The impact of lateral placenta on preeclampsia and small for gestational age neonates: a systematic review and meta-analysis

OBJECTIVES

We conducted a systematic review and meta-analysis to quantitatively summarize the present data on the association of prenatally identified lateral placenta in singleton pregnancies with small for gestational age (SGA) neonates, preeclampsia and other perinatal outcomes.

METHODS

From inception to November 2021, we searched PubMed/Medline, Scopus and The Cochrane Library for papers comparing the risk of SGA and preeclampsia, as well as other perinatal outcomes in singleton pregnancies with a prenatally identified lateral placenta to those with non-lateral placentas. The revised Newcastle-Ottawa Scale was used to evaluate the quality of eligible papers. The I² test was employed to evaluate the heterogeneity of outcomes among the studies. To investigate the possibility of publication bias, funnel plots were constructed. Prospero RN: CRD42021251590.

RESULTS

The search yielded 5,420 articles, of which 16 were chosen, comprising of 15 cohort studies and one case control study with a total of 4,947 cases of lateral and 96,035 of non-lateral placenta (controls) reported. SGA neonates were more likely to be delivered in cases with a lateral placenta (OR: 1.74; 95% CI: 1.54-1.96; p<0.00001; I²=47%). Likewise, placental laterality was linked to a higher risk of fetal growth restriction (OR: 2.18; 95% CI: 1.54-3.06; p<0.00001; I2=0%), hypertensive disorders of pregnancy (OR: 2.39; 95% CI: 1.65-3.51; p=0.0001; I²=80%), preeclampsia (OR: 2.92; 95% CI: 1.92-4.44; p<0.0001; I²=82%) and preterm delivery (OR: 1.65; 95% CI: 1.46-1.87; p<0.00001; I²=0%).

CONCLUSIONS

The prenatal diagnosis of a lateral placenta appears to be associated with a higher incidence of preeclampsia, fetal growth restriction, preterm delivery and SGA. This may prove useful in screening for these conditions at the second trimester anomaly scan.

Investigation and management of abnormal uterine bleeding in reproductive-aged women: a descriptive review of national and international recommendations

PURPOSE

To review and compare the most recently published recommendations on the investigation and management of abnormal uterine bleeding (AUB).

MATERIALS AND METHODS

A descriptive review of recommendations from the American College of Obstetricians and Gynaecologists (ACOG), the National Institute for Health and Care Excellence (NICE), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the International Federation of Gynaecology and Obstetrics (FIGO) on AUB in reproductive-aged women was carried out.

RESULTS

There is a consensus that detailed personal and family history along with physical examination are essential in the investigation of menstrual, intermenstrual or postcoital AUB. All the medical societies recommend transvaginal ultrasound as the first-line imaging modality to determine the AUB cause. Moreover, they agree (except for RANZCOG) that, in women with AUB, endometrial biopsy should only be performed if additional risk factors for endometrial cancer are present. Laboratory tests may be helpful in the AUB investigation; however, there are several discrepancies among the recommendations. Regarding AUB management, NICE, ACOG and SOGC agree that the administration of hormonal or non-hormonal medications should be the first-line treatment modality in bleeding disorders and absent or minor structural pelvic pathology. Surgical management should be preferred in cases of identified polyps, large fibroids or unsuccessful pharmacological treatment.

CONCLUSIONS

Since AUB affects a significant proportion of reproductive-aged women, the main objective is to improve the quality of life of these patients without missing cases of malignancy.

Impact of Marginal and Velamentous Cord Insertion on Uterine Artery Doppler Indices, Fetal Growth, and Preeclampsia

OBJECTIVES

To assess the impact of marginal (MCI) or velamentous (VCI) cord insertion on uterine artery pulsatility index (UtA PI), preeclampsia (PE), and offspring's birthweight (BW).

METHODS

A retrospective cohort study of singleton pregnancies, undergoing routine anomaly scan at 20⁺⁰ -23⁺⁶ gestational weeks, was conducted between 2016 and 2020. The effect of placental cord insertion on BW and UtA mean PI z-scores was assessed using the t test or analysis of variance and post-hoc tests; their association with PE was evaluated with the chi-square test. A multivariate logistic regression model was employed to assess the independent association of placental cord insertion and UtA PI z-score with PE, BW <10th, <5th centile, and intrauterine death (IUD), using specific confounders.

RESULTS

The study population included 4453 pregnancies. Conception via assisted reproductive technology (ART) was associated with increased risk of abnormal cord insertion (odds ratio [OR]: 2.237; 95% confidence interval [CI]: 1.561-3.206; P < .001). Women with MCI/VCI had higher mean UtA PI z-score than those with central/eccentric (0.29 vs 0.01; mean difference: -0.28; 95% CI: -0.399 to -0.165; P < .001). MCI/VCI were associated with higher rates of BW <10th centile (central/eccentric: 16.2% vs MCI: 21.9% vs VCI: 35.7%; P < .001) and BW <5th centile (9.8 vs 15.1 vs 23.2%, respectively; P < .001). No association was identified between MCI/VCI and PE (P = .968). Finally, VCI (aOR: 13.717; 95% CI: 1.576-119.379; P = .018) and increased BMI (aOR: 1.167; 95% CI: 1.071-1.271; P < .001) significantly correlated with IUD.

CONCLUSIONS

Abnormal cord insertion is more common in ART pregnancies. MCI/VCI are associated with higher mean UtA PI and lower BW centile, but not with increased risk of PE.

Investigation and management of stillbirth: a descriptive review of major guidelines

Stillbirth is a common and devastating pregnancy complication. The aim of this study was to review and compare the recommendations of the most recently published guidelines on the investigation and management of this adverse outcome. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynecologists (RCOG), the Perinatal Society of Australia and New Zealand (PSANZ), the Society of Obstetricians and Gynecologists of Canada (SOGC) on stillbirth was carried out. Regarding investigation, there is consensus that medical history and postmortem examination are crucial and that determining the etiology may improve care in a subsequent pregnancy. All guidelines recommend histopathological examination of the placenta, genetic analysis and microbiology of fetal and placental tissues, offering less invasive techniques when autopsy is declined and a Kleihauer test to detect large feto-maternal hemorrhage, whereas they discourage routine screening for inherited thrombophilias. RCOG and SOGC also recommend a complete blood count, coagulopathies' testing, anti-Ro and anti-La antibodies' measurement in cases of hydrops and parental karyotyping. Discrepancies exist among the reviewed guidelines on the definition of stillbirth and the usefulness of thyroid function tests and maternal viral screening. Moreover, only ACOG and RCOG discuss the management of stillbirth. They agree that, in the absence of coagulopathies, expectant management should be considered and encourage vaginal birth, but they suggest different labor induction protocols and different management in subsequent pregnancies. It is important to develop consistent international practice protocols, in order to allow effective determination of the underlying causes and optimal management of stillbirths, while identifying the gaps in the current literature may highlight the need for future research.

The use of antenatal corticosteroids for fetal maturation: clinical practice guideline by the WAPM-World Association of Perinatal Medicine and the PMF-Perinatal Medicine foundation

This practice guideline follows the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation, bringing together groups and individuals throughout the world, with the goal of improving the use of antenatal corticosteroids (ACS) for fetal maturation. In fact, this document provides further guidance for healthcare practitioners on the appropriate use of ACS with the aim to increase the timely administration and avoid unnecessary or excessive use. Therefore, it is not intended to establish a legal standard of care. This document is based on consensus among perinatal experts throughout the world and serves as a guideline for use in clinical practice.

The use of antenatal corticosteroids for fetal maturation in COVID-19: clinical practice statement by WAPM-World Association of Perinatal Medicine and the PMF-Perinatal Medicine Foundation

This statement follows the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation, bringing together groups and individuals throughout the world with the goal of improving the use of antenatal corticosteroids (ACS) for fetal maturation in Coronavirus Disease 2019 (COVID-19). Pregnant women with COVID-19 are at increased risk of hospitalization, admission to intensive care unit and mechanical ventilation compared to non-pregnant patients. Thus, obstetricians may face the dilemma of initiating maternal corticosteroid therapy for maternal indication while weighing its potential adverse effects on the fetus. As there is no evidence on the effect of betamethasone in pregnant women with COVID-19, dexamethasone should be preferably used for fetal maturation, if available. As a recommendation, for pregnant women with COVID-19 who are oxygen dependent or under mechanical ventilation and meet the criteria for ACS, the usual doses of dexamethasone should be administered, followed by oral prednisolone 40 mg OD or intravenous hydrocortisone 80 mg BD for up to 10 days.

The use of antenatal corticosteroids for fetal maturation: clinical practice guideline by the WAPM-World Association of Perinatal Medicine and the PMF-Perinatal Medicine Foundation

This practice guideline follows the mission of the World Association of Perinatal Medicine (WAPM) in collaboration with the Perinatal Medicine Foundation (PMF), bringing together groups and individuals throughout the world with the goal of improving the use of antenatal corticosteroids (ACS) for fetal maturation. In fact, this document provides further guidance for healthcare practitioners on the appropriate use of ACS with the aim to increase the timely administration and avoid unnecessary or excessive use. Therefore, it is not intended to establish a legal standard of care. This document is based on consensus among perinatal experts throughout the world and also serves as a guideline for use in clinical practice.

Adverse perinatal outcomes following the prenatal diagnosis of isolated single umbilical artery in singleton pregnancies: a systematic review and meta-analysis

OBJECTIVES

A systematic review and meta-analysis was conducted to quantitatively synthesize the current evidence on the association of prenatally diagnosed isolated single umbilical artery (iSUA) in singleton pregnancies with small for gestational age (SGA) neonates and other perinatal outcomes.

METHODS

A search of PubMed/Medline, Scopus and The Cochrane Library was conducted, from inception to February 2021, in order to identify studies comparing the risk of SGA and other perinatal adverse outcomes in prenatally diagnosed iSUA singleton pregnancies vs. those with a 3-vessel cord (3VC). The quality of eligible studies was assessed according to the improved Newcastle-Ottawa Scale (NOS). The heterogeneity of results across the studies was tested using the I² test. Funnel plots and Egger's test were used to assess the possibility of publication bias. Prospero RN: CRD42020182586.

RESULTS

The electronic search identified 7,605 studies, of which 11 were selected, including three retrospective cohort and eight retrospective case control studies, overall reporting on 1,533 iSUA cases. The risk of delivering SGA neonates was increased in cases with iSUA (OR: 2.90; 95% CI: 2.02-4.18; p<0.00001; I²=71%). Similarly, iSUA was associated with an increased risk of pregnancy-induced hypertension (PIH) (OR: 2.23; 95% CI: 1.41-3.54; p<0.000; I²=1%), intrauterine death (IUD) (OR: 2.62; 95% CI: 1.43-4.79; p=0.002; I²=0%), preterm birth (PTB) (OR: 2.48; 95% CI: 1.73-3.56; p<0.00001; I²=56%), cesarean section (CS) (OR: 1.64; 95% CI: 1.11-2.41; p=0.01; I²=78%) and admission to neonatal intensive care unit (NICU) (OR: 2.28; 95% CI: 1.52-3.44; p<0.000001; I²=73%).

CONCLUSIONS

In prenatally diagnosed iSUA there is a higher risk of SGA, PIH, IUD, PTB, CS and NICU admission. These findings support the value of prenatal diagnosis of iSUA, which may subsequently intensify surveillance for the detection of specific pregnancy complications.

Inguinal endometriosis: A systematic review

Inguinal endometriosis is a very rare entity with uncertain pathophysiology, that poses several diagnostic and therapeutic challenges. This study aimed to summarize published literature on the diagnosis and treatment of this condition. Thus, a systematic literature search was conducted in PubMed/MEDLINE, Scopus and the Cochrane Library. An effort was made to numerically analyze all parameters included in case reports and retrospective analyses, as well. The typical and atypical features of this condition, investigations used, type of treatment and histopathology were recorded. More specifications about the surgical treatment, such as operations previously performed, type of surgery and treatment after surgery have been acknowledged. Other sites of endometriosis, the presence of pelvic endometriosis and the follow-up and recurrence have been also documented. Overall, the search yielded 61 eligible studies including 133 cases of inguinal endometriosis. The typical clinical presentation includes a unilateral inguinal mass, with or without catamenial pain. Transabdominal or transvaginal ultrasound was typically used as the first line method of diagnosis. Groin incision and exploratory surgery was the treatment indicated by the majority of the authors, while excision of part of the round ligament was reported in about half of the cases. Chemotherapy and radiotherapy were initiated in cases of coexisting endometriosis-related neoplasia. Inguinal recurrence or malignant transformation was rarely reported. The treatment of inguinal endometriosis is surgical and a long-term follow-up is needed. More research is needed on the effectiveness of suppressive hormonal therapy, recurrence rate and its relationship with endometriosis-associated malignancies.

The Greek translation and validation of the electronic version of the Meno-D rating scale for post-menopausal depression

Menopausal transition and post-menopause constitute windows of increased vulnerability to depression. Recently, the Meno-D was introduced, a novel 12-item, with five distinct subscales. The aim of our study was to translate and validate the electronic version of the Meno-D among Greek post-menopausal women. Translation and back-translation were performed by an expert group, while face validity was assessed by five experts. Along with the Beck Depression Inventory-II, the Meno-D scale was distributed online to 502 post-menopausal women. A confirmatory factor analysis was performed to investigate construct validity and both convergent and discriminant validity were evaluated. The data analysis was performed using Statistical Package for Social Sciences and AMOS. The 5-factor model of Meno-D achieved adequate levels of goodness-of-fit indices, scoring lower values in discriminant validity examined with heterotrait-monotrait ratio and composite reliability. The significant correlation with the Beck Depression Inventory-ΙΙ revealed for all subscales was indicative of good convergent validity. An exploratory factor analysis was additionally performed, suggesting a 12-item tool comprising two subscales: (i) psychological and (ii) biological and achieving good levels of fit. Our data confirmed that the electronic version of Meno-D is a valid tool that can be used for screening and evaluation of depression in Greek post-menopausal women.

Giant uterine STUMP in pregnancy: A rare case report with preservation of fertility

BACKGROUND

Smooth muscle tumors of uncertain malignant potential (STUMPs) are infrequent and represent an extremely rare cause of oligohydramnios in pregnant women.

DESCRIPTION OF THE CASE

A 34-year-old woman at 25 weeks of gestation was referred with clinical features indicative of anemia. The transabdominal ultrasound revealed a fetus with appropriate growth for the gestational age, with oligohydramnios and a giant uterine mass. At 30 weeks of gestation, due to anhydramnios and repeated non-reassuring non-stress tests, a cesarean section was performed, followed by a myomectomy of a 9 kg mass. A neonate weighing 1,350 g was delivered (Apgar score 1΄: 4, 5΄: 7). The woman preserved her fertility and had an uneventful recovery during the puerperium, while the final histology revealed multiple STUMPs. The postoperative management included follow-up every six months for five years.

CONCLUSION

This is the only reported case of a pregnant woman with STUMPs of this size that underwent myomectomy during the cesarean section and avoided hysterectomy. HIPPOKRATIA 2021, 25 (4):169-171.

Chronic hypertension in pregnancy: synthesis of influential guidelines

Chronic hypertension in pregnancy accounts for a substantial proportion of maternal morbidity and mortality and is associated with adverse perinatal outcomes, most of which can be mitigated by appropriate surveillance and management protocols. The aim of this study was to review and compare recommendations of published guidelines on this condition. Thus, a descriptive review of influential guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada and the American College of Obstetricians and Gynecologists on chronic hypertension in pregnancy was conducted. All guidelines agree on the definition and medical management, the need for more frequent antenatal care and fetal surveillance and the re-evaluation at 6-8 weeks postpartum. There is also a consensus that the administration of low-dose aspirin is required to prevent preeclampsia, although the optimal dosage remains controversial. No universal agreement has been spotted regarding optimal treatment blood pressure (BP) targets, need for treating mild-to-moderate hypertension and postnatal BP measurements. Additionally, while the necessity of antenatal corticosteroids and magnesium sulfate for preterm delivery is universally recommended, the appropriate timing of delivery is not clearly outlined. Hence, there is a need to adopt consistent practice protocols to optimally manage these pregnancies; i.e. timely detect and treat any potential complications and subsequently reduce the associated morbidity and mortality.

Antenatal depression and anxiety during the COVID-19 pandemic: a cross-sectional study in pregnant women from routine health care contact in Greece

OBJECTIVES

The impact of the COVID-19 pandemic and the public health measures introduced to control it, on mental health, is largely unknown. Research conducted during past epidemics found that pregnant women are more vulnerable psychologically. The aim of this study was to investigate antenatal depressive and anxiety symptoms during this pandemic in Greece.

METHODS

All women receiving routine antenatal care, during a three-month period, starting one week after the total lockdown in Greece, in a University department, were asked to fill in two questionnaires, the Edinburg Postnatal Depression Scale (EPDS) and the State-Trait Anxiety Inventory (STAI).

RESULTS

Overall, 505 women (93.3% of the eligible population) agreed to participate. The prevalence of antenatal depression (EPDS score≥13) in the population of the study was 13.5%. Unplanned pregnancy (OR: 2.447; 95% CI: 1.235-4.846), smoking (OR: 2.268; 95% CI: 1.166-4.411) and antenatal anxiety (OR: 5.074; 95% CI: 2.898-8.883) increased the risk of antenatal depression during the COVID-19 pandemic. State (current)-anxiety affected 34.1% of the participants, whereas Trait (lifetime)-anxiety affected 15.8%. The State-anxiety score (median) was significantly higher than the Trait-anxiety (median) (41 vs. 36; p<0.001), revealing an increase in the levels of anxiety in the pandemic, while there was also a positive linear correlation between the two scales (rho=0.592; p<0.001).

CONCLUSIONS

The unprecedented situation of the COVID-19 pandemic has increased anxiety, but not depression levels of pregnant women in Greece. Population level interventions to address adverse effects on anxiety status in the initial phases of similar situations may be helpful in the future.

Diagnosis and Management of Gestational Trophoblastic Disease: A Comparative Review of National and International Guidelines

Importance

Gestational trophoblastic disease (GTD) is associated with increased mortality and morbidity in women of reproductive age, if managed in a suboptimal way, left untreated, or diagnosed after the development of extensive metastases.

Objective

The aims of this study were to review and compare the recommendations from published guidelines on these tumors of placental origin.

Evidence Acquisition

A descriptive review of guidelines from the Royal College of Obstetricians and Gynecologists, the International Federation of Gynecology and Obstetrics, the European Society for Medical Oncology, and the Royal Australian and New Zealand College of Obstetricians and Gynecologists on GTD was carried out.

Results

All the guidelines agree that suction evacuation is the optimal management for hydatidiform molar pregnancy and that chemotherapy, either single-agent (for low risk) or multiagent (for high risk), is the preferred treatment modality for choriocarcinoma. There is also a consensus that a future pregnancy should be avoided during follow-up; therefore, an effective contraception method should be used. All medical societies recommend the registration of such patients to GTD screening centers, endorse the use of International Federation of Gynecology and Obstetrics 2000 scoring system, and mention that the diagnosis of gestational trophoblastic neoplasia (GTN) should be based on the clinical presentation (from the genital tract and the metastatic sites) and the human chorionic gonadotropin evaluation. Additionally, all 4 medical societies recommend the surgical management of placental site trophoblastic tumors or epithelioid trophoblastic tumors, as chemotherapy is less effective in these cases. However, there is controversy regarding the appropriate follow-up after the treatment of hydatidiform mole, the administration of anti-D immunoglobulin, the time of oxytocin infusion, and the salvage regimens that may be used in cases of resistant or recurrent GTN.

Conclusions

There is need for consistent international practice protocols, which will lead to an earlier diagnosis and eventually to a more effective management of GTD worldwide and decrease in the recurrence rate and in the associated morbidity and mortality.

Risk of developing metabolic syndrome after gestational diabetes mellitus - a systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis were conducted to quantitatively synthesize the current evidence regarding the risk of developing metabolic syndrome (MetS) in women with a personal history of gestational diabetes mellitus (GDM), without pre-existing diabetes, compared with those without a history of GDM.

METHODS

Four electronic databases [MEDLINE (via PubMed), Scopus, Cochrane Library, PROSPERO] were searched for relevant literature until July 29th 2020. Cochran's Q test was applied for the assessment of heterogeneity. The random-effects model was applied by calculating the odds ratio (OR) and 95% confidence interval (CI) for each study. Publication bias was estimated with Egger's linear regression test.

RESULTS

The results from 23 studies (10,230 pregnant women; 5169 cases, 5061 controls), indicated that women with a history of GDM had a higher risk of developing MetS compared with those without such a history (OR 3.45; 95% CI 2.80-4.25, p < 0.0001). This risk remained higher, independently of maternal age and ethnicity (although the risk was not as high in Asians; OR 2.11; 95% CI 1.27-3.52). The risk of developing MetS was even higher in studies where women with GDM had increased body mass index (BMI) compared with the controls (OR 4.14; 95% CI 3.18-5.38).

CONCLUSIONS

The risk for developing MetS following delivery is higher in women with a history of GDM compared with women without such a history. Timely recognition and appropriate intervention are critical to halt progression to MetS and its associated morbidity.

Development and validation of a short culture-specific food frequency questionnaire for Greek pregnant women and their adherence to the Mediterranean diet

OBJECTIVES

The aim of this study was to develop and evaluate the validity of a short, culture-specific, semiquantitative food frequency questionnaire (FFQ) for Greek dietary habits and among a population of pregnant women, and to assess the adherence of reported nutritional habits to the Mediterranean diet.

METHODS

The validity of the FFQ was assessed by comparing FFQ-derived nutrient intakes against the average of two 24-h dietary recalls of 70 pregnant women. We used appropriate statistical methods to examine the nutrient correlation and level of agreement between the two figures (Pearson or Spearman correlation and Bland-Altman test, respectively). Calculation of the Mediterranean Diet Score was performed to evaluate participants' adherence to the Mediterranean diet.

RESULTS

Statistically significant positive correlations, of medium strength, were observed for almost all macronutrient groups (ρs ranging from 0.326 to 0.538). Dietary fiber intake was the only nutrient where a weak correlation was identified (ρ = -0.106; P > 0.05). Mean intakes, derived from the FFQ, agreed with results from the 24-h recalls based on Bland-Altman analysis, with the agreement ranging between 94.3% and 98.6% for the macronutrient groups under examination. The calculation of the Mediterranean Diet Score revealed that Greek pregnant women's habits are in accordance with the principles of the Mediterranean diet.

CONCLUSIONS

The developed FFQ is a valid tool that could provide reliable nutrient intake assessment in studies monitoring dietary habits of pregnant women, a group where nutritional monitoring is essential but to date remains limited.

Assessment of the Safety Signal for the Abuse Potential of Pregabalin and Gabapentin Using the FAERS Database and Big Data Search Analytics

Introduction: The latest decade, an emerging issue has been the abuse potential of the gabapentinoids pregabalin and gabapentin. The aim of our study was to assess this safety signal combining two different methods of surveillance: search analytics big data and the FDA spontaneous reporting system database. Methods: Analysis of big data and the FAERS was used to detect pregabalin's and gabapentin's abuse potential in comparison with two controls, clonazepam and levetiracetam, and further, the correlation between these domains was investigated. Data from the United States between 2007 and 2020Q2 were analyzed. Results: The FAERS analysis revealed the following pattern of signals: clonazepam > pregabalin ≥ gabapentin > levetiracetam, for both the primary term "drug abuse and dependence" and the secondary terms (withdrawal, tolerance, overdose). The Google domain pattern was slightly different: clonazepam ≥ gabapentin ≥ pregabalin≥ levetiracetam. A monotonic correlation was found between FAERS and Google searches for gabapentin (r = 0.558; p < 0.001), pregabalin (r = 0.587; p < 0.001), and clonazepam (r = 0.295; p = 0.030). Conclusion: Our results revealed that there is preliminary evidence of a safety signal for the abuse potential of pregabalin and gabapentin. Analysis of the FAERS database, supplemented by big data search analytics, suggests that there is potential of using these methods as a supplementary tool to detect drug abuse-related safety signals in pharmacovigilance.

Efficacy and Safety of Corticosteroids' Administration for Pulmonary Immaturity in Anticipated Preterm Delivery

Preterm delivery represents the major cause of neonatal morbidity and mortality. Respiratory morbidity is the primary cause of early neonatal mortality and disability. The administration of antenatal corticosteroids, in cases of imminent preterm delivery, can enhance fetal lung maturation and reduce the incidence of respiratory distress syndrome, leading to improved neonatal outcomes. Hence, for those cases, a single course of antenatal corticosteroids from 24 up to 34 gestational weeks should be offered. Betamethasone and dexamethasone are the most widely used drugs, with similar effectiveness and a recommended dosage of 24mg in divided doses, over a 24-hour period. However, there is an ongoing debate regarding the gestational age of administration. Some obstetric societies recommend their administration even at 22 weeks of gestation. Conflicting is also their usefulness in late preterm cases (between 34 and 37 weeks) or in cases of elective cesarean delivery at term. The use of repeated courses of corticosteroids may be considered in specific cases, however, concerns on the long-term outcomes of repeated courses beyond 34 gestational weeks have been raised. The scope of this narrative review was to synthesize available evidence on efficacy and safety of corticosteroids administration during the antenatal period for pulmonary immaturity in cases of anticipated preterm delivery.

Comparison of the efficacy and safety of two combined misoprostol regimens for second trimester medical abortion

OBJECTIVE

The aim of the study was to compare the efficacy and safety of two combined misoprostol regimens for second trimester medical abortion.

METHODS

This was a retrospective cohort study examining data on singleton pregnancies that underwent second trimester medical abortion between November 2011 and November 2019 in a tertiary care centre in northern Greece. In the first study period (November 2011 to August 2015), the management protocol (protocol 1) consisted of 800 μg vaginal misoprostol followed by 400 μg oral misoprostol, every 3 h, for up to five doses. In the second study period (September 2015 to November 2019), a new protocol (protocol 2) was introduced, where the oral route was changed to sublingual, using the same dosage. The two routes were compared in terms of efficacy and safety.

RESULTS

The study comprised 85 women: 43 (50.6%) received the protocol 1 regimen (vaginal-oral), while 42 (49.4%) received the protocol 2 regimen (vaginal-sublingual). The groups did not differ in terms of maternal age, gestational age and parity. Sublingual misoprostol was more effective than oral misoprostol, both in terms of dose needed (median 1600 μg vs 2000 μg; p = 0.031) and induction-to-abortion interval (8 h vs 11 h; p = 0.001). Surgical evacuation due to incomplete abortion was necessary in 11.9% of women in the sublingual group vs 18.6% in the oral group (p = 0.394). Women in the sublingual group reported a higher rate of severe pain (odds ratio [OR] 6.061; 95% confidence interval [95% CI] 1.240, 29.619) and shivering (OR 4.632; 95% CI 1.788, 11.995).

CONCLUSION

The administration of vaginal-sublingual misoprostol, when compared with the vaginal-oral regimen, was associated with a shorter induction-to-abortion interval but a higher incidence of severe pain and shivering.

Evaluation of the safety and efficacy of corifollitropin alfa combined with GnRH agonist triggering in oocyte donation cycles. A prospective longitudinal study

Objective:

In order to help make the dream of parenthood come true for oocyte acceptors, it is essential that the procedure is not dangerous or unpleasant for oocyte donors. The aim of this study was to identify differences in safety, efficacy and patient acceptability between a traditional stimulation antagonist protocol with recombinant-FSH (rFSH) with hCG-triggering, compared with an innovative antagonist protocol with corifollitropin alfa (Elonva^®) plus GnRH agonist triggering in oocyte donors.

Methods:

A prospective longitudinal study was conducted at an in vitro fertilization center in Greece. The same eighty donors underwent two consecutive antagonist stimulation schemes. Primary outcomes were patient satisfaction (scored by a questionnaire) and delivery rate per donor. Secondary outcomes were mean number of cumulus-oocyte-complexes, metaphase II (MII) oocytes and ovarian hyperstimulation syndrome (OHSS) rate.

Results:

Donors reported better adherence and less discomfort with the corifollitropin alpha + GnRH agonist-triggering protocol (p<0.001). No significant differences were identified in the clinical pregnancy rate per donor (p=0.13), the delivery rates, the number of oocytes (p=0.35), the number of MII oocytes (p=0.50) and the number of transferred embryos, between the two protocols. However, the luteal phase duration was significantly shorter (p<0.001) in the corifollitropin alpha + GnRH agonist-triggering protocol. Moreover, three cases of moderate OHSS (3.75%) were identified after hCG triggering, whereas no case of OHSS occurred after GnRH agonist ovulation induction (p=0.25).

Conclusion:

The use of corifollitropin alpha combined with a GnRH agonist for triggering is a safe, effective and acceptable protocol for oocyte donors.

Management of Breech Presentation: A Comparison of Four National Evidence-Based Guidelines

OBJECTIVE

The management of breech presentation may improve perinatal outcomes. The aim of this study was to synthesize and compare published evidence of four national guidelines on breech presentation.

STUDY DESIGN

A descriptive review of four recently published national guidelines on breech presentation and external cephalic version (ECV) was conducted: Royal College of Obstetricians and Gynaecologists guideline on "External Cephalic Version and Reducing the Incidence of Term Breech Presentation" and "Management of Breech Presentation", American College of Obstetricians and Gynecologists guideline on "External Cephalic Version" and "Mode of Term Singleton Breech Delivery," Society of Obstetricians and Gynaecologists of Canada guideline on "Vaginal Delivery of Breech Presentation" and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists guideline on "Management of breech presentation at term."

RESULTS

Regarding ECV, there is no recommendation by the SOGC, whereas all other national guidelines recommend this technique. Regarding breech vaginal delivery, there are limited recommendations by the ACOG, whereas all other guidelines provide similar recommendations. The RANZCOG makes no special recommendations on the intrapartum period.

CONCLUSION

The differences among national guidelines point out the need for the adoption of an international consensus on the management of breech presentation.