Risk of operative delivery for intrapartum fetal compromise in small-for-gestational-age fetuses at term: external validation of the IRIS algorithm.

OBJECTIVES: Small-for-gestational-age fetuses (SGA) are at high risk of intrapartum fetal compromise requiring operative delivery. In a recent study, we developed a model using a combination of three antenatal (gestational age at delivery, parity, cerebroplacental ratio) and three intrapartum (epidural use, labor induction and augmentation using oxytocin) variables for the prediction of operative delivery due to presumed fetal compromise in SGA fetuses - the Individual RIsk aSsessment (IRIS) prediction model. The aim of this study was to test the predictive accuracy of the IRIS prediction model in an external cohort of singleton pregnancies complicated by SGA. METHODS: This was an external validation study using a cohort of pregnancies from two tertiary referral centers in Spain and England. The inclusion criteria were singleton pregnancies diagnosed with an SGA fetus, defined as estimated fetal weight (EFW) below the 10th centile for gestational age at 36 weeks or beyond, which had fetal Doppler assessment and available data on their intrapartum care and pregnancy outcomes. The main outcome in this study was the operative delivery for presumed fetal compromise. External validation was performed using the coefficients obtained in the original development cohort. The predictive accuracies of models were investigated with receiver operating characteristics (ROC) curves. The Hosmer-Lemeshow test was used to test the goodness-of-fit of models and calibration plots were also obtained for visual assessment. A mobile application using the combined model algorithm was developed to facilitate clinical use. RESULTS: Four hundred twelve singleton pregnancies with an antenatal diagnosis of SGA were included in the study. The operative delivery rate was 22.8% (n = 94). The group which required operative delivery for presumed fetal compromise had significantly fewer multiparous women (19.1 versus 47.8%, p < 0.001 in the total study population; 19.0 versus 43.5 and 19.2 versus 49.6%, UK and Spain cohort, respectively), lower cerebroplacental ratio (CPR) multiples of median (MoM) (median: 0.77 versus 0.92, p < 0.001 in the total study population; 0.77 versus 0.92 and 0.77 versus 0.92, UK and Spain cohort, respectively), more inductions of labor (74.5 versus 60.1%, p = 0.010 in the total study population; 85.7 versus 77.2 and 71.2% and 53.1, UK and Spain cohort, respectively) and more use of oxytocin augmentation (57.4 versus 39.3%, p = 0.002 in the total study population; 19.0 versus 12.0 and 68.5 and 50.4%, UK and Spain cohort, respectively) compared to those who did not require operative delivery due to presumed fetal compromise. When the original antenatal model was applied to the present cohort, we observed moderate predictive accuracy (AUC: 0.70, 95% CI: 0.64-0.76), and no signs of poor fit (p = 0.464). The original combined model, when applied to the external cohort, had moderate predictive accuracy (AUC: 0.72, 95% CI: 0.67-0.77) and also no signs of poor fit (p = 0.268) without the need for refitting. A statistically significant increase in the predictive accuracy was not achieved via refitting of the combined model (AUC 0.76 versus 0.72, p = 0.060). CONCLUSIONS: Using our recently published model, the predictive accuracy for fetal compromise requiring operative delivery in term fetuses thought to be SGA was modest and showed no signs of poor fit in an external cohort. The IRIS tool for mobile devices has been developed to facilitate wide clinical use of this prediction model

Circulating irisin levels in functional hypothalamic amenorrhea: a new bone damage index? A pilot study.

Purpose: Patients with functional hypothalamic amenorrhea (FHA) could commonly have bone damage, often preceded by metabolic alterations due to a relative energy deficit state. To date, there are no markers capable of predicting osteopenia before it is manifested on DXA. Irisin is a myokine that promotes the differentiation of osteoblastic cells and appears to be inversely correlated with the incidence of bone fragility and fractures in postmenopausal women. The aim of this study was to measure irisin levels in FHA patients and to correlate it with bone density parameters. Methods: Thirty-two patients with FHA and 19 matched controls underwent the same clinical and laboratory evaluation. Results: Irisin and body mass index (BMI) were significantly lower in the case group than in healthy controls (2.03 ± 0.12 vs. 2.42 ± 0.09 p &lt; 0.05 and 19.43 ± 2.26 vs. 22.72 ± 0.67 p &lt; 0.05, respectively). Additionally, total body mass density (BMD g/cm2) was significantly lower in the case group than in the healthy controls (1.09 ± 0.08 vs. 1.14 ± 0.05, p &lt; 0.05), without signs of osteopenia. Conclusions: The FHA group showed lower irisin levels associated with significantly reduced BMD parameters that did not reach the severity of osteopenia. Therefore, we could speculate that irisin could predict DXA results in assessing modifications of body composition parameters. Future research is warranted to study these parameters in a larger population to confirm our results, so that irisin could be used as a predictor and screening method for bone deprivation. Furthermore, irisin is strictly related to energy metabolism and could be an indirect marker of nutritional status in FHA patients, identifying earlier states of energy deficit. Keywords: Amenorrhea; Body composition; Bone diseases; Energy metabolism; Osteoporosis

Does emigration by itself improve birth weight? Study in European newborns of Indo-Pakistan origin

Objective: Our aim was to evaluate the effect of emigration on fetal birth weight (BW) in a group of pregnant women coming from the Indian subcontinent. Methods: This was a retrospective study in a mixed population of pregnant women from the Indian subcontinent that either moved to Europe or stayed in their original countries. The influence of emigration along with several pregnancy characteristics: GA at delivery, fetal gender, maternal age, height, weight, body mass index (BMI) and parity on BW was evaluated by means of multivariable linear regression analysis. Results: According to European standards, babies born to Indo-Pakistan emigrants and babies born to women staying in the Indian subcontinent were similarly small (BW centile 30± 29 and 30.1 ± 28, p<0.68). Multivariable regression demonstrated that emigration by itself did not exert a direct influence on BW (p  = 0.27), being BMI and gestational age at delivery the true determinants of BW (p<0.0001). Conclusions: Maternal BMI is the most relevant parameter affecting fetal growth regardless of the place of residence

Hysterosalpingo-contrast-sonography (HyCoSy) in the assessment of tubal patency in endometriosis patients

Objective Tubal patency in women with endometriosis has traditionally been evaluated by laparoscopy. The aim of this study was to investigate the accuracy of hysterosalpingo-contrast-sonography (HyCoSy) in the assessment of tubal patency in these women. Study design A retrospective study was conducted at Physiopathology of Human Reproduction Unit. Infertile women who underwent HyCoSy and then a laparoscopy (dye test) within 6 months from the HyCoSy were included. Tubal patency was assessed by HyCoSy and the findings were compared with the results of laparoscopy, which was considered the gold standard for assessment of tubal patency. Sensitivity, specificity, positive and negative predictive values (PPV, NPV) and positive and negative likelihood ratios (Lh+, Lh-) were calculated including the 95% confidence interval (CI). Results A total of 1452 women underwent HyCoSy and 126 of them received a laparoscopy within 6 months from the HyCoSy. Of the 126 women, 42 (33.3%) had a diagnosis of pelvic endometriosis and 84 (66.7%) had no endometriosis. In the endometriosis population, HyCoSy showed a sensitivity, specificity, PPV, NPV, Lh+ and Lh- of 85% (95% CI 62-96), 93% (95% CI 82-97), 81% (95% CI 58-94), 94% (95% CI 84-98), 12.6 (95% CI 4.8-33) and 0.15 (95% CI 0.05-0.4) respectively. In the non-endometriosis group, HyCoSy showed a sensitivity, specificity, PPV, NPV, LR+ and LR- of 85% (95% CI 65-95), 93% (95% CI 87-96), 71% (95% CI 53-85), 97% (95% CI 92-99), 13.2 (95% CI 6.9-25) and 0.15 (95% CI 0.06-0.3) respectively. The diagnostic accuracy of HyCoSy was 91% in the endometriosis group and 92% in the non-endometriosis patients. Conclusions HyCoSy showed high accuracy in evaluating tubal patency in infertile non-endometriosis women and in those affected by endometriosis

Highly purified hMG versus recombinant FSH plus recombinant LH in intrauterine insemination cycles in women 6535 years: a RCT

Is the treatment with recombinant FSH (rFSH) plus recombinant LH (rLH) more effective than highly purified (HP)-hMG in terms of ongoing pregnancy rate (PR) in women 6535 years of age undergoing intrauterine insemination (IUI) cycles

Predictors of adverse perinatal outcome up to 34 weeks, a multivariable analysis study

The objective was to evaluate the best predictors of adverse perinatal outcome (APO) in foetuses examined up to 34 weeks and delivered by spontaneous or induced labour. This was a retrospective study of 129 pregnancies that underwent an ultrasound Doppler examination at 23–34 weeks and entered into labour within 30 days. Cerebroplacental ratio (CPR) and mean uterine artery pulsatility index (mUtA PI) were converted into multiples of the median (MoM) and estimated foetal weight (EFW) into centiles to adjust for gestational age (GA). Sonographic and clinical parameters were evaluated using logistic regression analysis. The multivariable model for the prediction of APO presented a notable accuracy: Detection rate (DR) was 39.5% for a false positive rate (FPR) of 5% and 56.8% for a FPR of 10%, AUC 0.82, p < .0001. Significant predictors were GA, EFW centile, and CPR MoM, but not mUtA PI MoM. Moreover, the type of labour onset did not exert any influence on APO. In conclusion, up to 34 weeks, prediction of APO after spontaneous or induced labour may be done measuring CPR and EFW.IMPACT STATEMENT What is already known on this subject? Earlier in pregnancy, foetal growth restriction is caused by placental disease causing progressive hemodynamic changes. These changes have been exhaustively described. Conversely, information about the best predictors of adverse outcome is scarce. What do the results of this study add? The findings of this study show that prior to 34 weeks and up to 1 month before labour, labour outcome might be predicted by gestational age, foetal cerebroplacental ratio (CPR) and estimated foetal weight (EFW). What are the implications of these findings for clinical practice and/or further research? If CPR behaves as a good marker of outcome not only at the end of pregnancy but also earlier in gestation, it might be interrogated along with EFW in foetuses attempting vaginal delivery to determine the risk of adverse outcome

The Performance of Serum Antimullerian Hormone and Antral Follicle Count in Predicting the Ovarian Response in Intrauterine Insemination

The Performance of Serum Antimullerian Hormone and Antral Follicle Count in Predicting the Ovarian Response in Intrauterine Inseminatio

Narrative Medicine: A Digital Diary in the Management of Bone and Soft Tissue Sarcoma Patients. Preliminary Results of a Multidisciplinary Pilot Study

Background. Guidelines for the implementation of narrative medicine in clinical practice exist; however, in Italy, no standard methodology is currently available for the management of oncological patients. Since 2017, at the “Regina Elena” National Cancer Institute, studies using “digital narrative diaries” (DNMLAB platform) have been carried out; this article focuses on a pilot, uncontrolled, real-life study aiming to evaluate the utility of DNM integrated with the care pathway of patients with bone and limb soft tissue sarcomas. Methods. Adult patients completed the diary during treatment or follow-up by writing their narrative guided by a set of narrative prompts. The endpoints were: (a) patients’ opinions about therapeutic alliance, awareness, and coping ability; (b) healthcare professionals’ (HCPs’) opinions about communication, therapeutic alliance, and information collection. Open- and closed-ended questions (Likert score: 1–5) were used to assess the items. Results. At the interim analysis of data from seven patients and five HCPs, DNM was shown to improve: (a) the expression of patients’ point of view, the perception of effective taking charge, disease awareness, and self-empowerment (score: 4.8/5); (b) patients’ communication, relationships, and illness knowledge (score: 4.6–4.8/5). Conclusions. The preliminary results supported the need to integrate patients’ narratives with clinical data and encourage further research

Melatonin Treatment May Be Able to Restore Menstrual Cyclicity in Women With PCOS: A Pilot Study

The objective of the study was to investigate the effects of 6 months of melatonin administration on clinical, endocrine, and metabolic features of women affected by polycystic ovary syndrome (PCOS). This is a prospective cohort study including 40 normal-weight women with PCOS between January and September 2016, enrolled in an academic research environment. Ultrasonographic pelvic examinations, hirsutism score evaluation, hormonal profile assays, oral glucose tolerance test, and lipid profile at baseline and after 6 months of melatonin administration were performed. Melatonin treatment significantly decreased androgens levels (free androgen index: P &lt; .05; testosterone: P &lt; .01; 17 hydroxyprogesterone: P &lt; .01). Follicle-stimulating hormone levels significantly raised ( P &lt; .01), and anti-Mullerian hormone serum levels significantly dropped after 6 months of melatonin treatment ( P &lt; .01). No significant changes occurred in glucoinsulinemic and lipid parameters after treatment except a significant decrease of low-density lipoprotein cholesterol. Almost 95% of participants experienced an amelioration of menstrual cycles. Until now, only few data have been published about the role of melatonin in women with PCOS. This is the first study focused on the effects of exogenous oral melatonin administration on the clinical, endocrine, and metabolic characteristics of patients with PCOS. After 6 months of treatment, melatonin seems to improve menstrual irregularities and biochemical hyperandrogenism in women with PCOS through a direct, insulin-independent effect on the ovary. Based on our results, melatonin could be considered a potential future therapeutic agent for women affected by PCO

Anti-M\ufcllerian hormone concentrations and antral follicle counts for the prediction of pregnancy outcomes after intrauterine insemination

Objective To evaluate anti-M\ufcllerian hormone (AMH) concentrations and antral follicle counts (AFCs) in the prediction of pregnancy outcomes after controlled ovarian stimulation among women undergoing intrauterine insemination. Methods A retrospective study included women with unexplained infertility aged 41 years or younger who attended a fertility clinic in Italy between December 2009 and May 2014. Ovarian stimulation was achieved with recombinant follicle-stimulating hormone or highly purified human menopausal gonadotropin. Receiver operating characteristic curves were generated to predict ongoing pregnancy. The primary outcome was the association between AMH/AFC and ongoing pregnancy, and was assessed by logistic regression. Results Overall, 276 women were included, of whom 43 (15.6%) achieved ongoing pregnancy. Multivariate analysis showed that women with a serum day-3 concentration of AMH higher than 2.3 ng/mL were more likely to have ongoing pregnancy than were those with a concentration lower than 2.3 ng/mL (odds ratio 5.84, 95% confidence interval 2.38-14.31; P < 0.001). No associations were recorded for AFCs. Conclusion AMH should be used to predict the pregnancy outcome of intrauterine insemination