Cervical cerclage in twin pregnancies

Purpose To evaluate the outcomes of cervical cerclage (CC) in twin pregnancies. Methods Retrospective analysis of twin pregnancies undergoing CC between January 2001 and December 2009 at our Institution. CC was offered in case of a cervical length measurement B20 mm (ultrasound-indicated CC) or in case of cervical dilatation with membranes at or beyond the external cervical os (physical examination-indicated CC). Cervicovaginal and rectal swabs were obtained preoperatively. Perioperative antibiotics and tocolysis were administered. Results There were 28 cases of ultrasound-indicated and 14 of physical examination-indicated CC. Positive swab cultures were observed in 21 % of cases. The incidence of preterm delivery\34 weeks was 32 % [95 % confidence interval (CI) 16–52 %] and 50 % (95 % CI 23–77 %) in the ultrasound-indicated and physical examination-indicated CC group, respectively. The incidence of premature rupture of membranes \34 weeks was 21 % (95 % CI 8–41 %) and 29 % (95 % CI 8–58 %) in the ultrasoundindicated and physical examination-indicated CC group, respectively. Perinatal survival was 96 % (95 % CI 88–100 %) in the ultrasound-indicated CC group, and 86 % (95 % CI 67–96 %) in the physical examinationindicated CC group.Conclusions We showed a high-risk of preterm delivery in both groups, but with a high overall perinatal survival. Our data stress the importance of re-evaluating the efficacy of CC in twin pregnancies by properly designed clinical trials, particularly if it is physical examination indicated

COVID-19 in pregnancy: Italian experience

It has been happened a significant increase of critically severe pneumonia cases in northern Italy by the end of February 2020 with consequent overcrowding of intensive care units (ICU). Due to the COVID-19 fast outbreak, a strict quarantine was imposed in the areas with the higher number of affected cases. The WHO declared COVID-19 a pandemic, with over 50 countries on the 10th of March. By the 10th of March Italy was the second most affected country after China, with more than nine thousand confirmed cases and more than 460 deaths, becoming the most affected in April

Hyperechoic amniotic membranes in patients with preterm premature rupture of membranes (p-PROM) and pregnancy outcome

Objectives The early identification of women with preterm premature rupture of membranes (p-PROM) who are at higher risk of imminent delivery remains challenging. The aim of our study was to evaluate if an increased echogenicity of the amniotic membranes may represent a sonographic marker of impending delivery in women with p-PROM. Methods This was a prospective study including women with singleton pregnancies and diagnosis of p-PROM between 22 and 37 gestational weeks. A sonographic examination was performed within 24h from the hospital admission and the appearance of the amniotic membranes close to the internal os was specifically evaluated. The membranes were defined as hyperechoic when their echogenicity was similar to that of the fetal bones or normoechoic in the other cases. The primary aim of the study was to compare the admission to spontaneous onset of labor interval and the pregnancy outcome between the cases of p-PROM with and without hyperechoic membranes. Results Overall, 45 women fulfilled the inclusion criteria with similar characteristics at admission. In women with hyperechoic membranes, the admission to spontaneous onset of labor interval was significantly shorter (11.5 [5.3-25.0] vs. 3.0 [1.5-9.0] p=0.04) compared to women with normo-echoic membranes. At binomial logistic regression after adjustment for GA at hospital admission, the presence of hyperechoic membranes was found as the only independent predictor of spontaneous onset of labor≤72h (aOR: 6.1; 95% CI: 1.0-36.9) Conclusions The presence of hyperechoic membranes is associated with a 6-fold higher incidence of spontaneous onset of labor within 72h independently from the gestational age at p-PROM

Intrapartum fetal heart rate between 150 and 160 bpm at or after 40 weeks and labor outcome

INTRODUCTION: A baseline fetal heart rate between 110 and 160 bpm is considered normal. However among normal fetuses the average baseline heart rate has been shown to diminish progressively and the 90th centile of the fetal heart rate at 40 weeks of gestation has been consistently found at around 150 bpm. The aim of our study was to assess the labor and neonatal outcome of fetuses at 40 gestational weeks or beyond, whose intrapartum baseline fetal heart rate was between 150 and 160 bpm.MATERIAL AND METHODS: Retrospective cohort study including singleton pregnancies with spontaneous onset of labor, gestational age between 40+0 and 42+0 , category I CTG trace according to the FIGO guidelines 2015 with baseline fetal heart rate between 110-160 bpm during the first 60 minutes of the active labor. Exclusion criteria were maternal hyperpyrexia at admission, fetal arrhythmias, maternal tachycardia (>110 bpm) and uterine tachysystole (>5 contractions/10 minutes). The following outcomes were compared between fetuses with a baseline ranging between 110-149 bpm and those with a baseline ranging between 150-160 bpm: incidence of meconium-stained amniotic fluid, intrapartum hyperpyrexia, mode of delivery, Apgar at 5th minute<7, arterial pH<7.1 and Neonatal Intensive Care Unit admission, incidence of a composite adverse neonatal outcome.RESULTS: One-thousand and four CTG traces were included in the analysis, 860 in Group 110-149 bpm and 144 in Group 150-160. Group 150-160 bpm had a significantly higher incidence of meconium-stained amniotic fluid (OR 2.6; 95%CI 1.8-3.8), maternal intrapartum hyperpyrexia (OR 4.7; 95%CI 1.1-14.6), urgent/emergent cesarean section for suspected fetal distress (OR 13.4; 95% CI 3.3-54.3), Apgar <7 at 5th min (OR 9.13; 95%CI 1.5-55.1) and neonatal acidemia (OR 3.5; 95%CI 1.5-55.1). Logistic regression including adjusted for potential confounders showed that fetal heart rate between 150-160 bpm is an independent predictor of meconium-stained amniotic fluid (aOR 2.2; 95% CI 1.5-3.3), cesarean section during labor for fetal distress (aOR 10.7; 95%CI 2.9-44.6), neonatal acidemia (aOR 2.6; 95%CI 1.1-6.7) and adverse composite neonatal outcome (aOR 2.6; 95% CI 1.2-5.6).CONCLUSIONS: In fetuses at 40 weeks or beyond, an intrapartum fetal heart rate baseline ranging between 150 and 160 bpm seems associated with a higher incidence of labor complications

Maternal Left Ventricular Function in Uncomplicated Twin Pregnancies: A Speckle-Tracking Imaging Longitudinal Study

Objective: The knowledge of maternal cardiovascular hemodynamic adaptation in twin pregnancies is incomplete. We aimed to longitudinally investigate maternal left ventricular (LV) function in uncomplicated twin pregnancies. Methods: 30 healthy and uncomplicated twin pregnant women and 30 controls with normal singleton pregnancies were prospectively enrolled to undergo transthoracic echocardiography at 10–15 week’s gestation (w) (T1), 19–26 w (T2) and 30–38 w (T3). LV dimensions and volumes, as well as LV ejection fraction (LVEF), mass (LVM) and diastolic parameters (at transmitral pulsed wave Doppler and mitral annular plane tissue Doppler), were calculated. Speckle-tracking imaging was also applied to evaluate LV global longitudinal (GLS), radial and circumferential 2D strains. Results: During twin pregnancy, maternal LV dimensions, volumes and LVM had an increasing trend from T1 to T3, similar to singletons, while LVEF remained stable. There was LV remodeling/hypertrophy in 50% of women at T2 and T3 in both groups. Diastolic function had a worsening trend from T1 to T3 with no differences between twins and singletons, except for higher LV filling pressure (i.e., E/E′) at T2 in twins. Two-dimensional strains did not vary during gestation in either group, except for a linear trend to increase (i.e., worsen) GLS in singletons. Radial and circumferential 2D strains were impaired in about half of the women at each trimester, while GLS was altered in one-fourth/one-third of them in both groups. Conclusion: Maternal LV geometry, dimensions and function are significantly impaired during twin pregnancies, in particular in the second half of gestation, with no significant differences compared to singletons

Hemodynamic findings in normotensive women with small for gestational age and growth restricted fetuses

INTRODUCTION: Fetal growth restriction (FGR) in most instances results as a consequence of primary placental dysfunction due to inadequate trophoblastic invasion. Maternal cardiac maladaptation to pregnancy has been proposed as a possible determinant of placental insufficiency and impaired fetal growth. This study aimed to compare the maternal hemodynamic parameters between normotensive women with small-for-gestational age (SGA) and FGR fetuses and to evaluate their correlation with neonatal outcome.MATERIAL AND METHODS: observational cohort study including singleton pregnancies referred to our tertiary care center due to fetal smallness. At the time of diagnosis, fetuses were classified as SGA or FGR according to the Delphi consensus criteria and pregnant women underwent hemodynamic assessment by using cardiac output monitor (USCOM 1A Ltd). A group of women with singleton uncomplicated pregnancies ≥35 weeks of gestation were recruited as controls. Cardiac output, systemic vascular resistance, stroke volume and heart rate were measured and compared among the three groups (controls vs. FGR vs. SGA). The correlation between antenatal findings and neonatal outcome was also evaluated by multivariate logistic regression analysis.RESULTS: 51 women with fetal smallness were assessed at 34.8±2.6 weeks. SGA and FGR were diagnosed in 22 and 29 cases, respectively. The control group included 61 women assessed at 36.5±0.8 weeks of gestation. Women with FGR had a lower cardiac output -Z score (respectively, -1.3±1.2 vs. -0.4±0.8 vs. -0.2±1.0; p<.001) and a higher systemic vascular resistance Z-score compared with both SGA and controls (respectively, 1.2±1.2 vs. 0.2±1.1 vs. -0.02±1.2; p<.001), while no difference in the hemodynamic parameters was found between women with SGA and controls. The incidence of NICU admission did not differ between SGA and FGR fetuses (18.2% vs 41.4%; p=0.13), however FGR had a longer hospitalization compared to SGA fetuses (14.2±17.7 vs. 4.5±1.6 days; p=0.02). Multivariate analysis showed that the cardiac output Z-score at diagnosis (p=0.012) and the birthweight Z-Score (p= 0.007) were independent predictors of the length of neonatal hospitalization.CONCLUSIONS: Different maternal hemodynamic profiles characterize women with SGA or FGR fetuses. Furthermore, a negative correlation was found between the maternal cardiac output and the length of neonatal hospitalization

Reduced short-term variation following antenatal administration of betamethasone: Is reduced fetal size a predisposing factor?

OBJECTIVE: To assess the association between fetal size and the incidence of reduced short-term variability (STV) following bethametasone administration for fetal lung maturity. STUDY DESIGN: This was a retrospective, multicenter, cohort study conducted in two Tertiary University Units. Only uncomplicated singleton pregnancies admitted for threatened preterm labor between 26 and 34 weeks and submitted to betamethasone for fetal lung maturity were included. Delivery occurring within 72h from betamethasone administration represented criteria for exclusion. Computerized cardiotocography was carried out on a daily basis. Cases were identified by persistently reduced STV, defined as <5th percentile for gestational age and lasting for at least 72h after the first dose of betamethasone. The primary outcome was estimated fetal weight (EFW) at ultrasound in fetuses with normal and in those with persistently reduced STV. Pregnancy outcomes were also evaluated. RESULTS: Persistently reduced STV occurred in 33/405 of the included patients (8.1%). Compared to women with normal STV, those with persistently reduced STV had significantly lower EFW (1472±435 vs 1812±532g, p 0.04), lower birthweight (2353±635 vs 2857±796g, p<0.01) and earlier gestational age at delivery (35.1±4.2 vs 37.3±2.4weeks, p<0.01), whereas all the other variables including gestational age on admission were comparable. CONCLUSIONS: Reduced STV following maternal betamethasone administration among appropriately grown fetuses seems to correlate with lower fetal size. Furthermore, fetuses with such abnormal response to steroids seem to carry a higher risk of perinatal complications, including lower birthweight and earlier gestational age at delivery

An update on maternal hydration strategies for amniotic fluid improvement in isolated oligohydramnios and normohydramnios: Evidence from a systematic review of literature and meta-analysis

open8Objective Several trials aimed at evaluating the efficacy of maternal hydration (MH) in increasing amniotic-fluid-volume (AFV) in pregnancies with isolated oligohydramnios or normohydramnos have been conducted. Unfortunately, no evidences support this intervention in routineclinical- practice. The aim of this systematic-literature-review and meta-analysis was to collect all data regarding proposed strategies and their efficacy in relation to each clinical condition for which MH-therapy was performed with the aim of increasing amniotic-fluid (AF) and improving perinatal outcomes. Materials and Methods A systematic literature search was conducted in electronic-database MEDLINE, EMBASE, ScienceDirect and the Cochrane-Library in the time interval between 1991 and 2014. Following the identification of eligible trials, we estimated the methodological quality of each study (using QADAS-2) and clustered patients according to the following outcome measures: route of administration (oral versus intravenous versus combined), total daily dose of fluids administered (2000), duration of hydration therapy: (1 day, >1 day but 1 week), type of fluid administered (isotonic versus hypotonic versus combination). Results In isolated-oligohydramnios (IO), maternal oral hydration is more effective than intravenous hydration and hypotonic solutions superior to isotonic solutions. The improvement in AFV appears to be time-dependent rather than daily-dose dependent. Regarding normohydramnios pregnancies, all strategies seem equivalent though the administration of hypotonicfluid appears to have a slightly greater effect than isotonic-fluid. Regarding perinatal outcomes, data is fragmentary and heterogeneous and does not allow us to define the real clinical utility of MH. Conclusions Available data suggests that MH may be a safe, well-tolerated and useful strategy to improve AFV especially in cases of IO. In view of the numerous obstetric situations in which a reduced AFV may pose a threat, particularly to the fetus, the possibility of increasing AFV with a simple and inexpensive practice like MH-therapy may have potential clinical applications. Considering the various strategies of maternal hydration implemented in the treatment of IO, better results were observed when treatment was based on a combination of intravenous (for a period of 1 day) and oral (for a period of at least 14 days) hypotonic fluids (≥2000ml).openGizzo, Salvatore; Noventa, Marco; Vitagliano, Amerigo; Dall'Asta, Andrea; D'Antona, Donato; Aldrich, Clive J.; Quaranta, Michela; Frusca, Tiziana; Patrelli, Tito SilvioGizzo, Salvatore; Noventa, Marco; Vitagliano, Amerigo; Dall'Asta, Andrea; D'Antona, Donato; Aldrich, Clive J.; Quaranta, Michela; Frusca, Tiziana; Patrelli, Tito Silvi

Randomised Italian Sonography for Occiput POSition Trial Ante Vacuum (R.I.S.POS.T.A.)

Objective: To assess whether sonographic diagnosis of fetal head position before instrumental vaginal delivery can reduce the risk of failed vacuum extraction and improve delivery outcome. Methods: Randomised Italian Sonography for occiput POSition Trial Ante vacuum (R.I.S.POS.T.A.) is a randomized controlled trial of term (37 + 0 to 41 + 6 weeks' gestation) singleton pregnancies with cephalic presentation requiring instrumental delivery by vacuum extraction, which was conducted between April 2014 and June 2017 and involved 13 Italian maternity hospitals. Patients were randomized to assessment of fetal head position before attempted instrumental delivery by either vaginal examination (VE) alone or VE plus transabdominal sonography (TAS). Primary outcome was incidence of emergency Cesarean section due to failed vacuum extraction. A sample size of 653 women per group was planned to compare the primary outcome between the two groups. The sample size estimation was based on the hypothesis that the risk of failed vacuum delivery in the VE group would be 5% and that ultrasound assessment of fetal position prior to vacuum extraction would decrease this risk to 2%. Results: On interim analysis, the trial was stopped for futility. During this period, 222 women were randomized and 221 were included in the final data analysis, of whom 132 (59.7%) were randomized to evaluation of fetal head position by VE only and 89 (40.3%) to assessment by VE plus TAS prior to vacuum extraction. No significant differences were observed between the two groups with respect to incidence of emergency Cesarean section due to failed instrumental delivery and other maternal and fetal outcomes. Women randomized to assessment by VE plus TAS showed higher incidence of non-occiput anterior position of the fetal head at randomization and lower incidence of incorrect diagnosis of occiput position compared with women undergoing assessment by VE alone. A higher rate of episiotomy was noted in the women undergoing both VE and TAS compared with those in the VE-only group. Conclusions: Our prematurely discontinued randomized controlled trial did not demonstrate any benefit in terms of reduced risk of failed instrumental delivery or maternal and fetal morbidity in women undergoing sonographic assessment of fetal head position prior to vacuum extraction. Copyright \ua9 2018 ISUOG. Published by John Wiley & Sons Ltd