Relationship between peripartum maternal cardiac phenotype and maternal outcome in women with hypertensive disorders of pregnancy

Background

Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal and neonatal morbidity worldwide.

Purpose

The aim of this study is to assess maternal cardiac function in women affected by HDP in singleton pregnancy and investigate the relationship between abnormal cardiac findings and maternal outcomes.

Methods

In this single-centre prospective longitudinal study, 190 women with a diagnosis of HDP underwent standard trans-thoracic echocardiography (TTE) in the immediate peripartum period from February 2019 to December 2020. Left ventricle morphology (LVM) and diastolic dysfunction (DD) were evaluated according to according to British Society of Echocardiography guidelines. Patients were classified into three groups according to TTE findings: (1) normal LVM and DD, (2) abnormal LVM or abnormal DD, (3) abnormal LVM and abnormal DD. Maternal indices were compared among these groups.

Results

56 (29.5%) patients affected by HDP were included in group 1, 69 (36.3%) in group 2 and 65 (34.2%) in group 3. Gestational age at delivery and birthweight centile were similar among the groups. Women in group 3 were significantly older than group 2 and group 1 (35.1±5.4 years vs 32.6±6.3 vs 33.1±5.8 years years, respectively, p=0.043). Group 2 and 3 showed a higher blood pressure in the first trimester of pregnancy compared to group 1 (mean arterial pressure: 94.3±7.2 mmHg vs 95.5±8.2 mmHg vs 91.6±8.3 mmHg, p=0.024), while no significant difference was found in body mass index among the three groups (group 1: 26.4±5.4, group 2: 28.0±6.4; group 3: 27.7±5.0, p=0.293). HDP women with LVM and DD (group 3) were more likely to be admitted to high dependency unit (35.4%) than women in group 2 and 1 (14.5% and 23.6%, respectively, p=0.019).

Conclusions

Abnormal echocardiographic findings were associated with a worse maternal cardiovascular phenotype that required a closer maternal cardiovascular monitoring in the peripartum period.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Veronica Giorgione and Carolina Di Fabrizio have received funding from European Union's Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 765274 (iPLACENTA project).

Opthalmic artery doppler measurements and cardiovascular assessment in pregnancies with placental dysfunction

 

Women affected by hypertensive disorders of pregnancy and fetal growth restriction frequently present alterations in the cardiovascular system, even before the clinical onset of the pathology. The objective of this study is to assess the relationship between peripheral vascular system (ophthalmic and uterine arteries), cardiac output and adverse fetomaternal outcomes.

Methods

Women with singleton pregnancies from mid second trimester until delivery were prospectively included in this observational study performed at our Hospital, between December 2020 and July 2021. The inclusion criteria included women with evidence of placental dysfunction (preeclampsia and fetal growth restriction) and normotensive controls.

Vascular systemic resistance (VSR), arterial stiffness and cardiac output were measured by ultrasound (uterine and ophthalmic arteries), plethysmography and continuous Doppler. Study variables were compared using t-test and Chi-squared test according to whether they were normally distributed or not.

Results

The analysis included 32% women with hypertensive disorders of pregnancy and 67% normal pregnancies.

Statistically significant difference was observed in the Second to First Peak Systolic Velocity Ratio (2PSVR) of the ophthalmic artery (p=0.011), heart Rate (p=0.03), stroke volume (p=0.004) and cardiac output (0.094) between the two groups. There were significant correlation between parameters of the central haemodynamics and those of the uteroplacental circulation, as well as ophthalmic artery Doppler.

Conclusion

Ophthalmic artery 2PSVR is a simple and potentially promising measurement to assess women with hypertensive disorders of pregnancy. However, this parameter must be validated against the well described Uterine artery Doppler. A bigger cohort is needed to clarify and determine its effectiveness.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): iPlacenta

Strain analysis by two-dimensional speckle tracking echocardiography for evaluating left ventricular systolic function in women with pre-eclampsia

Background

Previous echocardiographic studies have shown that most women affected by pre-eclampsia present with mild-to moderate diastolic dysfunction and left ventricle remodelling with a preserved systolic function. These alterations appear more severe when pre-eclampsia develops before 34 weeks of gestation.

Purpose

The aim of this study is to compare left ventricular systolic (LV) function by using 2-D speckle tracking echocardiography in women with early-onset and late-onset pre-eclampsia.

Methods

In this single-centre prospective longitudinal study, 119 women with a diagnosis of pre-eclampsia underwent standard trans-thoracic echocardiography (TTE) in the immediate peripartum period from February 2019 to December 2020. LV function was assessed using two-dimensional speckle-tracking strain imaging on 4-chamber views with a frame rate of 60–90 frames/second. Strain analysis quantification was performed using a commercial software.

Results

Pre-eclampsia was diagnosed before and after 34 weeks in 37.3% (44/119) and 62.7% (74/119) of the patients, respectively. Maternal characteristics, such as maternal age, body mass index, pre-existing hypertension and nulliparity, did not show any significant difference between the two groups. Although LV remodelling/hypertrophy and diastolic dysfunction occurred more often in early-onset pre-eclampsia compared to late-onset (65.9% vs 60.8% and 59.1% vs 51.4%, respectively), this difference was not statistically significant (p=0.580 and p=0.414, respectively). Similarly, LV mass index was 80.1±16.3 in pre-eclampsia <34 and 79.1±15 >34 (p=0.715) and E/e' was 7.8±1.9 and 7.6±1.7 (p=0.424). However, global longitudinal strain (GLS) was significantly lower (−16.4±2.4 vs −17.6±2.4, p=0.030) and apical rotation was higher (11.1±5.9 vs 8.7±4.7, p=0.019) in early-onset pre-eclampsia. A positive weak correlation has been found between GLS and difference in days from pre-eclampsia diagnosis to delivery (r=0.2, p=0.002).

Conclusions

Lower GLS in women affected by early-onset pre-eclampsia compared to late-onset pre-eclampsia might be useful to detect sub-clinical LV systolic impairment. Although further studies are needed, this sensitive marker may have a role in identifying women at risk of preterm delivery and/or severe maternal morbidity in the peripartum period.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Veronica Giorgione and Carolina Di Fabrizio have received funding from the European Union's Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 765274 (iPLACENTA project).

1547 An Alternative Approach to High-Risk Resternotomy

Introduction

Resternotomies are associated with substantial perioperative morbidity and mortality. Strategies described in literature mostly involve peripheral cannulation pre-sternotomy. Disadvantages of this technique relate to prolonged systemic heparinisation and cardiopulmonary bypass (CPB) time and the sequelae of hypothermic circulatory arrest. We describe a two-stage approach that potentially reduces the complications associated with high-risk resternotomy.

Method

3 high-risk patients (from pre-operative CT images) were referred for redo complex aortic surgery. A right mini-thoracotomy incision was first made in the 4th or 5th intercostal space. The right lung was isolated and careful blunt dissection was carried out to mobilise the heart and great vessels attached to the sternum. Once these structures were free, thoracotomy incision was closed. A standard median sternotomy was then performed and central cannulation carried out after systemic heparinisation. Rest of the surgery was performed routinely. In one patient, aortic aneurysm was heavily adherent and attempts to mobilise it fully proved impossible. Resultantly, systemic heparinisation was administered and the patient was cannulated in the right superficial femoral artery and right atrium (via mini-thoracotomy). CPB was instituted and the patient cooled to 28 °C. Right superior pulmonary vein vent was introduced to prevent left ventricular distension from hypothermic ventricular fibrillation. Once the heart and aneurysm were decompressed on full CPB, complete mobilisation was performed safely. All 3 patients survived surgery without major complications.

Conclusions

Meticulous preoperative planning is key to management of high-risk resternotomy. We describe a novel technique which we believe minimises risk of morbidity and mortality in these complex cases.

Defining the decision-to-delivery interval at caesarean section: narrative literature review and proposal for standardisation

The decision-to-delivery interval is a widely used term at non-elective caesarean section. While the definition may appear self-evident, there is no universally agreed consensus about when this period begins and ends. We reviewed the literature for original research utilising the terms 'decision-to-delivery', 'decision-to-incision' or 'incision-to-delivery' and examined definitions used for decision, delivery, incision, as well as any additional time intervals that were assessed. Our analysis demonstrated an inconsistent non-standardised approach to defining these intervals, which might have clinical practice and medicolegal ramifications. We propose that the decision-to-delivery interval should be defined as follows: the interval between the time at which the senior obstetrician makes the decision that a caesarean section is required and the time at which the fetus (or first fetus in the case of multiples) is delivered. The decision time should ideally be recorded contemporaneously in the medical notes or partogram.

Twin chorionicity-specific population birth-weight charts adjusted for estimated fetal weight

OBJECTIVES

To construct chorionicity-specific birth-weight reference charts for dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twin pregnancies, incorporating estimated-fetal-weight (EFW) data in order to adjust for the relationship between suboptimal growth and preterm delivery. An additional aim was to determine if the inclusion of complicated twin pregnancies impacts on the reference charts produced.

METHODS

The inclusion criteria for this retrospective cohort study were twin pregnancy of known DCDA or MCDA chorionicity, known pregnancy outcome, last ultrasound scan within 14 days before birth and delivery between 25 and 38 weeks' gestation (Analysis A). An analysis was also conducted excluding pregnancies with complications recorded (Analysis B). Previously published twin EFW reference ranges were used in the analysis. A joint statistical model for EFW and observed birth weight for each pregnancy was created in order to estimate population birth-weight reference ranges corresponding to the distribution expected if all pregnancies delivered at any given gestational age. It was not assumed that the median EFW was equal to birth weight for any given gestational age. The models were fitted using a Bayesian approach.

RESULTS

We retrieved data on 1664 twin pregnancies, of which 707 DCDA and 241 MCDA pregnancies met the inclusion criteria. In Analysis A, the estimated population median birth weight was similar to the median EFW at around 27 weeks' gestation but fell below the EFW values with increasing gestation, being 156 g lower in both DCDA and MCDA pregnancies at 35 weeks; this finding was confirmed by direct comparison of the last EFW and birth-weight values in each pregnancy. When the analysis was repeated after excluding complicated twin pregnancies (Analysis B), compared with Analysis A, there was very little difference in the median birth-weight results obtained across gestation. The largest absolute difference between Analyses A and B for DCDA twins was at 31, 32 and 33 weeks, with a 9-g lower median birth weight in Analysis A compared with Analysis B. The largest absolute difference for MCDA twins was greater than that for DCDA twins, with a 21-g lower median birth weight at 25 weeks in Analysis A compared with Analysis B.

CONCLUSIONS

We have established population chorionicity-specific birth-weight reference charts for DCDA and MCDA twin pregnancies, corresponding to the range expected were all pregnancies to deliver at any given gestational age. In this population of twins, the median birth weight was consistently lower than that reported for singletons, and there was variation in the median birth weight at different gestational ages according to chorionicity. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. - Legal Statement: This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Clinical Impact of Surgical Lung Biopsy for Interstitial Lung Disease in a Reference Center

BACKGROUND

Diagnosis of interstitial lung disease is based on the analysis of clinical, biological, radiological and pathological findings during a multidisciplinary discussion (MDD). When a definitive diagnosis is not possible, guidelines recommend obtaining lung samples through surgical lung biopsy (SLB). We sought to determine morbidity, mortality, diagnostic yield, and therapeutic impact of SLB in the management of patients with interstitial lung disease.

METHODS

We retrospectively analyzed morbidity, mortality, diagnostic yield, and therapeutic changes following SLB for interstitial lung disease performed electively from January 2015 to May 2019 in a reference center. Each case was reviewed during two MDD, first without (MDD1) and then with (MDD2) the result of the SLB.

RESULTS

Study group included 73 patients (male 56%, age 66 years [57-70], FVC 79% [69-91], DLCO 52% [46-63]). Median postoperative hospital length of stay was 2 days [0-11]. Thirteen patients (17%) experienced at least one complication, including pain at 1 month (n=8) and residual pneumothorax (n=6). No serious complication or postoperative death was noticed. After MMD1, the working diagnosis was idiopathic non-specific interstitial pneumonia in 20 (27%), idiopathic pulmonary fibrosis in 18 (25%), fibrotic hypersensitivity pneumonitis in 15 (21%), unclassifiable interstitial lung disease in 5 (7%) and other diagnosis in 15 patients (21%). After SLB and MDD2, the final diagnosis was modified in 35 patients (48%) and led to therapeutic changes in 33 patients (45%).

CONCLUSIONS

SLB is associated with no serious complication or death and notably changes the diagnosis and treatment of interstitial lung disease.

Study of Thoracic CT in COVID-19: The STOIC Project

Background There are conflicting data regarding the diagnostic performance of Chest computed tomography (CT) for COVID-19 pneumonia. Disease extent on CT has been reported to influence prognosis. Purpose To create a large publicly available dataset and assess the diagnostic and prognostic value of CT in COVID-19 pneumonia. Materials and Methods This multicenter observational retrospective cohort study (ClinicalTrials.gov: NCT04355507) involved 20 French university hospitals. Eligible subjects presented at the emergency departments of the hospitals involved between March 1st and April 30th, 2020 and underwent both thoracic CT and RT-PCR for suspected COVID-19 pneumonia. CT images were read blinded to initial reports, RT-PCR, demographic characteristics, clinical symptoms, and outcome. Readers classified CT scans as positive or negative for COVID-19, based on criteria published by the French Society of Radiology. Multivariable logistic regression was used to develop a model predicting severe outcome (intubation or death) at 1-month follow-up in subjects positive for both RT-PCR and CT, using clinical and radiological features. Results Of 10,930 subjects screened for eligibility, 10,735 (median age 65 years, interquartile range, 51-77 years; 6,147 men) were included and 6,448 (60.0%) had a positive RT-PCR result. With RT-PCR as reference, the sensitivity and specificity and CT were 80.2% (95%CI: 79.3, 81.2) and 79.7% (95%CI: 78.5, 80.9), respectively with strong agreement between junior and senior radiologists (Gwet's AC1 coefficient: 0.79) Of all the variables analysed, the extent of pneumonia on CT (OR 3.25, 95%CI: 2.71, 3.89) was the best predictor of severe outcome at one month. A score based solely on clinical variables predicted a severe outcome with an AUC of 0.64 (95%CI: 0.62, 0.66), improving to 0.69 (95%CI: 0.6, 0.71) when it also included the extent of pneumonia and coronary calcium score on CT. Conclusion Using pre-defined criteria, CT reading is not influenced by reader's experience and helps predict the outcome at one month. Published under a CC BY 4.0 license. See also the editorial by Rubin.

Randomised trial of first-line bronchial artery embolisation for non-severe haemoptysis of mild abundance

Background

Whereas first-line bronchial artery embolisation (BAE) is considered standard of care for the management of severe haemoptysis, it is unknown whether this approach is warranted for non-severe haemoptysis.

Research question

To assess the efficacy on bleeding control and the safety of first-line BAE in non-severe haemoptysis of mild abundance.

Study design and methods

This multicentre, randomised controlled open-label trial enrolled adult patients without major comorbid condition and having mild haemoptysis (onset <72 hours, 100–200 mL estimated bleeding amount), related to a systemic arterial mechanism. Patients were randomly assigned (1:1) to BAE associated with medical therapy or to medical therapy alone.

Results

Bleeding recurrence at day 30 after randomisation (primary outcome) occurred in 4 (11.8%) of 34 patients in the BAE strategy and 17 (44.7%) of 38 patients in the medical strategy (difference −33%; 95% CI −13.8% to −52.1%, p=0.002). The 90-day bleeding recurrence-free survival rates were 91.2% (95% CI 75.1% to 97.1%) and 60.2% (95% CI 42.9% to 73.8%), respectively (HR=0.19, 95% CI 0.05 to 0.67, p=0.01). No death occurred during follow-up and no bleeding recurrence needed surgery.

Four adverse events (one major with systemic emboli) occurred during hospitalisation, all in the BAE strategy (11.8% vs 0%; difference 11.8%, 95% CI 0.9 to 22.6, p=0.045); all eventually resolved.

Conclusion

In non-severe haemoptysis of mild abundance, BAE associated with medical therapy had a superior efficacy for preventing bleeding recurrences at 30 and 90 days, as compared with medical therapy alone. However, it was associated with a higher rate of adverse events.

Trial registration number

NCT01278199

Controversies in the management of twin pregnancy

Despite many advances in antenatal care, twin pregnancies still experience more adverse outcomes, in particular perinatal morbidity and mortality. They also pose a multitude of challenges and controversies, as outlined in this Review. Moreover, they are less likely to be included in clinical trials. Many issues on classification and management remain under debate. Efforts at standardizing diagnostic criteria, monitoring protocols, management and outcome reporting are likely to reduce their perinatal risks. The top 10 most important research uncertainties related to multiple pregnancies have been identified by both clinicians and patients. More robust research in the form of randomized trials and large well-conducted prospective cohort studies is needed to address these controversies. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

57 The Use of a Hemi Glabella Flap for Reconstruction of Medial Canthus Defects

Background

Medial canthal reconstruction is a challenging task due to the complex anatomy. The glabellar flap is a common viable technique; however, this results in narrowing of the eyebrows, bulky nasal dorsum and horizontal scarring which is aesthetically displeasing. The senior author in this paper has developed an intuitive modification to the technique.

Method

A rotational advancement flap involving the upper lateral nasal wall with the hemi glabella was formed and transferred to the medial canthal defect. The donor site was closed in a V-Y manner. Complete closure of defect was achieved in all patients.

Results

Reconstruction using the Hemi-Glabellar technique was performed on 12 patients following resection of BCC in or near the medial canthus area. Superficial cellulitis was noted in 2 patients, they were managed oral antibiotics. There was bruising in 7 patient which resolve spontaneously in 4-7 days. All patients had a good outcome at 2 months and 6 months follow up. There was no flap loss and all patients were satisfied with the aesthetic outcome.

Conclusions

The technique highlighted can be performed easily and is applicable to reconstruction to defects of the medial canthus with excellent aesthetic outcomes with an inconspicuous scar and supple skin with matching colour

Counseling in maternal-fetal medicine: SARS-CoV-2 infection in pregnancy

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a zoonotic coronavirus that crossed species to infect humans, causing coronavirus disease 2019 (COVID-19). Despite a potentially higher risk of pregnant women acquiring SARS-CoV-2 infection compared with the non-pregnant population (particularly in some ethnic minorities), no additional specific recommendations to avoid exposure are needed in pregnancy. The most common clinical symptoms and laboratory signs of SARS-CoV-2 infection in pregnancy are fever, cough, lymphopenia and elevated C-reactive protein levels. Pregnancy is associated with a higher risk of severe SARS-CoV-2 infection compared with the non-pregnant population, including pneumonia, admission to the intensive care unit and death, even after adjusting for potential risk factors for severe outcomes. The risk of miscarriage does not appear to be increased in women with SARS-CoV-2 infection. Evidence with regards to preterm birth and perinatal mortality is conflicting, but these risks are generally higher only in symptomatic, hospitalized women. The risk of vertical transmission, defined as the transmission of SARS-CoV-2 from the mother to the fetus or the newborn, is generally low. Fetal invasive procedures are considered to be generally safe in pregnant women with SARS-CoV-2 infection, although the evidence is still limited. In pregnant women with COVID-19, use of steroids should not be avoided if clinically indicated; the preferred regimen is a 2-day course of dexamethasone followed by an 8-day course of methylprednisolone. Non-steroidal anti-inflammatory drugs may be used if there are no contraindications. Hospitalized pregnant women with severe COVID-19 should undergo thromboprophylaxis throughout the duration of hospitalization and at least until discharge, preferably with low molecular weight heparin. Hospitalized women who have recovered from a period of serious or critical illness with COVID-19 should be offered a fetal growth scan about 14 days after recovery from their illness. In asymptomatic or mildly symptomatic women who have tested positive for SARS-CoV-2 infection at full term (i.e. ≥ 39 weeks of gestation), induction of labor might be reasonable. To date, there is no clear consensus on the optimal timing of delivery for critically ill women. In women with no or few symptoms, management of labor should follow routine evidence-based guidelines. Regardless of COVID-19 status, mothers and their infants should remain together and breastfeeding, skin-to-skin contact, kangaroo mother care and rooming-in throughout the day and night should be practiced, while applying necessary infection prevention and control measures. Many pregnant women have already undergone vaccination, mostly in the USA where the first reports show no significant difference in pregnancy outcomes in pregnant women receiving SARS-CoV-2 vaccination during pregnancy compared with the background risk. Vaccine-generated antibodies were present in the umbilical cord blood and breast milk samples of pregnant and lactating women who received the mRNA COVID-19 vaccine. Based on the available limited data on the safety of the COVID-19 vaccine in pregnancy, it seems reasonable to offer the option of vaccination to pregnant women after accurate counseling on the potential risk of a severe course of the disease and the unknown risk of fetal exposure to the vaccine. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Radiation dose reduction with the wide-volume scan mode for interstitial lung diseases

OBJECTIVES

The wide-volume mode, available on wide-area detector row CTs, has the advantage of reducing exposure time and radiation dose. It is infrequently used for lung diseases. The purpose of this study is to compare image quality and radiation dose of wide-volume chest CT to those of standard helical CT in the setting of interstitial lung diseases.

METHODS

Retrospective monocentric study including 50 consecutive patients referred for follow-up or screening of interstitial lung diseases, requiring prone scan, acquired with the wide-volume mode, in addition to the routine supine scan, acquired with the helical mode. The optimal collimation in wide-volume mode (320 × 0.5mm or 240 × 0.5mm) was chosen according to the length of the thorax. Wide-volume acquisitions were compared to helical acquisitions for radiation dose (CTDI_vol, DLP) and image quality, including analysis of normal structures, lesions, overall image quality, and artifacts (Wilcoxon signed-rank test).

RESULTS

Median CTDI_vol and DLP with wide volumes (3.1 mGy and 94.6 mGy·cm) were significantly reduced (p < 0.0001) as compared to helical mode (3.7mGy and 122.1 mGy·cm), leading to a median 21% and 32% relative reduction of CTDI_vol and DLP, respectively. Image noise and quality were not significantly different between the two modes. Misalignment artifact at the junction of two volumes was occasionally seen in the wide-volume scans and, when present, did not impair the diagnostic quality in the majority of cases.

CONCLUSIONS

Wide-volume mode allows 32% radiation dose reduction compared to the standard helical mode and could be used routinely for diagnosis and follow-up of interstitial lung diseases.

KEY POINTS

• Retrospective monocentric study showed that wide-volume scan mode reduces radiation dose by 32% in comparison to helical mode for chest CT in the setting of interstitial lung diseases. • Mild misalignment may be observed at the junction between volumes with the wide-volume mode, without decrease of image quality in the majority of cases and without impairing diagnostic quality. • Wide-volume mode could be used routinely for the diagnosis and follow-up of interstitial lung diseases.

Effect of monochorionicity on perinatal outcome and growth discordance in triplet pregnancy: collaborative multicenter study in England, 2000-2013

OBJECTIVES

To compare perinatal outcome and growth discordance between trichorionic triamniotic (TCTA) and dichorionic triamniotic (DCTA) or monochorionic triamniotic (MCTA) triplet pregnancies.

METHODS

This was a multicenter cohort study using population-based data on triplet pregnancies from 11 Northern Survey of Twin and Multiple Pregnancy (NorSTAMP) maternity units and the Southwest Thames Region of London Obstetric Research Collaborative (STORK) multiple pregnancy cohort, for 2000-2013. Perinatal outcomes (from ≥ 24 weeks' gestation to 28 days of age), intertriplet fetal growth and birth-weight (BW) discordance and neonatal morbidity were analyzed in TCTA compared with DCTA/MCTA pregnancies.

RESULTS

Monochorionic placentation of a pair or trio in triplet pregnancy (n = 72) was associated with a significantly increased risk of perinatal mortality (risk ratio, 2.7 (95% CI, 1.3-5.5)) compared with that in TCTA pregnancies (n = 68), due mainly to a much higher risk of stillbirth (risk ratio, 5.4 (95% CI, 1.6-18.2)), with 57% of all stillbirth cases resulting from fetofetal transfusion syndrome, while there was no significant difference in neonatal mortality (P = 0.60). The associations with perinatal mortality and stillbirth persisted when considering only pregnancies not affected by a major congenital anomaly. DCTA/MCTA triplets had lower BW and demonstrated greater BW discordance than did TCTA triplets (P = 0.049). Severe BW discordance of > 35% was 2.5-fold higher in DCTA/MCTA compared with TCTA pregnancies (26.1% vs 10.4%), but this difference did not reach statistical significance (P = 0.06), presumably due to low numbers. Triplets in both groups were delivered by Cesarean section in over 95% of cases, at a similar gestational age (median, 33 weeks' gestation). The rate of respiratory (P = 0.28) or infectious (P = 0.08) neonatal morbidity was similar between the groups.

CONCLUSIONS

Despite close antenatal surveillance, monochorionic placentation of a pair or trio in triamniotic triplet pregnancy was associated with a significantly increased stillbirth risk, mainly due to fetofetal transfusion syndrome, and with greater size discordance. In liveborn triplets, there was no adverse effect of monochorionicity on neonatal outcome. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Arterial Thrombotic Events in Adult Inpatients With COVID-19

OBJECTIVE

To evaluate the clinical course of and risk factors for arterial thrombotic events in adult inpatients with coronavirus disease 2019 (COVID-19).

METHODS

All consecutive adult patients admitted for COVID-19 infection in a referral center in France and discharged from the hospital between April 1 and April 30, 2020, were included. All arterial thrombotic events that occurred through discharge were considered for analysis. Epidemiologic, demographic, clinical, laboratory, treatment, and outcome data were extracted from electronic medical records with use of a standardized data collection form.

RESULTS

Overall, 531 COVID-19+ patients were analyzed. Among them, 30 (5.6%) experienced arterial thrombotic events. Arterial thrombotic events in the setting of COVID-19 infection happened at a median of 11 (5-20) days after the first symptoms of infection; occurred in high-risk patients according to traditional cardiovascular risk factors; had an atypical pattern, such as thrombosis of the aorta, upper limb, or renal arteries or cerebral microvasculopathy in 7 (23.3%) cases; and were associated with an in-hospital mortality rate of 40%. Arterial thrombotic events increased the risk of death by 3-fold in COVID-19+ patients (hazard ratio, 2.96; 95% CI, 1.4 to 4.7; P=.002). A subdistribution survival hazard model showed that a concentration of D-dimer above 1250 ng/mL increased the risk of arterial thrombotic events in COVID-19+ patients by more than 7 (subdistribution hazard ratio, 7.68; 95% CI, 2.9 to 20.6; P<.001).

CONCLUSION

A dramatically high rate of in-hospital death was observed in patients who suffered arterial thrombotic events in the setting of COVID-19 infection. A D-dimer level above 1250 ng/mL at entry may identify COVID-19+ patients at risk for arterial thrombotic events.

A critical analysis of 57 cases of Hughes-Stovin syndrome (HSS). A report by the HSS International Study Group (HSSISG)

BACKGROUND

Hughes-Stovin syndrome (HSS) is a systemic disease characterized by widespread vascular thrombosis and pulmonary vasculitis with serious morbidity and mortality. The HSS International Study Group is a multidisciplinary taskforce aiming to study HSS, in order to generate consensus recommendations regarding diagnosis and treatment.

METHODS

We included 57 published cases of HSS (43 males) and collected data regarding: clinical presentation, associated complications, hemoptysis severity, laboratory and computed tomography pulmonary angiography (CTPA) findings, treatment modalities and cause of death.

RESULTS

At initial presentation, DVT was observed in 29(33.3 %), thrombophlebitis in 3(5.3%), hemoptysis in 24(42.1%), and diplopia and seizures in 1 patient each. During the course of disease, DVT occurred in 48(84.2%) patients, and superficial thrombophlebitis was observed in 29(50.9%). Hemoptysis occurred in 53(93.0%) patients and was fatal in 12(21.1%). Pulmonary artery (PA) aneurysms (PAAs) were bilateral in 53(93%) patients. PAA were located within the main PA in 11(19.3%), lobar in 50(87.7%), interlobar in 13(22.8%) and segmental in 42(73.7%). Fatal outcomes were more common in patients with inferior vena cava thrombosis (p = 0.039) and ruptured PAAs (p < 0.001). Death was less common in patients treated with corticosteroids (p < 0.001), cyclophosphamide (p < 0.008), azathioprine (p < 0.008), combined immune modulators (p < 0.001). No patients had uveitis; 6(10.5%) had genital ulcers and 11(19.3%) had oral ulcers.

CONCLUSIONS

HSS may lead to serious morbidity and mortality if left untreated. PAAs, adherent in-situ thrombosis and aneurysmal wall enhancement are characteristic CTPA signs of HSS pulmonary vasculitis. Combined immune modulators contribute to favorable outcomes.

[Lung imaging in severe asthma]

INTRODUCTION

Asthma is a common disease whose diagnosis does not typically rely on the results of imaging. However, chest CT has gained a key place over the last decade to support the management of patients with difficult to treat and severe asthma.

STATE OF THE ART

Bronchial wall thickening and mild dilatation or narrowing of bronchial lumen are frequently observed on chest CT in people with asthma. Bronchial wall thickening is correlated to the degree of obstruction and to bronchial wall remodeling and inflammation. Diverse conditions which can mimic asthma should be recognized on CT, including endobronchial tumours, interstitial pneumonias, bronchiectasis and bronchiolitis. Ground-glass opacities and consolidation may be related to transient eosinophilic infiltrates, infection or an associated disease (vasculitis, chronic eosinophilic pneumonia). Hyperdense mucous plugging is highly specific for allergic bronchopulmonary aspergillosis.

PERSPECTIVES

Airway morphometry, air trapping and quantitative analysis of ventilatory defects, with CT or MRI, can help to identify different morphological subgroups of patients with different functional or inflammatory characteristics. These imaging tools could emerge as new biomarkers for the evaluation of treatment response.

CONCLUSION

Chest CT is indicated in people with severe asthma to search for additional or alternative diagnoses. Quantitative imaging may contribute to phenotyping this patient group.