Endometrial scratching during hysteroscopy in women undergoing in vitro fertilization: a systematic review and meta-analysis

Objective

Endometrial scratching (ES) during hysteroscopy before embryotransfer (ET) remains doubtable on whether it benefits the reproductive outcomes. The optimal technique is not clear and repeated implantation failure as a challenging field in in vitro fertilization (IVF) seems to be the springboard for clinicians to test its effectiveness.

Methods

Medline, PMC, ScienceDirect, Scopus, CENTRAL, Google Scholar were searched from their inception up to April 2023 for studies to evaluate the effectiveness of adding endometrial scratching during hysteroscopy before ET.

Results

The initial search yielded 959 references, while 12 eligible studies were included in the analyses, involving 2,213 patients. We found that hysteroscopy and concurrent ES before ET resulted in a statistically significant improvement in clinical pregnancy rate (CPR) [RR = 1.50, (95% CI 1.30-1.74), p < 0.0001] and live birth rate (LBR) [RR = 1.67, (95% CI 1.30-2.15), p < 0.0001] with no statistically significant difference on miscarriage rate [RR = 0.80 (95% CI 0.52-1.22), p = 0.30].

Conclusion

Our meta-analysis suggests that hysteroscopy with concurrent ES may be offered in IVF before ET as a potentially improving manipulation. Future randomized trials comparing different patient groups would also provide more precise data on that issue, to clarify specific criteria in the selection of patients.

Systematic Review Registration

PROSPERO (CRD42023414117).

Selective feticide reverses intrahepatic cholestasis of pregnancy in twins discordant for growth: A case report

Twin gestations are associated with an increased risk of intrahepatic cholestasis in pregnancy (ICP), probably attributed to the elevated pregnancy hormones. We report a case of a dichorionic diamniotic twin pregnancy, at the third trimester, complicated with ICP and severe, selective fetal growth restriction (sFGR). A 32-year-old primiparous woman with a dichorionic, diamniotic twin gestation conceived via in vitro fertilization (IVF) presented with pruritus at the maternity care unit at 26+4 weeks of pregnancy. Following a detailed assessment, she was diagnosed with severe sFGR and ICP. During her hospitalization, selective feticide of the FGR fetus was decided and a remarkable improvement in the symptoms and the laboratory findings of ICP was noticed. The incidence of ICP is reported to be higher in twin pregnancies, especially those conceived via IVF, compared with singletons. The optimal timing of delivery and management of twin pregnancies complicated with ICP remain unclear. In our case, selective reduction of the FGR fetus led to the resolution of ICP.

Cervical Cerclage: A Comprehensive Review of Major Guidelines

Importance

Cervical cerclage (CC) represents one of the few effective measures currently available for the prevention of preterm delivery caused by cervical insufficiency, thus contributing in the reduction of neonatal morbidity and mortality rates.

Objective

The aim of this study was to review and compare the most recently published major guidelines on the indications, contraindications, techniques, and timing of placing and removal of CC.

Evidence Acquisition

A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC), and the International Federation of Gynecology and Obstetrics (FIGO) on CC was carried out.

Results

There is a consensus among the reviewed guidelines regarding the recommended techniques, the indications for rescue CC, the contraindications, as well as the optimal timing of CC placement and removal. All medical societies also agree that ultrasound-indicated CC is justified in women with history of prior spontaneous PTD or mid-trimester miscarriage and a short cervical length detected on ultrasound. In addition, after CC, serial sonographic measurement of the cervical length, bed rest, and routine use of antibiotics, tocolysis, and progesterone are unanimously discouraged. In case of established preterm labor, CC should be removed, according to ACOG, RCOG, and SOGC. Furthermore, RCOG and SOGC agree on the prerequisites that should be met before attempting CC. These 2 guidelines along with FIGO recommend history-indicated CC for women with 3 or more previous preterm deliveries and/or second trimester pregnancy miscarriages, whereas the ACOG suggests the use of CC in singleton pregnancies with 1 or more previous second trimester miscarriages related to painless cervical dilation or prior CC due to painless cervical dilation in the second trimester. The role of amniocentesis in ruling out intra-amniotic infection before rescue CC remains a matter of debate.

Conclusions

Cervical cerclage is an obstetric intervention used to prevent miscarriage and preterm delivery in women considered as high-risk for these common pregnancy complications. The development of universal international practice protocols for the placement of CC seems of paramount importance and will hopefully improve the outcomes of such pregnancies.

Fetal and neonatal alloimmune thrombocytopenia: A rare case report of prenatal treatment

Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a rare but serious condition. The first-line antenatal management of FNAIT consists of weekly IVIG with or without corticosteroids, ideally starting before 16 weeks of gestation.

Diagnosis and Management of Neonatal Hypoglycemia: A Comprehensive Review of Guidelines

Hypoglycemia represents one of the most frequent metabolic disturbances of the neonate, associated with increased morbidity and mortality, especially if left untreated or diagnosed after the establishment of brain damage. The aim of this study was to review and compare the recommendations from the most recently published influential guidelines on the diagnosis, screening, prevention and management of this common neonatal complication. Therefore, a descriptive review of the guidelines from the American Academy of Pediatrics (AAP), the British Association of Perinatal Medicine (BAPM), the European Foundation for the Care of the Newborn Infants (EFCNI), the Queensland Clinical Guidelines-Australia (AUS), the Canadian Pediatric Society (CPS) and the Pediatric Endocrine Society (PES) on neonatal hypoglycemia was carried out. There is a consensus among the reviewed guidelines on the risk factors, the clinical signs and symptoms of NH, and the main preventive strategies. Additionally, the importance of early recognition of at-risk infants, timely identification of NH and prompt initiation of treatment in optimizing the outcomes of hypoglycemic neonates are universally highlighted. All medical societies, except PES, recommend screening for NH in asymptomatic high-risk and symptomatic newborn infants, but they do not provide consistent screening approaches. Moreover, the reviewed guidelines point out that the diagnosis of NH should be confirmed by laboratory methods of BGL measurement, although treatment should not be delayed until the results become available. The definition of NH lacks uniformity and it is generally agreed that a single BG value cannot accurately define this clinical entity. Therefore, all medical societies support the use of operational thresholds for the management of NH, although discrepancies exist regarding the recommended cut-off values, the optimal treatment and surveillance strategies of both symptomatic and asymptomatic hypoglycemic neonates as well as the treatment targets. Over the past several decades, ΝH has remained an issue of keen debate as it is a preventable cause of brain injury and neurodevelopmental impairment; however, there is no clear definition or consistent treatment policies. Thus, the establishment of specific diagnostic criteria and uniform protocols for the management of this common biochemical disorder is of paramount importance as it will hopefully allow for the early identification of infants at risk, the establishment of efficient preventive measures, the optimal treatment in the first hours of a neonate's life and, subsequently, the improvement of neonatal outcomes.

Incidence and Risk Factors for Postpartum Hemorrhage: A Case-Control Study in a Tertiary Hospital in Greece

Background and Objectives: Postpartum hemorrhage (PPH) is an obstetrical emergency and although the mortality rate from PPH has decreased, it is still considered a challenge in obstetrics. This study aimed to estimate the rate of primary PPH, as well as to investigate the potential risk factors and management options. Material and methods: This was a retrospective case-control study of all cases with PPH (blood loss > 500 mL, irrespective of the mode of delivery) managed in the Third Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Greece, from 2015 to 2021. The ratio of cases to controls was estimated to be 1:1. The chi-squared test was used to examine if there was any relationship between several variables and PPH, while subgroup multivariate logistic regression analyses of certain causes of PPH were also conducted. Results: During the study period, from a total of 8545 births, 219 (2.5%) pregnancies were complicated with PPH. A maternal age > 35 years (OR: 2.172; 95% CI: 1.206-3.912; p = 0.010), preterm delivery (<37 weeks) (OR: 5.090; 95% CI: 2.869-9.030; p < 0.001) and parity (OR: 1.701; 95% CI: 1.164-2.487; p = 0.006) were identified as risk factors for PPH. Uterine atony was the main cause of PPH in 54.8% of the women, followed by placental retention in 30.5% of the sample. Regarding management, 57.9% (n = 127) of the women received uterotonic medication, while in 7.3% (n = 16), a cesarean hysterectomy was performed to control PPH. Preterm delivery (OR: 2.162; 95% CI: 1.138-4.106; p = 0.019) and delivery via a cesarean section (OR: 4.279; 95% CI: 1.921-9.531; p < 0.001) were associated with a higher need for multiple treatment modalities. Prematurity (OR: 8.695; 95% CI: 2.324-32.527; p = 0.001) was identified as an independent predictor for an obstetric hysterectomy. From the retrospective analysis of the births complicated by PPH, no maternal death was identified. Conclusions: Most of the cases complicated with PPH were managed with uterotonic medication. An advanced maternal age, prematurity and multiparity had a significant impact on the occurrence of PPH. More research is needed on the risk factors of PPH, while the establishment of validated predictive models would be of value.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Prenatal Diagnosis of Isolated Single Umbilical Artery: Incidence, Risk Factors and Impact on Pregnancy Outcomes

Objectives: To assess the incidence of prenatally diagnosed isolated single umbilical artery (iSUA) and its impact on major pregnancy outcomes, as well as to investigate potential risk factors. Materials and methods: A prospective study of singleton pregnancies, undergoing routine anomaly scans at 20⁺⁰-24⁺⁰ weeks of gestation, was carried out from 2018 to 2022. The effect of sonographically detected iSUA on small-for-gestational-age neonates (SGA) and preterm delivery (PTD) was evaluated using parameterized Student's t-test, nonparametric Mann-Whitney U test and the chi-square test. Multivariable logistic regression models were implemented to assess the independent association between iSUA and the main outcomes, as well as with potential risk factors, while adjusting for specific confounders. Results: The study population included 6528 singleton pregnancies and the incidence of prenatally diagnosed iSUA was 1.3%. Prenatally diagnosed iSUA had a statistically significant association with both SGA neonates (aOR: 1.909; 95% CI: 1.152-3.163) and PTD (aOR: 1.903; 95% CI: 1.035-3.498), while no association was identified between this sonographic finding and preeclampsia. With regard to risk factors, conception via assisted reproductive technology (ART) was associated with increased risk of iSUA (aOR: 2.234; 95% CI: 1.104-4.523), while no other independent predictor for the development of this anatomical variation was identified. Conclusions: Prenatally diagnosed iSUA seems to be associated with a higher incidence of SGA and PTD and is more common in pregnancies following ART, which constitutes a novel finding.

Towards an Explainable AI-Based Tool to Predict Preterm Birth

Preterm birth (PTB) is defined as delivery occurring before 37 weeks of gestation. In this paper, Artificial Intelligence (AI)-based predictive models are adapted to accurately estimate the probability of PTB. In doing so, pregnant women' objective results and variables extracted from the screening procedure in combination with demographics, medical history, social history, and other medical data are used. A dataset consisting of 375 pregnant women is used and a number of alternative Machine Learning (ML) algorithms are applied to predict PTB. The ensemble voting model produced the best results across all performance metrics with an area under the curve (ROC-AUC) of approximately 0.84 and a precision-recall curve (PR-AUC) of approximately 0.73. An attempt to provide clinicians with an explanation of the prediction is performed to increase trustworthiness.

Investigation and Management of Recurrent Pregnancy Loss: A Comprehensive Review of Guidelines

Importance

Recurrent pregnancy loss (RPL) is one of the most frustrating clinical entities in reproductive medicine requiring not only diagnostic investigation and therapeutic intervention, but also evaluation of the risk for recurrence.

Objective

The aim of this study was to review and compare the most recently published major guidelines on investigation and management of RPL.

Evidence Acquisition

A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the European Society of Human Reproduction and Embryology, the American Society for Reproductive Medicine, the French College of Gynecologists and Obstetricians, and the German, Austrian, and Swiss Society of Gynecology and Obstetrics on RPL was carried out.

Results

There is consensus among the reviewed guidelines that the mainstays of RPL investigation are a detailed personal history and screening for antiphospholipid syndrome and anatomical abnormalities of the uterus. In contrast, inherited thrombophilias, vaginal infections, and immunological and male factors of infertility are not recommended as part of a routine RPL investigation. Several differences exist regarding the necessity of the cytogenetic analysis of the products of conception, parental peripheral blood karyotyping, ovarian reserve testing, screening for thyroid disorders, diabetes or hyperhomocysteinemia, measurement of prolactin levels, and performing endometrial biopsy. Regarding the management of RPL, low-dose aspirin plus heparin is indicated for the treatment of antiphospholipid syndrome and levothyroxine for overt hypothyroidism. Genetic counseling is required in case of abnormal parental karyotype. The Royal College of Obstetricians and Gynaecologists, the European Society of Human Reproduction and Embryology, and the French College of Gynecologists and Obstetricians guidelines provide recommendations that are similar on the management of cervical insufficiency based on the previous reproductive history. However, there is no common pathway regarding the management of subclinical hypothyroidism and the surgical repair of congenital and acquired uterine anomalies. Use of heparin for inherited thrombophilias and immunotherapy and anticoagulants for unexplained RPL are not recommended, although progesterone supplementation is suggested by the American Society for Reproductive Medicine and the German, Austrian, and Swiss Society of Gynecology and Obstetrics.

Conclusions

Recurrent pregnancy loss is a devastating condition for couples. Thus, it seems of paramount importance to develop consistent international practice protocols for cost-effective investigation and management of this early pregnancy complication, with the aim to improve live birth rates.

Hysteroscopic Identification of Intrauterine Pathology in Oocyte Donation Cycles: A Retrospective Study

BACKGROUND

Hysteroscopy remains the gold standard for the diagnosis and treatment of intracavitary uterine anomalies. As for recipients where oocyte donation is mandatory, accurate evaluation of previously missed intrauterine pathology may be an important step to optimize implantation process. The aim of this study was to hysteroscopically assess the incidence of unidentified intrauterine pathology prior to embryo transfer in an oocyte recipient population.

METHODS

A retrospective descriptive study was conducted between 2013 and 2022 at Assisting Nature In Vitro Fertilization (IVF) Centre in Thessaloniki, Greece. The study population consisted of oocyte recipient women who underwent hysteroscopy one-three months before embryo transfer. Furthermore, oocyte recipients after repeated implantation failure were investigated as a subgroup. Any identified pathology was treated accordingly.

RESULTS

In total, 180 women underwent diagnostic hysteroscopy prior to embryo transfer with donor oocytes. The mean maternal age at the time of intervention was 38.9 (+5.2) years, while the mean duration of infertility was 6.03 (+1.23) years. Additionally, 21.7% (n=39) of the study population had abnormal hysteroscopic findings. In particular, congenital uterine anomalies (U1a: 1.1% {n=2}, U2a: 5.6% {n=10}, U2b: 2.2% {n=4}) and polyps (n=16) were the main findings in the sample population. Furthermore, 2.8% (n=5) had submucous fibroids and 1.1% (n=2) were diagnosed with intrauterine adhesions. Notably, in recipients after repeated implantation failure intrauterine pathology rates were even higher (39.5%).

CONCLUSIONS

Oocyte recipients and especially those with repeated implantation failures probably have high rates of previously undiagnosed intrauterine pathology so, hysteroscopy would be justified in these subfertile populations.

Sepsis in Pregnancy and the Puerperium: A Comparative Review of Major Guidelines

Introduction

Sepsis is one of the leading causes of maternal morbidity and mortality worldwide and a major public health concern, often associated with delayed diagnosis, suboptimal management, and poor perinatal outcomes.

Objectives

The aim of this study was to review and compare the most recently published influential guidelines on the prevention, diagnosis, and management of this complication during antenatal, intrapartum, and postpartum periods.

Evidence Acquisition

A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG), the Society for Maternal-Fetal Medicine (SMFM), the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ), the World Health Organization (WHO), and the Society of Obstetricians and Gynecologists of Canada (SOGC) on maternal and puerperal sepsis was carried out.

Results

RCOG, SMFM, and SOMANZ provide guidance on the diagnosis and management of sepsis in pregnancy and the puerperium, whereas the WHO and the SOGC refer only to the prevention of peripartum infections. There is a consensus among the reviewed guidelines that a detailed personal history, along with physical examination, cultures, laboratory tests, and appropriate imaging, is the mainstay in sepsis diagnosis; however, there are several discrepancies regarding the diagnostic criteria. On management, the necessity of broad-spectrum antibiotics administration, within the first hour from recognition, and early source control are underlined by RCOG, SMFM, and SOMANZ. Furthermore, adequate fluid resuscitation with crystalloids is required, targeting for a mean arterial pressure (MAP) >65 mm Hg, whereas persistent hypotension or tissue hypoperfusion should be managed with vasopressors. In addition, RCOG, SMFM, and SOMANZ agree that increased fetal surveillance is warranted in case of maternal sepsis and point out that the decision regarding the optimal time of delivery should be guided according to maternal and fetal condition. In case of preterm labor, the use of corticosteroids should be considered. Moreover, SOMANZ and SMFM recommend thromboprophylaxis for septic women. With regards to prevention of peripartum infections, the WHO recommends prophylactic antibiotic administration in case of cesarean delivery, group B Streptococcus colonization, manual placenta removal, third/fourth-degree perineal tears, and preterm premature rupture of membranes, while discouraging antibiotics in case of preterm labor with intact membranes, prelabor rupture of membranes at term, meconium-stained amniotic fluid, uncomplicated vaginal birth, episiotomy, and operative vaginal delivery. Finally, SOGC, although supporting antibiotic prophylaxis for cesarean delivery and third/fourth-degree perineal injury, does not recommend this intervention in case of manual placenta removal, postpartum dilatation, and curettage for retained products of conception, operative vaginal delivery, and cervical cerclage.

Conclusions

Sepsis remains a significant contributor of maternal morbidity and mortality with a constantly rising global incidence, despite the advances in diagnostic and therapeutic techniques. Thus, the development of consistent international practice protocols for the prevention, timely recognition, and effective management of this complication both in pregnancy and in the puerperium seems of paramount importance to safely guide clinical practice and subsequently improve perinatal outcomes.

Utilizing Amniotic Fluid Metabolomics to Monitor Fetal Well-Being: A Narrative Review of the Literature

Fetal and perinatal periods are critical phases for long-term development. Early diagnosis of maternal complications is challenging due to the great complexity of these conditions. In recent years, amniotic fluid has risen in a prominent position in the latest efforts to describe and characterize prenatal development. Amniotic fluid may provide real-time information on fetal development and metabolism throughout pregnancy as substances from the placenta, fetal skin, lungs, gastric fluid, and urine are transferred between the mother and the fetus. Applying metabolomics to monitor fetal well-being, in such a context, could help in the understanding, diagnosis, and treatment of these conditions and is a promising area of research. This review shines a spotlight on recent amniotic fluid metabolomics studies and their methods as an interesting tool for the assessment of many conditions and the identification of biomarkers. Platforms in use, such as proton nuclear magnetic resonance (¹H NMR) and ultra-high-performance liquid chromatography (UHPLC), have different merits, and a combinatorial approach could be valuable. Metabolomics may also be used in the quest for habitual diet-induced metabolic signals in amniotic fluid. Finally, analysis of amniotic fluid can provide information on exposure to exogenous substances by detecting the exact levels of metabolites carried to the fetus and associated metabolic effects.

Cervical length screening for predicting preterm birth: A comparative review of guidelines

A cervical length (CL) assessment may predict preterm birth (PTB). This study aimed to analyze and compare the recommendations of guidelines on the role of CL in the prediction of PTB. There is no consensus regarding universal screening of asymptomatic women without a history of prior spontaneous PTB (sPTB), using CL. On the other hand, CL assessment is recommended in cases with a history of sPTB due to the high recurrence rate. Finally, there is discrepancy regarding CL assessment in asymptomatic women with multiple pregnancy. Although far from perfect, CL measurement remains the best available method to predict PTB.

Effect of Gestational Weight Gain during the First Half of Pregnancy on the Incidence of GDM, Results from a Pregnant Cohort in Northern Greece

The aim of this study was to evaluate the effect of gestational weight gain (GWG) up to 23⁺⁶ weeks of gestation on the incidence of Gestational Diabetes Mellitus (GDM). A pregnant cohort of 5948 women in Northern Greece was recruited. Anthropometric features before and during pregnancy were recorded, the GWG by 23⁺⁶ weeks was calculated and a Generalized Linear Regression Model (GLM) with subgroup analyses based on weight status were computed. GDM was diagnosed in 5.5% of women. GLM results showed that GDM likelihood increased with maternal age (MA) and pre-pregnancy BMI (aOR: 1.08, 95%CI: [1.06, 1.11] and aOR: 1.09, 95%CI: [1.09, 1.11], respectively). Ιn the normal pre-pregnancy weight group, when the extra weight gain was >8 kgs, the odds of GDM increased (OR: 2.13, 95%CI: [0.98, 4.21], p = 0.03). Women with pre-pregnancy level 2 clinical obesity (OB2 pre) (BMI > 35 and <40 kg/m²) that shifted to OB3 category (BMI ≥ 40 kg/m²) had an increased GDM likelihood (OR: 4.85, 95%CI: [1.50, 15.95]). Women of higher MA may require stricter monitoring for GDM from early pregnancy, while in obese women, recommended GWG may need to be re-evaluated, since refraining from any weight gain may have a preventive effect for GDM.

Pre-Pregnancy Adherence to Mediterranean Diet and Risk of Gestational Diabetes Mellitus: A Prospective Cohort Study in Greece

Gestational Diabetes Mellitus (GDM) is a growing epidemic affecting pregnant women and their offspring. This study aimed to identify the relationship between adherence to a Mediterranean diet (MD) before conception and the risk of GDM in a contemporary Greek pregnant cohort. A prospective cohort of pregnant women was recruited at the routine first trimester visit. Nutritional intake was evaluated using a population specific validated food frequency questionnaire (FFQ). Pre-pregnancy adherence to MD was derived using two different scoring systems, the Mediterranean diet index score (MDS), and a modified version. Adjusted odds ratios (aOR) were computed using multiple logistic regression models for each score derived. Of 743 participating women, 112 (15.1%) developed GDM. The MDS index showed that scoring 5-9 points (high adherence) was associated with a lower GDM incidence (aOR: 0.57 95% CI (0.32, 0.90), p = 0.02), while the modified MDS index showed no significant association for any level of adherence. Pre-pregnancy consumption of "meat and derivatives" and "fatty meat and processed meat" was associated with a higher risk of GDM, with both scoring systems (p = 0.008, p = 0.004, respectively). A higher adherence to a MD pre-pregnancy, especially with less meat consumption, may have a protective effect on the occurrence of GDM.

Impact of velamentous cord insertion on perinatal outcomes: a systematic review and meta-analysis

OBJECTIVE

Velamentous cord insertion may be identified prenatally, but the clinical implications of this diagnosis remain controversial. This meta-analysis aimed to quantitatively summarize current data on the association of velamentous cord insertion and adverse perinatal outcomes.

DATA SOURCES

A systematic search was performed in MEDLINE, Scopus, and the Cochrane Library from inception until May 22, 2022 to identify eligible studies.

STUDY ELIGIBILITY CRITERIA

Observational studies including singleton pregnancies with velamentous cord insertion, either prenatally or postnatally identified, and comparing them with those with central/eccentric cord insertion were considered eligible.

METHODS

The quality of the studies was assessed with the Newcastle-Ottawa scale and the risk of bias with the Quality In Prognosis Studies (QUIPS) tool. The main outcome was small-for-gestational-age neonates. Heterogeneity of the studies was evaluated using a Q test and an I² index. Analyses were performed using a random-effects model, with outcome data reported as relative risk or mean difference with 95% confidence interval.

RESULTS

In total, 9 cohort and 2 case-control studies, of which 4 had prenatal and 7 had postnatal velamentous cord insertion diagnosis, were included. The overall prevalence of velamentous cord insertion was estimated to be 1.4% among singleton pregnancies. Compared with the central/eccentric cord insertion control group, pregnancies with velamentous cord insertion were at higher risk of several adverse perinatal outcomes, namely small-for-gestational-age neonates (relative risk, 1.93; 95% confidence interval, 1.54-2.41), preeclampsia (relative risk, 1.85; 95% confidence interval, 1.01-3.39), pregnancy-induced hypertension (relative risk, 1.58; 95% confidence interval, 1.46-1.70), stillbirth (relative risk, 4.12; 95% confidence interval, 1.92-8.87), placental abruption (relative risk, 2.94; 95% confidence interval, 1.72-5.03), preterm delivery (relative risk, 2.14; 95% confidence interval, 1.73-2.65), emergency cesarean delivery (relative risk, 2.03; 95% confidence interval, 1.22-3.38), 1-minute Apgar score <7 (relative risk, 1.53; 95% confidence interval, 1.14-2.05), 5-minute Apgar score <7 (relative risk, 1.97; 95% confidence interval, 1.43-2.71), and neonatal intensive care unit admission (relative risk, 1.63; 95% confidence interval, 1.32-2.02). In a subgroup analysis, prenatally diagnosed velamentous cord insertion was associated with small-for-gestational-age neonates (relative risk, 1.66; 95% confidence interval, 1.19-2.32), stillbirth (relative risk, 4.78; 95% confidence interval, 1.42-16.08), and preterm delivery (relative risk, 2.69; 95% confidence interval, 2.01-3.60). In a sensitivity analysis of studies excluding cases with vasa previa, velamentous cord insertion was associated with an increased risk of small-for-gestational-age neonates (relative risk, 2.69; 95% confidence interval, 1.73-4.17), pregnancy-induced hypertension (relative risk, 1.94; 95% confidence interval, 1.24-3.01), and stillbirth (relative risk, 9.42; 95% confidence interval, 3.19-27.76), but not preterm delivery (relative risk, 1.92; 95% confidence interval, 0.82-4.54).

CONCLUSION

Velamentous cord insertion is associated with several adverse perinatal outcomes, including stillbirth, and these associations persist when only prenatally diagnosed cases are considered and when vasa previa cases are excluded. According to these findings, the exact pathophysiology should be further investigated and an effective prenatal monitoring plan should be developed.

Hemoperitoneum due to spontaneous bleeding from a smooth muscle tumor of uncertain malignant potential: A rare case report

INTRODUCTION AND IMPORTANCE

Smooth muscle tumors of uncertain malignant potential (STUMPs) are uncommon tumors representing an extremely rare cause of hemoperitoneum.

CASE PRESENTATION

We report a case of a 48-year-old Caucasian, premenopausal woman that presented in the emergency department with acute abdominal pain. There was no remarkable past medical and surgical history except from a known uterine leiomyoma. The ultrasound and the computed tomography imaging showed an intraperitoneal fluid collection and a heterogenous uterine mass. The patient underwent emergent exploratory laparotomy; a subserosal uterine tumor was identified with an actively bleeding vessel on its surface. The uterine lesion was completely excised and the histopathology set the diagnosis of a STUMP. After consultation on the significance of this finding with the patient, an abdominal total hysterectomy and bilateral salpingo-oophorectomy were scheduled and performed and the subsequent histopathology detected no malignancy.

CLINICAL DISCUSSION

This case demonstrates that a STUMP may be a rare cause of acute intraperitoneal bleeding. Careful evaluation of clinical history, imaging findings and, if needed, surgical exploration are important for the diagnosis, while appropriate follow-up is also of major importance for the management of these rare tumors.

CONCLUSION

We presented an extremely rare case of hemoperitoneum due to spontaneous bleeding from a STUMP. From an oncological perspective, this case poses a diagnostic, management and follow-up challenge.

Impact of marginal cord insertion on perinatal outcomes: a systematic review and meta-analysis

OBJECTIVE

Despite its high prevalence and the possible link with perinatal complications, marginal cord insertion is surrounded by considerable controversy regarding management. This meta-analysis aimed to study its association with several perinatal outcomes in a manner that provides trustworthy and exact effect measures, enabling us eventually to evaluate its overall risk for pregnancy.

DATA SOURCES

A systematic search was performed in Medline, Scopus, and the Cochrane Library on July 30, 2022, to identify eligible studies.

STUDY ELIGIBILITY CRITERIA

Observational studies, including singleton pregnancies and comparing MCI with central cord insertion or eccentric cord insertion, either prenatally or postnatally identified, were considered eligible.

METHODS

The Newcastle-Ottawa Scale was used to assess study quality, and the Quality in Prognosis Studies tool was used to assess bias risk. The main outcome was small-for-gestational-age neonates. A Q test and an I² score were used to assess study heterogeneity. The analyses were performed using a random-effects model, and the results were expressed as relative risk or mean difference with a 95% confidence interval.

RESULTS

Overall, 15 studies (13 cohort studies and 2 case-control studies) contributed data to the analysis. There was a prenatal diagnosis in 7 studies and a postnatal diagnosis in 8 studies. The overall prevalence of marginal cord insertion was 6.15% (range, 1.13%-11.3%). Pregnancies with marginal cord insertion compared with pregnancies with central cord insertion were found to be at higher risk of small-for-gestational-age neonates (relative risk, 1.25; 95% confidence interval, 1.21-1.29), preeclampsia (relative risk, 1.61; 95% confidence interval, 1.54-1.67), placental abruption (relative risk, 1.53; 95% confidence interval, 1.34-1.75), stillbirth (relative risk, 1.97; 95% confidence interval, 1.02-3.78), preterm delivery (relative risk, 1.47; 95% confidence interval, 1.24-1.75), lower mean gestational age at birth (mean difference, -0.20; 95% confidence interval, -0.38 to -0.01), emergency cesarean delivery (relative risk, 1.39; 95% confidence interval, 1.35-1.44), lower mean birthweight (mean difference, -139.19; 95% confidence interval, -185.78 to -92.61), 5-minute Apgar score of <7 (relative risk, 1.48; 95% confidence interval, 1.00-2.19), and neonatal intensive care unit admission (relative risk, 1.57; 95% confidence interval, 1.20-2.06). When only pregnancies with prenatally diagnosed MCI were considered, the risk remained high regarding small for gestational age (relative risk, 1.34; 95% confidence interval, 1.21-1.48), preeclampsia (relative risk, 1.42; 95% confidence interval, 1.01-1.99), stillbirth (relative risk, 2.99; 95% confidence interval, 1.03-8.70), preterm delivery (relative risk, 1.41; 95% confidence interval, 1.19-1.68), lower mean gestational age at birth (mean difference, -0.22; 95% confidence interval, -0.33 to -0.11), and lower mean birthweight (mean difference, -122.41; 95% confidence interval, -166.10 to -78.73).

CONCLUSION

Here, the higher risk that marginal cord insertion poses for pregnancy, regarding several adverse outcomes, became evident. Many of these associations persisted among the prenatally diagnosed pregnancies. The underlining pathophysiology should be investigated, and further research is needed on the effect of increased surveillance in improving perinatal outcomes.

Adverse pregnancy outcomes in women with celiac disease: a systematic review and meta-analysis

Background

The aim of this meta-analysis was to evaluate the risk of adverse pregnancy outcomes in women affected with celiac disease (CD), and to further estimate the impact of early disease diagnosis and subsequent adherence to a gluten-free diet (GFD) on obstetric complications.

Methods

A systematic search for English language observational studies was conducted in Medline, Scopus, and the Cochrane Library, from inception till April 2022, to identify relevant studies reporting on the incidence of adverse pregnancy outcomes in women with CD. Odds ratios (OR) and relative risks (RR) with 95% confidence intervals (CIs) were used to combine data from case-control and cohort studies, respectively. The quality of the included studies was assessed using the Newcastle-Ottawa scale.

Results

In total, 14 cohort and 4 case-control studies were included and our analysis demonstrated that the risk for spontaneous abortion (RR 1.35, 95%CI 1.10-1.65), fetal growth restriction (RR 1.68, 95%CI 1.34-2.10), stillbirth (RR 1.57, 95%CI 1.17-2.10), preterm delivery (RR 1.29, 95%CI 1.12-1.49), cesarean delivery (RR 1.10, 95%CI 1.03-1.16) and lower mean birthweight (mean difference -176.08, 95%CI -265.79 to -86.38) was significantly higher in pregnant women with CD. The subgroup analysis demonstrated that only undiagnosed CD increased risk for fetal growth restriction, stillbirth, preterm delivery and lower mean birthweight, whereas early diagnosis of CD was not linked to any adverse pregnancy outcomes.

Conclusions

Undiagnosed CD is associated with a higher risk of adverse pregnancy outcomes. Early CD diagnosis and appropriate management with GFD may ameliorate these associations.

Obesity in Pregnancy: A Comprehensive Review of Influential Guidelines

Importance

Obesity is one of the most common clinical entities complicating pregnancies and is associated with short- and long-term consequences for both the mother and the offspring.

Objective

The aim of this study were to review and compare the most recently published influential guidelines on the management of maternal obesity in the preconceptional, antenatal, intrapartum, and postpartum period.

Evidence Acquisition

A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynecologists of Canada, the Royal College of Obstetricians and Gynecologists, and the Royal Australian and New Zealand College of Obstetricians and Gynecologists on obesity in pregnancy was carried out.

Results

There is an overall agreement among the reviewed guidelines regarding the importance of prepregnancy weight loss with behavioral modification, optimization of gestational weight gain, and screening for comorbidities in improving pregnancy outcomes of obese women. Women with previous bariatric surgery should be screened for nutritional deficiencies and have a closer antenatal surveillance, according to all guidelines. In addition, folic acid supplementation is recommended for 1 to 3 months before conception and during the first trimester, but several discrepancies were identified with regard to other vitamins, iodine, calcium, and iron supplementation. All medical societies recommend early screening for gestational diabetes mellitus and early anesthetic assessment in obese women and suggest the use of aspirin for the prevention of preeclampsia when additional risk factors are present, although the optimal dosage is controversial. The International Federation of Gynecology and Obstetrics, Society of Obstetricians and Gynecologists of Canada, Royal College of Obstetricians and Gynecologists, and Royal Australian and New Zealand College of Obstetricians and Gynecologists point out that specific equipment and adequate resources must be readily available in all health care facilities managing obese pregnant women. Moreover, thromboprophylaxis and prophylactic antibiotics are indicated in case of cesarean delivery, and intrapartum fetal monitoring is justified during active labor in obese patients. However, there are no consistent protocols regarding the fetal surveillance, the monitoring of multiple gestations, the timing and mode of delivery, and the postpartum follow-up, although weight loss and breastfeeding are unanimously supported.

Conclusions

Obesity in pregnancy is a significant contributor to maternal and perinatal morbidity with a constantly rising global prevalence among reproductive-aged women. Thus, the development of uniform international protocols for the effective management of obese women is of paramount importance to safely guide clinical practice and subsequently improve pregnancy outcomes.

Anatomic Distribution of Benign Ovarian Tumors in Perimenopausal and Postmenopausal Women

Introduction We aim to report the histotypes and reassess the anatomic distribution of benign ovarian tumors in perimenopausal and postmenopausal women. Methods Medical and pathology reports of women with histologically confirmed benign ovarian pathology were investigated. Data were collected, retrospectively between 2000 and 2020, and analyzed from perimenopausal and postmenopausal women with benign ovarian tumors, after bilateral salpingo-oophorectomy (BSO) with or without total abdominal hysterectomy (TAH). The ovarian masses histology and the distribution of locations were further evaluated. Results The total sample consisted of 1,355 women with benign ovarian tumors; 929 (68.6%) of the perimenopausal and 426 (31.4%) of the postmenopausal age. A dermoid cyst was prominent in the right ovary (52.8%), compared to the left side (41%) (p<0.01). Conversely, in patients with endometriomas and cysts of Morgagni, the observed proportion was more prominent in the left-sided ovary (61.8% vs 27%; p<0.001 and 52.3% vs 36.4%; p<0.01, respectively). Moreover, in the perimenopausal women, we mostly detected endometrioma (18.3%), dermoid cyst (15.5%) and cyst of Morgagni (4%) compared to postmenopausal women, where serous cysts (29.8%) and ovarian fibroids (8%) were the most common tumors. Conclusions Benign ovarian tumors are frequently seen in perimenopausal women and most histotypes present anatomical differences between the left and right ovaries. Serous cysts, followed by paraovarian, dermoid cysts and endometrioma present the commonest ovarian benign masses. Gynecologists should pay special attention to adnexal tumors in the postmenopausal period to choose the right operating setting for women at risk for ovarian cancer.

Maternal perception of fetal movements: onset and associated factors

OBJECTIVES

The purpose of this study was to determine the onset of fetal movements' perception and to identify parameters that affect this timing.

METHODS

This was a prospective cohort study including singleton pregnancies that attended routine prenatal care, in a tertiary care center, in northern Greece, between January 2020 and July 2021. We collected data on medical and obstetric history, and invited women to record the time that they perceived the fetal movements for the first time, that being the primary outcome of the study. Furthermore, we studied the associations between this timing and several obstetric and sociodemographic parameters.

RESULTS

In total, 2,009 women participated in the study. The mean gestational age at first perception of fetal movements was 19 weeks (±1.5). This ranged from as early as 14⁺⁰-14⁺⁶ weeks (0.1%) to 24⁺⁰-24⁺⁶ weeks (0.1%). The majority of women (73.3%) reported initial perception of fetal movements between 18⁺⁰ and 20⁺⁶ weeks. Following multivariate logistic regression analysis, we found that nulliparity (OR: 2.607; 95% CI: 1.876-3.622; p<0.001), anterior placental position (OR: 1.918; 95% CI: 1.575-2.336; p<0.001), increasing body mass index (OR: 1.063; 95% CI: 1.040-1.088; p=0.001) and advancing maternal age (OR: 1.062; 95% CI: 1.040-1.084; p<0.001) were associated with a delayed perception of fetal movements. Multiparous women reported the onset of fetal movements almost one week earlier on average (18.6±1.4 weeks) compared to nulliparous (19.4±1.4 weeks; MD: 0.843; 95% CI: 0.718-0.968; p<0.001).

CONCLUSIONS

The onset of maternal perception of fetal movements is around 19 weeks and this timing may be delayed by higher maternal age, higher body mass index, nulliparity and anterior placental position.

Invasive Prenatal Diagnostic Testing for Aneuploidies in Singleton Pregnancies: A Comparative Review of Major Guidelines

Sophisticated screening protocols for genetic abnormalities constitute an important component of current prenatal care, aiming to identify high-risk pregnancies and offer appropriate counseling to parents regarding their options. Definite prenatal diagnosis is only possible by invasive prenatal diagnostic testing (IPDT), mainly including amniocentesis and chorionic villous sampling (CVS). The aim of this comparative review was to summarize and compare the existing recommendations on IPDT from the most influential guidelines. All the reviewed guidelines highlight that IPDT is indicated based on a positive screening test rather than maternal age alone. Other indications arise from medical history and sonography, with significant variations identified between the guidelines. The earlier time for amniocentesis is unequivocally set at ≥15 gestational weeks, whereas for CVS, the earlier limit varies from ≥10 to ≥11 weeks. Certain technical aspects and the overall approach demonstrate significant differences. Periprocedural management regarding Rhesus alloimmunization, virologic status and use of anesthesia or antibiotics are either inconsistent or insufficiently addressed. The synthesis of an evidence-based algorithm for IPDT is of crucial importance to healthcare professionals implicated in prenatal care to avoid unnecessary interventions without compromising optimal prenatal care.