outcomes were known. Serum PAPP-A and β-hCG levels were measured in the first trimester. The results were expressed in absolute values and in MoM (multiples of median). Subgroups were compared with mono- and dichorionic pregnancies, complicated and uncomplicated pregnancies, distributed according to MoM index: within the reference values (0.5-2.0), below or above the reference values.Results. PAPP-A MoM values in the spontaneous pregnancy group were 1.12 [0.8; 1.57], in the IVF group - 1.35 [1.11; 1.72] (p = 0.01). In subgroup of low PAPP-A MoM antenatal fetal death occurred in 50 %, in subgroup of normal PAPP-A MoM - in 14.58 %, in subgroup of high PAPP-A MoM - in 5.88 % (p = 0.011). In addition, a positive correlation was found between serum PAPP-A level and time of fetal death (rs = 0.564; p = 0.036). Low PAPP-A MoM values were associated with 50 % fetal mortality, 75 % of them were attributable to pregnancy as a result of IVF.Conclusion. Identification of adverse outcomes in multiple pregnancies is still a difficult task, but evaluation of serum biochemical markers during the first trimester screening can help in early diagnosis of necessity and extent of timely prophylaxis

First trimester prenatal screening in multiple pregnancies. Part I: comparative analysis of serum proteins PAPP-A and p-hCG in pregnancies conceived spontaneously or by in vitro fertilization

Introduction. Serum proteins PAPP-A (pregnancy-associated plasma protein-A) and β-hCG (the в-subunit of human chorionic gonadotropin) levels are components of the 1st trimester combined screening aimed to detect fetal aneuploidies. In contrast to singleton pregnancies, where the values are well established, this is not the case in twins.Aim: a comparative analysis of serum proteins PAPP-A and β-hCG levels, as well as parameters PAPP-A MoM and β-hCG MoM in the first trimester during pregnancy with dichorionic diamniotic twins that occurred spontaneously or as a result of in vitro fertilization (IVF).Materials and methods. The study group included multiple pregnancies as a result of IVF procedure (n = 100) and spontaneous multiple pregnancies (n = 121) considered as controls. The levels of PAPP-A, β-hCG, PAPP-A MoM and β-hCG MoM were compared using nonparametric Mann-Whitney U test.Results. The PAPP-A MoM level resulted higher in the group of IVF twins (p = 0,007) compared to spontaneous twins: 1.28 [0.97; 1.89] vs. 1.12 [0.87; 1.40] (median [interquartile range]). There were no statistically significant differences in в-hCG levels between the groups of IVF twins and spontaneous twins.Conclusion. The results justify the need for further study of PAPP-A and β-hCG to establish their association with adverse outcomes in both groups of multiple pregnancies

HIBISCUS: Hydroxychloroquine for the secondary prevention of thrombotic and obstetrical events in primary antiphospholipid syndrome

The relapse rate in antiphospholipid syndrome (APS) remains high, i.e. around 20%-21% at 5 years in thrombotic APS and 20-28% in obstetrical APS [2, 3]. Hydroxychloroquine (HCQ) appears as an additional therapy, as it possesses immunomodulatory and anti-thrombotic various effects [4-16]. Our group recently obtained the orphan designation of HCQ in antiphospholipid syndrome by the European Medicine Agency. Furthermore, the leaders of the project made the proposal of an international project, HIBISCUS, about the use of Hydroxychloroquine in secondary prevention of obstetrical and thrombotic events in primary APS. This study has been launched in several countries and at now, 53 centers from 16 countries participate to this international trial. This trial consists in two parts: a retrospective and a prospective study. The French part of the trial in thrombosis has been granted by the French Minister of Health in December 2015 (the academic trial independent of the pharmaceutical industry PHRC N PAPIRUS) and is coordinated by one of the members of the leading consortium of HIBISCUS

MONOCHORIONIC MULTIPLE PREGNANCY

The article describes the concept of monochorionic multiple pregnancies, the relevance and epidemiology of the topic, as well as complications in pregnancy and delivery in monochorionic twins

FATHER OF BRITISH OBSTETRICS

The article highlights historic aspects of medical and research work of the British obstetrician of the XVIII century William Smelli