Congenital toxoplasmosis and proposal of a new classification for the likelihood of primary maternal infection: analysis of 375 cases in Southeast Italy

Objective: The aim of this study was to propose a classification in order to stratify the probability of an acute Toxoplasma infection in pregnancy and to estimate the risk of vertical transmission.Study design: We evaluated the likelihood of a primary maternal infection according to the Lebech classification and to the modified-Lebech classification proposed for our group of 375 patients referred for a suspected primary maternal infection. Fetal diagnosis included the examination of amniotic fluid by PCR to detect Toxoplasma DNA as a confirmation test.Results: Differences between the old and new classification resulted statistically significant for old classes defined as probable and unlikely with a clear shift of cases from the unlikely to the probable class in the new classification. Transmission rate showed a significant (p < .05) increase of the transmission rate in the probable class in our new classification as compared with the Lebech one.Conclusions: Results obtained in the present study suggest that the new IgG avidity-based classification herein proposed could estimate more precisely the likelihood of a primary maternal Toxoplasma infection as well as the risk of fetal infection, when compared with the historical Lebech Classification.

A phase II study: dose-dense carboplatin and paclitaxel as neoadjuvant chemotherapy in locally advanced cervical cancer

This study evaluates the efficacy and toxicity of dose-dense weekly paclitaxel and carboplatin as neoadjuvant chemotherapy in locally advanced cervical cancer (LACC). We collected 23 cases of LACC treated with weekly paclitaxel and carboplatin for nine cycles: 20 patients had complete or partial response to chemotherapy and were submitted to surgery, 3 with poor response received chemoradiation therapy. Pathologic examination showed complete response in four patients, myometrial invasion <50% in nine and >50% in seven patients, parametrial involvement in two, vaginal metastasis in one and lymphovascular space invasion, with positive margins, in another case. Despite seven patients had radiological evidence of lymph nodes involvement at diagnosis, only one had nodal metastases. Five patients showed grade 3-4 of hematologic toxicity.

Tunneling nanotubes evoke pericyte/endothelial communication during normal and tumoral angiogenesis

BACKGROUND

Nanotubular structures, denoted tunneling nanotubes (TNTs) have been described in recent times as involved in cell-to-cell communication between distant cells. Nevertheless, TNT-like, long filopodial processes had already been described in the last century as connecting facing, growing microvessels during the process of cerebral cortex vascularization and collateralization. Here we have investigated the possible presence and the cellular origin of TNTs during normal brain vascularization and also in highly vascularized brain tumors.

METHODS

We searched for TNTs by high-resolution immunofluorescence confocal microscopy, applied to the analysis of 20-µm, thick sections from lightly fixed, unembedded samples of both developing cerebral cortex and human glioblastoma (GB), immunolabeled for endothelial, pericyte, and astrocyte markers, and vessel basal lamina molecules.

RESULTS

The results revealed the existence of pericyte-derived TNTs, labeled by proteoglycan NG2/CSPG4 and CD146. In agreement with the described heterogeneity of these nanostructures, ultra-long (> 300 µm) and very thin (< 0.8 µm) TNTs were observed to bridge the gap between the wall of distant vessels, or were detected as short (< 300 µm) bridging cables connecting a vessel sprout with its facing vessel or two apposed vessel sprouts. The pericyte origin of TNTs ex vivo in fetal cortex and GB was confirmed by in vitro analysis of brain pericytes, which were able to form and remained connected by typical TNT structures.

CONCLUSIONS

None of the multiple roles described for TNTs can be excluded from a possible involvement during the processes of both normal and pathological vessel growth. A possible function, suggested by the pioneering studies made during cerebral cortex vascularization, is in cell searching and cell-to-cell recognition during the processes of vessel collateralization and vascular network formation. According to our results, it is definitely the pericyte-derived TNTs that seem to actively explore the surrounding microenvironment, searching for (site-to-site recognition), and connecting with (pericyte-to-pericyte and/or pericyte-to-endothelial cell communication), the targeted vessels. This idea implies that TNTs may have a primary role in the very early phases of both physiological and tumor angiogenesis in the brain.

Colpocytological abnormalities in HIV infected and uninfected pregnant women: prevalence, persistence and progression

In this retrospective case-control study, we analyse data of 48 HIV-positive pregnant patients, versus a control group of 99 HIV-negative pregnant women, followed as outpatients by our department from 2009 to 2014. The aims of the study were to investigate the prevalence, persistence and progression of cervical squamous intraepithelial lesions (SIL) in each group and to correlate colpo-cytological lesions to the socio-demographic and clinical-laboratory findings in the HIV + pregnant women. In our study we observed that immunosuppression, HPV infection and vaginal coinfections were predictive of cervical lesions. Pap smear and colposcopy should be part of routine care for HIV-infected pregnant women because these lesions behave aggressively in these patients. Success of prevention depends on massive access of patients to screening. HAART reduces viral load and maintains CD4 count and can affect progression of SIL. Multidisciplinary services on the same site appear to be one promising strategy to improve compliance in patients. Impact Statement What is already known on this subject: Our study provided novel information on a highly vulnerable population of young HIV + pregnant women. What the results of this study add: We observed that immunosuppression, HPV infection and vaginal coinfections were predictive of cervical lesions remarkable with colposcopy. We could consider these important risk factors to evaluate to establish an appropriate strategy of management for these patients. What the implications are of these findings for clinical practice and/or further research: Association of the risk between SIL presence and HIV and HPV infection also deserves additional investigation. We believe that Pap smears and colposcopies should be part of the routine care for HIV-infected women because these lesions behave particularly aggressively in these patients.

Rate, correlates and outcomes of repeat pregnancy in HIV-infected women

OBJECTIVES

The aim of the study was to assess the rate, determinants, and outcomes of repeat pregnancies in women with HIV infection.

METHODS

Data from a national study of pregnant women with HIV infection were used. Main outcomes were preterm delivery, low birth weight, CD4 cell count and HIV plasma viral load.

RESULTS

The rate of repeat pregnancy among 3007 women was 16.2%. Women with a repeat pregnancy were on average younger than those with a single pregnancy (median age 30 vs. 33 years, respectively), more recently diagnosed with HIV infection (median time since diagnosis 25 vs. 51 months, respectively), and more frequently of foreign origin [odds ratio (OR) 1.36; 95% confidence interval (CI) 1.10-1.68], diagnosed with HIV infection in the current pregnancy (OR: 1.69; 95% CI: 1.35-2.11), and at their first pregnancy (OR: 1.33; 95% CI: 1.06-1.66). In women with sequential pregnancies, compared with the first pregnancy, several outcomes showed a significant improvement in the second pregnancy, with a higher rate of antiretroviral treatment at conception (39.0 vs. 65.4%, respectively), better median maternal weight at the start of pregnancy (60 vs. 61 kg, respectively), a higher rate of end-of-pregnancy undetectable HIV RNA (60.7 vs. 71.6%, respectively), a higher median birth weight (2815 vs. 2885 g, respectively), lower rates of preterm delivery (23.0 vs. 17.7%, respectively) and of low birth weight (23.4 vs. 15.4%, respectively), and a higher median CD4 cell count (+47 cells/μL), with almost no clinical progression to Centers for Disease Control and Prevention stage C (CDC-C) HIV disease (0.3%). The second pregnancy was significantly more likely to end in voluntary termination than the first pregnancy (11.4 vs. 6.1%, respectively).

CONCLUSIONS

Younger and foreign women were more likely to have a repeat pregnancy; in women with sequential pregnancies, the second pregnancy was characterized by a significant improvement in several outcomes, suggesting that women with HIV infection who desire multiple children may proceed safely and confidently with subsequent pregnancies.

La risonanza magnetica del feto

La RM fetale si candida come metodica di approfondimento nella diagnostica per immagini prenatale, dopo il classico approccio ecografico entrato ormai nel depistage di massa delle anomalie fetali. Il ricorso alla RM fetale ha una storia breve ma l'interesse dei vari autori a questa metodica è risultato crescente nell'ultimo decennio.

In questo lavoro viene presentata una breve revisione critica dei dati della letteratura con alcune annotazioni sulle diverse soluzioni tecniche proposte. Viene soprattutto discusso il problema legato ai movimenti fetali che tendono a degradare l'immagine RM dando particolare risalto alle manovre eco-guidate di curarizzazione fetale. Vengono quindi riportati i risultati su una casistica di 27 pazienti gravide in epoca gestazionale compresa tra il secondo ed il terzo trimestre, 22 delle quali sottoposte a curarizzazione fetale. In particolare sono presentati i diversi risultati RM in relazione al diverso dosaggio e al diverso agente curaro-simile impiegato e alcuni dettagli tecnici sull'esecuzione della RM fetale. In questa prima parte del nostro lavoro viene infine discussa l'anatomia normale del cervello fetale all'RM.

La risonanza magnetica del feto

Vengono riportati i quadri patologici osservati in 27 RM fetali prenatali e catalogati in sezioni.

Nella sezione riguardante l'anencefalia e la microcefalia sono discussi rispettivamente un caso di anencefalia classica, una microcefalia vera di Evrard, una microcefalia semplice associata a malformazioni in altri apparati ed una rara osservazione di iniencefalia. Nella sezione delle oloprosencefalie sono riportate due oloprosencefalie alobari e due oloprosencefalie semilobari. Nella sezione della agenesia del corpo calloso, sono illustrati 5 casi di agenesia totale, 2 casi isolati, e 3 associati ad altre anomalie del sistema nervoso. Una cisti in tensione del setto pellucido è stata arbitrariamente inserita in quest'ultima sezione.

Fra i complessi di Dandy-Walker sono enumerate una malformazione classica di Dandy-Walker, 2 Dandy-Walker variant ed una megacisterna magna.

Le anomalie di Chiari riscontrate sono state 2 e si riferiscono entrambe ad una condizione a tipo Chiari I, associata ad idrocefalo in un caso, ad agenesia del corpo calloso nell'altro. In un ultima sezione vengono presentati 2 casi di moderata idrocefalia e due casi di cospicua idrocefalia. Vengono infine presentate alcune brevi considerazioni conclusive sulla validità della metodica.

Ultrasound diagnosis of uterine myomas

Myomas represent a large part of benign gynecological pathology, widely spread in fertile female population. First step to diagnose fibroids is ultrasound (US) that can be 2-dimensional (2D), 3-dimensional (3D), Color Doppler (CD) and sonohysterography (SHG). This review develops according to MUSA's sonographic features (Morphological Uterus Sonographic Assessment). One of the main topic of interest for ultrasonographer today is endo/myometrial junctional zone (JZ), because it may be useful to discern a diagnosis of myoma and adenomyosis. Another important aspect of ultrasound is the analysis of vascularization in front of a uterine lesion. Indeed, vascular pattern can be used to make differential diagnosis between myoma-adenomyosis and leiomyosarcomas. Myomas should be described accurately according to sonographic guidelines. Sonographic features correlated with symptoms should guide an appropriate surgical or medical treatment.

US-color Doppler early diagnosis of uterine rupture with protrusion of umbilical cord

OBJECTIVE

to analyze a case of uterine rupture in a pregnant woman that had a previous laparoscopic myomectomy.

METHODS

pregnant woman at 34 weeks gestation came to our emergency room for abdominal pain. She had undergone a previous laparoscopic multiple myomectomy. Patient was evaluated in our Department, that is a tertiary center, by a team of experienced ultrasonographers.

RESULTS

at a first clinical examination, the findings were a deep abdominal pain, dysuria and a positive Giordano's sign on the right. 2D ultrasound showed an alive intrauterine foetus, normal anterior fundal placenta and mild reduction of amniotic fluid. It revealed also a maternal right pyelectasis. A further meticulous ultrasound evaluation plus color Doppler revealed on the left side of the uterus the presence of a small vascularised area with venous and arterial flow that seemed to be in continuity with umbilical cord and that had its ultrasound characteristics. Emergency laparotomy was performed and confirmed the hypothesis of uterine rupture.

DISCUSSION

uterine rupture seems to occur more frequently as a consequence of a laparoscopic myomectomy and the classic signs and symptoms are fetal distress, loss of uterine contractility, abdominal pain, hemorrhage and shock, so the early US suspect of uterine rupture was extremely important in the decision to perform an emergency caesarean section.

CONCLUSION

the correlation between clinical examination and ultrasound-Doppler findings has been essential to recognise an obstetrical emergency and to perform prompt surgery.

Rate, predictors, and consequences of late antenatal booking in a national cohort study of pregnant women with HIV in Italy

OBJECTIVE

To evaluate the prevalence and consequences of late antenatal booking (13 or more weeks gestation) in a national observational study of pregnant women with HIV.

METHODS

The clinical and demographic characteristics associated with late booking were evaluated in univariate analyses using the Mann-Whitney U test for quantitative data and the chi-square test for categorical data. The associations that were found were re-evaluated in multivariable logistic regression models. Main outcomes were preterm delivery, low birthweight, nonelective cesarean section, birth defects, undetectable (<50 copies/mL) HIV plasma viral load at third trimester, delivery complications, and gender-adjusted and gestational age-adjusted Z scores for birthweight.

RESULTS

Rate of late booking among 1,643 pregnancies was 32.9%. This condition was associated with younger age, African provenance, diagnosis of HIV during pregnancy, and less antiretroviral exposure. Undetectable HIV RNA at third trimester and preterm delivery were significantly more prevalent with earlier booking (67.1% vs 46.3%, P < .001, and 23.2% vs 17.6, P = .010, respectively), whereas complications of delivery were more common with late booking (8.2% vs 5.0%, P = .013). Multivariable analyses confirmed an independent role of late booking in predicting detectable HIV RNA at third trimester (adjusted odds ratio [AOR], 1.7; 95% CI, 1.3-2.3; P < .001) and delivery complications (AOR, 1.8; 95% CI, 1.2-2.8; P = .005).

CONCLUSIONS

Late antenatal booking was associated with detectable HIV RNA in late pregnancy and with complications of delivery. Measures should be taken to ensure an earlier entry into antenatal care, particularly for African women, and to facilitate access to counselling and antenatal services. These measures can significantly improve pregnancy management and reduce morbidity and complications in pregnant women with HIV.

Birth defects in a national cohort of pregnant women with HIV infection in Italy, 2001-2011

OBJECTIVE

We used data from a national study of pregnant women with HIV to evaluate the prevalence of congenital abnormalities in newborns from women with HIV infection.

DESIGN

Observational study.

SETTING

University and hospital clinics.

POPULATION

Pregnant women with HIV exposed to antiretroviral treatment at any time during pregnancy.

METHODS

The total prevalence of birth defects was assessed on live births, stillbirths, and elective terminations for fetal anomaly. The associations between potentially predictive variables and the occurrence of birth defects were expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs) for exposed versus unexposed cases, calculated in univariate and multivariate logistic regression analyses.

MAIN OUTCOME MEASURES

Birth defects, defined according to the Antiretroviral Pregnancy Registry criteria.

RESULTS

A total of 1257 pregnancies with exposure at any time to antiretroviral therapy were evaluated. Forty-two cases with major defects were observed. The total prevalence was 3.2% (95% CI 1.9-4.5) for exposure to any antiretroviral drug during the first trimester (23 cases with defects) and 3.4% (95% CI 1.9-4.9) for no antiretroviral exposure during the first trimester (19 cases). No associations were found between major birth defects and first-trimester exposure to any antiretroviral treatment (OR 0.94, 95% CI 0.51-1.75), main drug classes (nucleoside reverse transcriptase inhibitors, OR 0.95, 95% CI 0.51-1.76; non-nucleoside reverse transcriptase inhibitors, OR 1.20, 95% CI 0.56-2.55; protease inhibitors, OR 0.92, 95% CI 0.43-1.95), and individual drugs, including efavirenz (prevalence for efavirenz, 2.5%).

CONCLUSIONS

This study adds further support to the assumption that first-trimester exposure to antiretroviral treatment does not increase the risk of congenital abnormalities.

Two cases of complete hydatidiform mole and coexistent live fetus

The aim of this study was to report the clinical features, management, and outcome of complete hydatidiform mole with a coexisting viable fetus. Two cases are reported. In both cases ultrasound examination demonstrated a normally growing live fetus alongside a normal placenta and an additional intrauterine echogenic mass with features of hydatidiform mole. The hCG levels were significantly increased and fetal karyotypes were normal. A cesarean section performed at 28 weeks' gestation in the first case and at 26 weeks' gestation in the second one resulted in the delivery of live normal infant and two adjoining placentas in both cases. Microscopic examination of the abnormal placentas confirmed complete hydatidiform mole. The babies did well and serial maternal serum hCG levels showed a declining trend and were undetectable by a few months after delivery. Continuation of a twin pregnancy with complete hydatidiform mole (CHMF) is an acceptable option. There is, although, an increased risk of developing maternal and fetal complications. Close surveillance of an ongoing pregnancy is compulsory to detect potential early signs of complications.

Increased nuchal translucency and short femur length as possible early signs of osteogenesis imperfecta type III

OBJECTIVE

this paper reports an association between an increased Nuchal Translucency (NT) and Osteogenesis Imperfecta (OI), a type of skeletal dysplasia. Measurement of fetal NT at 10-14 weeks of gestation is a sensitive and effective screening method for chromosomal abnormalities.

METHODS

a 35-year- old Caucasian woman in her fourth pregnancy was referred to our clinic for an ultrasound scan at 12 weeks of gestation, that confirmed increased Nuchal Translucency. Chorionic villi sampling was performed, showing a normal karyotype. The patient was evaluated by a team of experienced ultra sonographers for pregnancy follow-up at our Department, that is a tertiary center.

RESULTS

in our case the ultrasound scan at 12 week of gestation revealed only an increased NT (3 mm). Cytogenetic analysis on chorionic villi demonstrated a normal male karyotype. US follow-up, performed every 3-4 weeks, confirmed normal anthropometric parameters except for shortening of both femurs, but at 23 weeks an incorrect attitude of the feet was revealed. A clinical and radiographic diagnosis of OI type III was made only at birth, and through follow-up continuing to date.

DISCUSSION

NT screening was successful for chromosomal abnormalities at 11-14 weeks of gestation. An increased NT thickness is also associated with numerous fetal anomalies and genetic syndromes in a chromosomally normal fetus. In our case there were no sonographic signs of imperfect osteogenesis in the first trimester, although there was an increased NT with a normal karyotype.

CONCLUSION

currently, in literature, there are not other cases of OI type III associated with an increased NT. Our report is the first to suggest an association between an increased nuchal translucency, short femur length and osteogenesis imperfecta type III.

Accuracy of transvaginal sonography and contrast-enhanced magnetic resonance-colonography for the presurgical staging of deep infiltrating endometriosis

OBJECTIVE

To investigate the accuracy of transvaginal sonography (TVS) and contrast-enhanced magnetic resonance-colonography (CE-MR-C) for the presurgical assessment of deep infiltrating endometriosis (DIE).

METHODS

Ninety women were enrolled prospectively for suspicion of DIE. All patients underwent TVS and CE-MR-C, with each operator blinded to the results of the other exam, before laparoscopy. The sites of DIE examined by both imaging techniques were: rectovaginal septum, pouch of Douglas, uterosacral ligaments, vesicouterine pouch, bowel, bladder and vagina. The presence of adhesions and the involvement of adnexa and of a previous abdominal scar, when there was clinical suspicion, were also evaluated. TVS and CE-MR-C findings were compared with laparoscopic and histological results.

RESULTS

Endometriosis was confirmed by laparoscopy in 95.6% (86/90) of cases. In 82.2% (74/90) of patients there was DIE. The global accuracy for TVS in the detection of DIE was 89.2%, sensitivity was 81.1%, specificity was 94.2%, positive predictive value was 89.6%, negative predictive value was 89.0%, the positive likelihood ratio was 13.9 and the negative likelihood ratio was 0.2. For CE-MR-C, these values were 87.2%, 71.1%, 97.1%, 93.7%, 84.6%, 24.4 and 0.3, respectively. CE-MR-C allowed diagnosis of all cases of bowel involvement; the accuracy for infiltration and stenosis was 100%. The accuracy of TVS for rectosigmoid nodules was 91.1% and that for infiltration was 88.9%.

CONCLUSIONS

Both TVS and CE-MR-C showed satisfactory results for the presurgical assessment of DIE. TVS appears to be a powerful, simple, feasible, cost-effective tool for preoperative staging of DIE. CE-MR-C is an 'X-ray free' technique, which could be reserved for cases with deep infiltrating rectosigmoid lesions and for the prediction of stenosis and involvement of the upper part of the colon and small intestine.

Correlative study of angiogenesis in endometrial cancer assessed by the color Doppler ultrasound and by the chick embryo chorioallantoic membrane

Angiogenesis is required for both tumor growth and progression and the degree of vascularization seems to correlate with prognosis in several human tumors including uterine malignant neoplasms. In this study we have investigated if three Doppler parameters, such as peak systolic velocity (PSV), resistance index (RI) and pulsatily index (PI), measured in patients with endometrial cancer, were correlated to the angiogenic response induced by grafting of bioptic specimens obtained from the same patients onto the chick embryo chorioallantoic membrane (CAM), a useful in vivo model for such an investigation. Results showed that only PSV was directly correlated to the degree of angiogenesis measured by means of the CAM assay. Moreover, these two parameters were also directly correlated to the malignancy grade of the disease.

Diabetic placenta: ultrastructure and morphometry of the term villi

OBJECTIVE

To verify the ultrafine conformation of term villi in diabetic and normal placentae. Villar dysmaturity and chorangiosis are considered the most frequent findings in diabetic placentae, but their histogenesis is still unclear.

STUDY DESIGN

We performed a morphometric study of 38 term villi in 5 diabetic placentae and of 37 term villi of 5 normal placentae in order to know the different extension of endothelial surface (VL), the maximum (D max) and minimum (D min) distance of the vessels from the basal membrane, as well as the exact thickness of basal membrane (MT BM). The villi were examined with transmission electron microscopy, and parameters were automatically acquired with the iTEM software (Soft Imaging System, Münster, Germany).

RESULTS

VL results were statistically higher in diabetic placentae than in normal ones. Also D max and D min were higher in diabetic disease. MT BM was not different in the two groups.

CONCLUSION

Our findings show that, in the presence of chorangiosis, the vessel surface in diabetic placentae is higher than in normal group, but the vessels are randomly distributed in term villi. The basal membrane is not different in the two groups. Morphometric evaluation seems to be more accurate using ultrafine samples.

Deep pelvic endometriosis: accuracy of pelvic MRI completed by MR colonography

PURPOSE

This study assessed the diagnostic accuracy of pelvic magnetic resonance (MR) imaging completed by MR colonography for the preoperative evaluation of deep pelvic endometriosis in patients undergoing laparoscopic surgery.

MATERIALS AND METHODS

A total of 143 patients (mean age 34.3 ± 5.1 years) with a clinical suspicion of deep pelvic endometriosis were assessed by pelvic MR and MR colonography. All patients underwent laparoscopic surgery 3-10 weeks after the MR examination. The presence, location, number and extent of endometriotic lesions were evaluated. Data obtained with MR were compared with surgical findings. MR sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and diagnostic accuracy values were calculated for each site by considering the laparoscopic and histological findings as the reference standard.

RESULTS

Laparoscopy confirmed the presence of endometriosis in 119/143 patients (83%); in 76/119 (64%) deep pelvic endometriosis was diagnosed, whereas in the remaining 43/119 (36%), superficial peritoneal implants and endometriomas were found. In 32/119 (27%) patients, intestinal lesions were detected. MR had sensitivity, specificity, PPV, NPV and diagnostic accuracy values of 67-100%, 85-100%, 83-100%, 84-100% and 84-100%, respectively, in recognising lesions located in different pelvic sites.

CONCLUSIONS

MR imaging combined with colonography is a highly accurate tool for characterising deep endometriotic lesions in patients scheduled for laparoscopic surgery. In particular, MR colonography has very high accuracy in detecting colorectal involvement.

Correlation between ultrasound diagnosis and autopsy findings of fetal malformations

OBJECTIVE

to compare ultrasound (US) and autopsy findings of fetal malformations in second trimester terminations of pregnancy to evaluate the degree of agreement between US and fetal autopsy.

METHODS

in this study, all second trimester termination of pregnancy between 2003-2010 were considered. US and autopsy findings were compared and all cases were classified into five categories according to the degree of agreement between US and pathology (A1: full agreement between US and autopsy; A2: autopsy confirmed all US findings but revealed additional anomalies 'rarely detectable' prenatally; B: autopsy demonstrated all US findings but revealed additional anomalies 'detectable' prenatally; C: US findings were only partially demonstrated at fetal autopsy; D: total disagreement between US and autopsy).

RESULTS

144 cases were selected. In 49% of cases there was total agreement between US and autopsy diagnosis (A1). In 22% of cases additional information were about anomalies 'not detectable' by US (A2). In 12% of cases autopsy provided additional information about anomalies not observed but 'detectable' by US (B). In 13% of cases some anomalies revealed at US, such as valve insufficiencies, pericardial and pleural effusions, were not verified at autopsy (C). Total lack of agreement was noted only in 4% of cases (D). Main areas of disagreement concerned cardiovascular, CNS and complex malformations. The degree of agreement was higher if malformations were diagnosed in a tertiary center.

CONCLUSIONS

this study shows an overall high degree of agreement between definitive US and autopsy findings in second trimester termination of pregnancy for fetal malformations. Autopsy reveals to be the best tool to diagnose malformations and often showed other abnormalities of clinical importance not detected by US, but sometimes also US could provide additional information about functional anomalies because US is a dynamic examination.

Pregnancy outcomes in women with advanced HIV infection in Italy

Pregnancy has been associated with a low risk of HIV disease progression. Most pregnancies with HIV currently involve women who have not experienced AIDS-defining events, and are clinically classified as Centers for Disease Control and Prevention (CDC) groups A or B. We evaluated the main maternal outcomes among pregnant women with more advanced HIV disease, defined by CDC-C disease stage. Data from the Italian National Program on Surveillance on Antiretroviral Treatment in Pregnancy were used. A total of 566 HIV-infected mothers, 515 in stage A or B (CDC-AB group) and 51 in stage C (CDC-C group) were evaluated. The two groups had similar baseline characteristics. No differences were found in the main maternal and neonatal outcomes. Most of the women achieved viral suppression at end of pregnancy (>1000 copies per milliliter: CDC-C: 17.2%; CDC-AB: 13.7%). One year after delivery, HIV replication (HIV-RNA >1000 copies per milliliter) was present in 11.5% of CDC-AB women and 30.0% CDC-C women. Despite lower initial CD4 counts (300 versus 481 cells per microliter), CDC-C women maintained stable CD4 levels during pregnancy, and 1 year after delivery, a significant increase in CD4 count from preconception values was observed in both groups (CDC-C: +72 cells per microliter, p=0.031; CDC-AB: +43 cells per microliter, p<0.001). Only one AIDS event occurred in a woman with a previous diagnosis of AIDS. In CDC-C women, pregnancy is not associated with an increased rate of adverse maternal or neonatal outcomes, and a good immunovirologic response can be expected. During postpartum care, women with more advanced HIV infection should receive particular care to prevent loss of virologic suppression.