The Contribution of Proteomics in Understanding Endometrial Protein Expression in Women with Recurrent Implantation Failure

Recurrent implantation failure (RIF) poses a significant challenge in assisted reproductive technology (ART) outcomes. The endometrium plays a crucial role in embryo implantation, and its protein expression profile is integral in determining receptivity. Proteomics has emerged as a valuable tool in unraveling the molecular intricacies underlying endometrial receptivity and RIF. The aim of the present review is to analyze the contribution of proteomics to the understanding of endometrial protein expression in women with RIF, based on the results of significant proteomic studies. Medline/Pubmed databases were searched using keywords pertaining to proteomics combined with terms related to RIF. 15 studies were included in the present review. Several proteins have been found to exbibit differential expression in endometrial biopsies and fluid samples between fertile women and women with RIF during the receptive endometrial phase. The profile of endometrial proteins varied significantly among the studies. Nevertheless, similar changes in the expression levels of annexin-6, progesterone receptor, MMP-2, and MMP-9 in the endometrium of women with RIF, were found in more than one study indicating that certain proteins could potentially be effective biomarkers of endometrial receptivity. Proteomics contributes significantly to the understanding of protein expression in the endometrium of women with RIF and the analysis of proteins in endometrial fluid are promising for improving the clinical management of RIF.

Prenatal Identification of a Missense Mutation of the L1CAM Gene Associated With Hydrocephalus Using Next-Generation Sequencing

We present the case of a 35-year-old pregnant woman who visited our department for a routine ultrasonography screening scan for fetus anatomy during the 22nd week of gestation. Our report revealed a male fetus with marked hydrocephalus and severe intrauterine growth retardation. After extensive counseling, the couple decided to proceed with an invasive diagnosis via amniocentesis. The cytogenetic analysis showed findings related to clinical history and ultrasound findings related to the presence of a nucleotide change in c.578T>C with an amino acid change in p.Leu198Pro of the L1CAM gene. The result was reported as a hemizygote missense L1CAM gene variant of unknown significance. After extensive parental counseling, the couple decided on pregnancy termination. We report the present case of L1CAM mutation in p.Leu198Pro to add to the limited knowledge regarding the clinical presentation of mutations of the L1CAM gene with emphasis on prenatal diagnosis.

Supervised Pelvic Floor Muscle Training Improves Sexual Function and Diminishes Sexual Distress in Women with Relapsing-Remitting Multiple Sclerosis: A Randomised Controlled Study

This study investigates the impact of pelvic floor muscle training (PFMT) on sexual function and distress in women with multiple sclerosis (MS), a prevalent chronic nervous system disorder associated with sexual dysfunction. This study's primary aim was to assess the effectiveness of PFMT at improving sexual function and alleviating sexual distress in this population. In a randomised controlled trial, 82 women with MS were divided into two groups: Group A (41 women) underwent 12 weeks of PFMT, while Group B (41 women) served as a control group with no intervention. Both groups were assessed at the beginning and end of this study using the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R). Statistical analysis, including Chi-square tests, was employed to compare the outcomes between the two groups, with a p-value of less than 0.05 considered significant. The results revealed no significant differences in baseline sexual function and distress between the groups. However, at the conclusion of the 12-week period, Group A exhibited statistically significant improvements in nearly all domains of FSFI and FSDS-R compared to Group B, except in the pain domain. This study concludes that PFMT can effectively enhance sexual function and reduce sexual distress in women suffering from MS. These findings underscore the potential of PFMT as a therapeutic intervention in managing sexual dysfunction associated with MS.

Endometriosis Predictive Models Based on Self-Assessment Questionnaire, Evidence from Clinical Examination or Imaging Findings: A Narrative Review

OBJECTIVE

The aim of this narrative review is to evaluate existing questionnaires on predictive models for endometriosis. These symptom-based models have the potential to serve as screening tools for adult women to detect endometriosis.

DATA SOURCES

A comprehensive search of PubMed and Embase databases was conducted to identify studies on endometriosis screening.

SELECTION OF STUDIES

The search targeted predictive models for endometriosis localisation, bowel involvement, need for bowel surgery and fertility. Due to the heterogeneity identified, a systematic review was not possible. A total of 23 studies were identified.

DATA EXTRACTION AND SYNTHESIS

Among these studies, twelve included measures for general endometriosis, two targeted specific sites, four focused on deep infiltrating endometriosis (DIE), and three addressed the need for endometriosis-related bowel surgery. Many measures combined clinical, imaging and laboratory tests with patient questionnaires. Validation of these models as screening tools was lacking in all studies, as the focus was on diagnosis rather than screening.

CONCLUSION

This review did not identify any fully validated, symptom-based questionnaires for endometriosis screening in adult women. Substantial validation work remains to establish the efficacy of such tools.

Genetic Disorders Underlying Polyhydramnios and Congenital Hypotonia: Three Case Reports and a Review of the Literature

An abnormal rise in the amount of amniotic fluid is a frequent prenatal observation called polyhydramnios, which can indicate a number of underlying problems. Even while it frequently goes undiagnosed during pregnancy, it may be linked to dangerous fetal illnesses. In three cases of newborns with congenital hypotonia, polyhydramnios was the sole prenatal symptom reported in this study. This fact highlights the significance of understanding the possible connection between genetic abnormalities or neurological problems and polyhydramnios, underscoring the responsibility obstetricians have in educating expectant mothers who are at potential risk for these uncommon but serious illnesses. Whole-genome sequencing (WES), an advanced kind of prenatal testing, is essential for determining genetic reasons and assisting families in making decisions. Working together with specialists in fetal medicine is crucial in guaranteeing the best possible treatment and results for the mother and child.

Pregnancy physical activity questionnaire: Translation and cross-cultural adaptation of a Greek version

OBJECTIVE

The aim of this study was to translate and adapt the Pregnancy Physical Activity Questionnaire (PPAQ) into Greek culture.

STUDY DESIGN

The procedure followed to translate the PPAQ included the stages: forward translation, synthesis, backward translation and an expert committee review. Members of the research team discussed ambiguities, discordances and equivalence at each stage. Then, the pre-final Greek version of the PPAQ was pre-tested on 46 pregnant women; a quantitative and qualitative analysis was conducted.

RESULTS

Few modifications were done to the original PPAQ, in order to ensure cultural adaptation and clinical implementation. Appropriate changes to the international metric units were done. In addition, two items have been modified to achieve relevance with Greek culture. Two items were merged into one and three items were splitted, which maintained their initial meaning. Those changes were made to match the energy expenditure compendium update for physical activities. Participants at the pre-test had a mean age of 34,23 years, response time to the questionnaire varied between 5 and 10 min and there were no missing data. No difficulties or misunderstandings were reported by the participants during pre-testing. Thus, the research team agreed on the pre-final PPAQ Greek version.

CONCLUSION

The final PPAQ Greek version indicated transcultural equivalence to the original PPAQ in English. It is also a unique questionnaire for assessing physical activity in Greek pregnant women and will be a useful tool in clinical routine.

ANRIL rs4977574 Gene Polymorphism in Women with Recurrent Pregnancy Loss

BACKGROUND

ANRIL rs4977574 gene polymorphism has been associated with arterial thrombosis and cardiovascular disease development. ANRIL rs4977574 gene polymorphism could also be associated with recurrent pregnancy loss (RPL) since there is increasing evidence in favor of a potential shared pathophysiological mechanism with cardiovascular disease, potentially through arterial thrombosis. This study's goal is to investigate the differences in ANRIL rs4977574 gene polymorphism between women with and without RPL, if any, as well as a potential association with the number of pregnancy losses.

METHODS

DNA was isolated from peripheral blood samples, and the sequence containing the polymorphism of interest was amplified with PCR. Results were visualized under UV light following electrophoresis in 3% agarose gel with ethidium bromide. ANRIL rs4977574 (A>G) prevalence was compared between 56 women with and 69 without RPL. Results were adjusted for women's age and BMI, while a stratified analysis was performed according to number of pregnancy losses.

RESULTS

Allele A was significantly more prevalent in the control group compared to RPL women [31 (44.9%) vs. 14 (25%), p = 0.021]. Although not reaching statistical significance, a gradually decreasing prevalence of allele A with an increasing number of pregnancy losses was observed [31 (44.9%) in control, eight (30.7%) with two, six (23.1%) with three, and 0 (0.0%) with four pregnancy losses, p = 0.078]. Results were also similar following adjustment.

CONCLUSIONS

This is the first study that demonstrates an association between RPL presence and ANRIL rs4977574 gene polymorphism (lower prevalence of allele A), while a difference according to the number of pregnancy losses cannot be excluded.

Leydig cell hyperplasia as a cause of virilization in a postmenopausal woman: A case report

Virilization is a rare condition in postmenopausal women, usually attributed to androgen excess of ovarian or adrenal origin. A 62-year-old woman presented with excessive hair loss of 3 months' duration and was investigated for an endocrine cause of alopecia. The hormonal evaluation revealed increased testosterone but normal levels of androstenedione and dehydroepiandrosterone sulfate, while the results of transvaginal ultrasonography and abdominal computed tomography were unremarkable. Based on these findings, the possibility of an adrenal androgen-secreting tumor was ruled out and suspicion of Leydig cell hyperplasia was raised. A bilateral laparoscopic salpingo-oophorectomy was performed due to the age of the patient and the diagnosis of Leydig cell hyperplasia was confirmed by histopathological examination. The postoperative course of the patient was uneventful and a repeat hormonal evaluation after the operation showed a normalization of androgen levels. In conclusion, Leydig cell hyperplasia should be considered as a likely cause of hyperandrogenism of ovarian origin in women who develop virilization. In postmenopausal women, bilateral oophorectomy will treat the disorder and provide a conclusive diagnosis via histopathological examination.

Ovarian Masses in Children and Adolescents: A Review of the Literature with Emphasis on the Diagnostic Approach

Most abdominal masses in the pediatric population derive from the ovaries. Ovarian masses can occur in all ages, although their incidence, clinical presentation and histological distribution vary among different age groups. Children and adolescents may develop non-neoplastic ovarian lesions, such as functional cysts, endometrioma, torsion, abscess and lymphangioma as well as neoplasms, which are divided into germ cell, epithelial, sex-cord stromal and miscellaneous tumors. Germ cell tumors account for the majority of ovarian neoplasms in the pediatric population, while adults most frequently present with epithelial tumors. Mature teratoma is the most common ovarian neoplasm in children and adolescents, whereas dysgerminoma constitutes the most frequent ovarian malignancy. Clinical manifestations generally include abdominal pain, palpable mass, nausea/vomiting and endocrine alterations, such as menstrual abnormalities, precocious puberty and virilization. During the investigation of pediatric ovarian masses, the most important objective is to evaluate the likelihood of malignancy since the management of benign and malignant lesions is fundamentally different. The presence of solid components, large size and heterogenous appearance on transabdominal ultrasonography, magnetic resonance imaging and computed tomography indicate an increased risk of malignancy. Useful tumor markers that raise concern for ovarian cancer in children and adolescents include alpha-fetoprotein, lactate dehydrogenase, beta subunit of human chorionic gonadotropin, cancer antigen 125 and inhibin. However, their serum levels can neither confirm nor exclude malignancy. Management of pediatric ovarian masses needs to be curative and, when feasible, function-preserving and minimally invasive. Children and adolescents with an ovarian mass should be treated in specialized centers to avoid unnecessary oophorectomies and ensure the best possible outcome.

Diagnosis and Treatment of Adenomyosis with Office Hysteroscopy-A Narrative Review of Literature

INTRODUCTION

Adenomyosis is a common chronic disease in women of reproductive age, characterised by the presence of ectopic endometrial tissue within myometrium. Even though adenomyosis presents with chronic pelvic pain, menorrhagia or abnormal uterine bleeding, dysmenorrhoea, and dyspareunia and is often recognised after hysterectomies. However, the development of ultrasonography and magnetic resonance imaging has improved the pre-operative diagnosis of the disease. Hysteroscopy provides information in real time from the uterine cavity and the offers the possibility of obtaining direct biopsies.

MATERIAL AND METHODS

The literature was searched via Pubmed and Embase with the following headings: diagnosis of adenomyosis or adenomyoma and office hysteroscopy, hysteroscopy findings of adenomyosis or adenomyoma, treatment of adenomyosis or adenomyoma with office hysteroscopy.

RESULTS

The literature showed that hysteroscopy can identify superficial adenomyosis. There are a variety of hysteroscopic images that can be connected with the disease. New equipment like the spirotome has been used to access deeper layers of myometrium and obtain biopsies under direct vision from the adenomyotic areas. Different methods of treatment have been also described, like enucleation of focal superficial adenomyoma, coagulation, evacuation of cystic adenomyosis when the lesion is smaller than 1.5 cm, and resection of adenomyotic nodules in case of bigger lesions (>1.5 cm). Diffuse superficial adenomyosis is also managed by resection.

CONCLUSIONS

Hysteroscopy has revolutionised the approach to adenomyosis. It is a useful tool in assessing mainly superficial adenomyosis. The role of hysteroscopy in surgical management of adenomyosis need to be confirmed with further studies.

A Large Exophytic Tumor of the Cervix Causing Vaginal Bleeding in Pregnancy: A Case Report

Vaginal bleeding in the second and third trimesters of pregnancy is usually due to placental causes, namely placental abruption and placenta previa. Other causes include uterine rupture, vasa previa, and hematologic disorders. However, benign or malignant lesions of the vagina and the cervix may also cause vaginal bleeding or spotting. Although cervical cancer in pregnancy is rare, about 8% of pregnant women have an abnormal Pap smear and 3% of the total cervical cancers are diagnosed during pregnancy. We report a case of a 20-week pregnant woman who presented with vaginal bleeding; a visual inspection revealed a large exophytic lesion of the cervix. The Pap smear demonstrated a low-grade squamous intraepithelial lesion (LSIL) related to human papillomavirus (HPV) infection. The differential diagnosis based on the findings of the colposcopy included invasive cervical carcinoma, warty lesions, and perishable lesion. A cesarean section and the removal of the cervical tumor were scheduled and carried out as planned at 37 weeks of gestation. The histologic examination showed extensive lesions of low-grade squamous intraepithelial cervical neoplasia (LSIL/CIN1). Despite the fact that exophytic tumors of the cervix are extremely rare, in women presenting with vaginal bleeding or spotting during the second or third trimester of pregnancy, the ultrasound scan must be followed by a visual inspection of the vagina and the cervix.

Placental Ultrasonographical Findings during SARS-CoV-2 Infection

Infection with SARS-CoV-2 virus (COVID-19) during pregnancy has been associated with several complications. Increasing evidence suggests that COVID-19 infection leaves tell-tale signs of placental injury. During ultrasound examination and placental evaluation of COVID-19 infected pregnancies, we recorded signs of placental involvement, with findings indicating malperfusion, chorangiosis, deciduitis, and subchorionitis. Early detection of placental damage through the use of specific ultrasound findings could indicate which pregnancies are at increased risk for complications.

Chorionic villi derived mesenchymal like stem cells and expression of embryonic stem cells markers during long-term culturing

Mesenchymal stem cells (MSCs) can be obtained from a variety of human tissues. MSCs derived from placental chorionic villi of the first trimester are likely to resemble, biologically, embryonic stem cells (ESC), due to the earlier development stage of placenta. In the present study long-term cultures of MSC-like cells were assessed in order to evaluate MSCs multipotent characteristics and molecular features during the period of culture. CV-cells obtained from 10 samples of chorionic villus displayed typical fibroblastoid morphology, undergone 20 passages during a period of 120 days, maintaining a stable karyotype throughout long term expansion. The cells were positive, for CD90, CD73, CD105, CD29, CD44, HLA ABC antigens and negative for CD14, CD34, AC133, and HLA DR antigens as resulted from the flow cytometry analysis. CV-cells were differentiated in adipocytes, osteoblasts, chondrocytes and neuronal cells under specific culture conditions. The expression of the ESC-gene markers POU5F1 (Oct-4) and NANOG was observed at earliest stages (4-12 passages) and not at the late stages (14-20 passages) by RT-PCR analysis. ZFP42 and SOX2 expression were not detected. Moreover, CV-cells were found to express GATA4 but not NES (Nestin). Chorionic villi-derived cells possess multipotent properties, display high proliferation rate and self-renew capacity, share common surface antigens with adult MSCs and express certain embryonics stem cells gene markers. These characteristics highlight chorionic villi as an attractive source of MSCs for the needs of regenerative medicine.

Applicability of self-obtained urine and vaginal samples for HPV-16, -18, -31 and -45 cervical cancer screening in pregnancy: a pilot cross-sectional study

ABSTRACT: Aim: To conduct a pilot cross-sectional study to evaluate the rates of detection of four common high-risk HPV (hr-HPV) types using first-void urine paired with vaginal self-obtained samples in a nonvaccinated population of pregnant women. We also aimed to compare these results with a matched nonpregnant group in order to test the applicability of self-sampled hr-HPV cervical cancer screening during antenatal visits. Materials & methods: Samples from 550 pregnant women were subjected to hr-HPV-16, -18, -31 and -45 type detection by inhouse PCR and compared with 250 paired urine, vaginal and cervical samples from an age-matched cohort of nonpregnant women. Results: Comparing overall hr-HPV prevalence in urine and vaginal samples between pregnant (15 out of 550; 2.7%) and nonpregnant women (eight out of 250; 3.2%) for each HPV type revealed no significant differences. All paired urine/vaginal samples were both positive for the same type of hr-HPV and there was no positive urine sample with the other samples being negative. Conclusion: hr-HPV detection in pregnant women using self-obtained urine and vaginal samples seems to be a feasible cervical cancer screening method.

Effects of leptin on the expression of fatty acid-binding proteins in human placental cell cultures

The present study aimed to evaluate the protein expression of the transmembrane translocase FAT/CD36 and cytoplasmic H-FABP and L-FABP in human trophoblast tissue and evaluate the effects of exogenous leptin upon differential expression of each biomolecule; consequently, it aimed to derive information regarding the effects of leptin upon the expression of proteins implicated in fatty acid metabolism. Protein and total RNA were isolated from 72 samples of trophoblast tissue obtained from chorionic villous sampling. Of these, 36 samples were evaluated for protein (supernatant and pellet fraction separated) and the other 36 for total RNA expression. For each subgroup of samples, 12 were treated immediately and 24 were cultured. Half of the cultured samples were treated with 10 ng/-ml exogenously added leptin and the other half were untreated. Western blotting and PCR techniques were used for the evaluation of biomolecule expression. Our results were obtained from samples at a mean gestational week of 12+5 (n=72; min, 11+0; max, 14+1 gw; SD,0.89). In promptly treated samples we observed the presence of FAT/‌CD36 protein and absence of cytoplasmic FABPs. In the latter, only mRNA transcription of H-FABP was noted. A cytoplasmic pool of FAT/CD36 was also noted in the supernatant fraction of proteins. For cultured samples, when leptin was added, a statistically significant increase in FAT/CD36 protein expression was observed (n=24, p<0.001; mean difference, 0.219; SD, 0.0315; CI, -0.284 to -0.154). In our study we demonstrated the protein and mRNA expression of biomolecules implicated in fatty acid metabolism in human placenta. A cytoplasmic pool of the transmembrane protein FAT/CD36 was noted. Leptin caused the increase in FAT/CD36 protein expression in the cultured samples. Therefore, we conclude that leptin has an immediate effect and plays a role in lipid metabolism in human placenta.

Elective cerclage vs. ultrasound-indicated cerclage in high-risk pregnancies

OBJECTIVE

To compare pregnancy outcome after elective vs. ultrasound-indicated cervical cerclage in women at high risk of spontaneous mid-trimester loss or early preterm birth.

METHODS

This was a retrospective study comparing two management strategies in women with singleton pregnancies who had at least one previous spontaneous delivery at 16-33 weeks of gestation. One group was managed by the placement of an elective cerclage at 12-16 weeks and the other group had transvaginal ultrasound examinations of the cervix at 12-15+6, 16-19+6, and 20-23+6 weeks and cervical cerclage was carried out if the cervical length was 25 mm or less.

RESULTS

A total of 90 patients were examined, including 47 that were managed expectantly and 43 treated by elective cerclage. In the expectantly managed group, 59.6% (28/47) required a cervical cerclage. We excluded from further analysis three patients who were lost to follow-up and three because of fetal death or iatrogenic preterm delivery. Miscarriage or spontaneous delivery before 34 weeks' gestation occurred in 14.6% (6/41) of the elective cerclage group, compared with 20.9% (9/43) in the expectantly managed group (chi2 = 0.219, P = 0.640).

CONCLUSION

In women at increased risk of spontaneous mid-trimester or early preterm delivery, a policy of sonographic surveillance followed by cervical cerclage in those with a short cervix reduces the need for surgical intervention without significantly increasing adverse pregnancy outcome.

Trichorionic triplet pregnancies at 10-14 weeks: outcome after embryo reduction compared to expectant management

OBJECTIVE

To compare the outcome of trichorionic triplet pregnancies managed expectantly with those reduced to twins or singletons.

METHODS

This was a retrospective study of trichorionic triplet pregnancies with three live fetuses at 10-14 (median 12) weeks' gestation referred to our unit for consideration of embryo reduction. Women were counselled as to the available options of either expectant management or embryo reduction. In those choosing reduction, a needle was inserted into the uterus transabdominally and potassium chloride was injected into the fetal heart. Using data derived from this study and from a review of studies reporting on survival and handicap by gestational age in singletons, the effects of embryo reduction on survival and handicap rates were estimated. Main outcome measures were miscarriage before 24 weeks of gestation, preterm delivery before 32 weeks, perinatal death and handicap rates.

RESULTS

In total, there were 280 trichorionic triplet pregnancies and 125 of these were managed expectantly, 133 were reduced to two fetuses and 22 were reduced to one fetus. The rates of miscarriage were 3.2% for those managed expectantly, 8.3% for those reduced to twins and 13.6% for those reduced to singletons. The rates of early preterm delivery in those pregnancies that did not miscarry were 23.1%, 9.8% and 5.3%, respectively. The percentages for pregnancies with at least one survivor were 95.2%, 91.0% and 81.8%, respectively, and the median gestation at delivery was 34 weeks for the non-reduced, 36 weeks for those reduced to twins and 38 weeks for those reduced to singletons. From the published series on early preterm delivery, it was estimated that survival increases from about 27% at 24 weeks to about 98% at 32 weeks, and handicap decreases from 28% at 24 weeks to less than 5% at 32 weeks. From these estimates and the data on triplet pregnancies, it was calculated that, in triplets reduced to twins, compared to those managed expectantly, the chance of survival is similar (90.3% compared to 93.3%), but the risk of handicap may be lower (0.6% compared to 1.5% per fetus).

CONCLUSIONS

In trichorionic triplet pregnancies, embryo reduction to twins does not improve the chance of survival but may reduce the rate of handicap. Reduction from triplets to singletons may reduce both the survival rate and the handicap rate among survivors.

Short-term safety of celocentesis for the mother and the fetus

OBJECTIVE

Celocentesis offers the potential for prenatal diagnosis from as early as 6 weeks of gestation. The aim of this study was to examine the short-term safety of celocentesis.

METHODS

Eligible for the study were pregnant women with single live fetuses at 6-10 weeks of gestation, requesting pregnancy termination for social indications. At presentation, the patients were asked if they were willing to undergo celocentesis and in those women who agreed the procedure was performed at the time of the initial scan. A second scan was carried out just before termination to measure fetal crown-rump length and heart rate.

RESULTS

Four hundred and forty-seven women requested termination of pregnancy and 108 of these agreed to have celocentesis. There were no significant differences between the groups in maternal age, prevalence of primigravidas, cigarette smokers, existence of uterine fibroids, the median fetal crown-rump length or the interval between the initial scan (or celocentesis) at presentation and the pregnancy termination. At the time of termination, ultrasound examination demonstrated fetal death in five (4.7%) of the celocentesis group and nine (2.7%) of the controls (odds ratio, 1.804; 95% confidence interval, 0.5912-5.504). In all other cases, there was normal fetal growth and there were no significant differences between the groups in fetal crown-rump length.

CONCLUSIONS

The procedure related fetal loss associated with celocentesis may be approximately 2%.

Measurement of fetal nuchal translucency thickness by three-dimensional ultrasound

OBJECTIVE

To investigate the feasibility and repeatability of nuchal translucency thickness measurement using three-dimensional ultrasound.

METHODS

Forty consecutive women with uncomplicated singleton pregnancies attending for Down syndrome screening at 11-14 weeks' gestation were included in this prospective crossover trial. Nuchal translucency thickness was measured using both two-dimensional and three-dimensional ultrasound. In each case two three-dimensional volumes were recorded and then examined by using the technique of planar reformatted sections. The initial plane of the first volume always contained a clear image of the nuchal region ('sagittal volume'), whilst the initial plane of the second volume was selected randomly regardless of fetal position ('random volume'). The repeatability of nuchal translucency measurement was examined by constructing a scatter diagram of the difference between the measurements plotted against the mean of two readings.

RESULTS

Nuchal translucency measurements could be repeated in 38/40 (95%) sagittal volumes and 24/40 (60%) random volumes. The mean difference between two-dimensional measurements and those obtained by reslicing of sagittal three-dimensional volumes was -0.097 mm (95% limits of agreement from -0.481 to 0.675) and 0.225 mm (95% limits of agreement from -0.369 to 0.819) when random volumes were examined.

CONCLUSIONS

Reslicing of stored three-dimensional volumes can be used to replicate nuchal translucency measurements only when nuchal skin can also be clearly seen on two-dimensional ultrasound.

Cervical length and funneling at 23 weeks of gestation in the prediction of spontaneous early preterm delivery

OBJECTIVES

To establish the relationship of cervical length at 23 weeks of gestation to the risk of spontaneous delivery before 33 weeks and to determine the possible additional risk if funneling is present.

METHODS

During a 36-month period, 6819 women with singleton pregnancies underwent transvaginal sonographic cervical assessment at 22-24 weeks as a screening test for preterm delivery. The distribution of cervical length and the prevalence of funneling, defined as dilatation of the internal os of > or = 5 mm in width, were established. Women who underwent cervical cerclage, iatrogenic preterm delivery or were lost to follow-up were excluded from further analysis. In the remaining 6334 pregnancies, logistic regression was used to examine the contribution of cervical length and funneling to the risk of spontaneous preterm delivery before 33 weeks.

RESULTS

The median cervical length was 36 mm and in 1.6% of cases the length was < or = 15 mm. There was a significant inverse association between cervical length and percentage rate of spontaneous delivery before 33 weeks. Funneling of the internal os was present in about 4% of pregnancies and the prevalence decreased with increasing cervical length from 98% when the length was < or = 15 mm to about 25% for lengths of 16-30 mm and less than 1% at lengths of > 30 mm. The rate of preterm delivery was 6.9% in those with funneling compared to 0.7% in those without funneling (chi2 = 86.7; P < 0.0001). However, logistic regression analysis demonstrated that funneling did not provide a significant additional contribution to cervical length in the prediction of spontaneous delivery before 33 weeks (odds ratio for short cervix = 24.9, Z = 4.43, P < 0.0001; odds ratio for funneling = 1.8, Z = 0.84, P = 0.40).

CONCLUSION

In the prediction of preterm delivery, funneling does not provide any significant contribution in addition to cervical length.

Twin chorionicity and pre-eclampsia

OBJECTIVE

To determine whether the incidence of pre-eclampsia is different in dichorionic compared to monochorionic twin pregnancies.

METHODS

The study involved 666 twin pregnancies resulting in two live births after 24 weeks of gestation. Ultrasound examination at 10-14 weeks of gestation demonstrated that 171 (25.7%) were monochorionic and 495 (74.3%) were dichorionic twins. Pregnancy outcome information regarding the development of pre-eclampsia was obtained from the maternity units. The incidence of pre-eclampsia in the dichorionic and monochorionic twin pregnancies was compared.

RESULTS

The incidence of pre-eclampsia in monochorionic twin pregnancies (9.4%) was not significantly different from that in dichorionic pregnancies (7.3%) ( P = 0.48). Multiple logistic regression revealed that chorionicity has no effect on the development of pre-eclampsia after adjusting for maternal age, ethnic group, maternal smoking, parity and gestational age at delivery ( P = 0.6; odds ratio for monochorionic compared with dichorionic twin pregnancies, 1.19; 95% confidence interval, 0.61-2.3).

CONCLUSION

In twin pregnancies chorionicity does not affect the incidence of pre-eclampsia.

Cervical length at 22-24 weeks of gestation: comparison of transvaginal and transperineal-translabial ultrasonography

OBJECTIVES

To investigate the feasibility of measuring cervical length by transperineal or translabial sonography and compare the measurements obtained by this approach with those obtained transvaginally.

METHODS

In 500 women measurement of cervical length by translabial-transperineal sonography was attempted immediately before transvaginal scanning at 22-24 (median 23) weeks of gestation. In the first phase of the study, considered to be the learning period, 200 patients were examined and their results reviewed, before carrying out the second phase in which 300 patients were examined. A comparison was made of the patient acceptability of both techniques.

RESULTS

Cervical length was successfully measured transvaginally in all cases. In the first phase of the study cervical length was measured by translabial-transperineal sonography in 84% of the 200 patients but there was poor agreement with measurements obtained transvaginally and the 95% tolerance interval for paired observations was -11.0 mm to 16.1 mm. After audit of results it became apparent that the translabially-transperineally derived images were inadequate in more than half of the cases but in those with adequate paired measurements there was a very good agreement between the two and the 95% tolerance interval for paired observations was -5.8 mm to 5.2 mm. In the second phase of the study special attention was paid towards recording measurements of cervical length only in cases where both the internal and external os were adequately visualized. Successful measurements by translabial-transperineal sonography were obtained in 78% of cases and the 95% tolerance interval for paired observations was -5.8 mm to 6.1 mm. The degree of patient acceptability of the two methods was similar.

CONCLUSIONS

The findings of this study suggest that at 22-24 weeks of gestation the cervix can be visualized adequately by translabial-transperineal sonography in about 80% of patients and the measurements of cervical length obtained by this approach are very similar to those obtained by transvaginal sonography.

Cervical assessment at the routine 23-week scan: standardizing techniques

OBJECTIVE

To examine the frequency of curvature of the cervix and to establish the degree of curvature with increasing cervical length. To assess the significance of this phenomenon in terms of the classification of patients as high risk for pre-term delivery.

METHOD

Cervical length was measured prospectively by transvaginal sonography in 301 women at 23 weeks of gestation. The distance between the internal and external os was measured both as a straight line and also as a curved line along the endocervical canal. In addition, a search of our database was made to identify all women who had undergone cervical assessment as part of a policy of routine screening. In those with cervical length of less than 26 mm the thermal images of the cervix were used to obtain straight and curved measurements. The frequency of curved cervix was calculated and the relationship between the ratio of straight to curved measurement to the curved one was determined.

RESULTS

In the prospective study curvature of the cervix was observed in 143 (48%) of the 301 women. Curvature was observed in 51% (135 of 267) with cervical length of 26-55 mm, 25% (8 of 32) with length of 16-25 mm, and none of the two with length of 1-15 mm. The ratio of the straight to the curved measurement decreased with increasing cervical length (r = -0.27, P = 0.001). In the retrospective study curvature of the cervix was found in 72 (15%) of 471 with length of 16-25 mm and in none of the 76 with length of 1-15 mm.

CONCLUSION

Cervical length is influenced by the degree of cervical curvature. The disparity of measurements between the internal and external os taken as a straight line or along the cervical canal increases with cervical length. However, this disparity may not have any clinical implications because at short cervical length (less than 16 mm) the cervix appears to be always straight.

Prediction of preterm delivery in twins by cervical assessment at 23 weeks

OBJECTIVE

To establish the relation between cervical length at 23 weeks of gestation in twin pregnancies and risk of spontaneous delivery before 33 weeks.

METHODS

Cervical length was measured by transvaginal sonography at 23 (range 22-24) weeks of gestation in 464 twin pregnancies attending for routine antenatal care. In the patients who were managed expectantly the relation between cervical length and the rate of spontaneous delivery before 33 weeks was determined.

RESULTS

The cervical length distribution was skewed to the left and the median value was 36 mm. The rate of spontaneous delivery before 33 weeks was inversely related to cervical length at 23 weeks. It increased gradually from about 2.5% at 60 mm, to 5% at 40 mm and 12% at 25 mm, and exponentially below this length to 17% at 20 mm and 80% at 8 mm. Cervical length of 20 mm or less is found in about 8% of the population and this group contained about 40% of women delivering spontaneously before 33 weeks.

CONCLUSIONS

In twin pregnancies measurement of cervical length provides useful prediction of risk for spontaneous early preterm delivery.

Cervical length at 23 weeks in triplets: prediction of spontaneous preterm delivery

OBJECTIVES

To establish the distribution of cervical length at 23 weeks of gestation in triplet pregnancies and to examine the relation to preterm delivery before 33 weeks.

METHODS

Cervical length was measured by transvaginal sonography at 23 (range 22-24) weeks of gestation in 43 triplet pregnancies. The distribution of cervical length was determined and the relationship between cervical length and the rate of spontaneous preterm delivery before 33 weeks was calculated.

RESULTS

The cervical length distribution was skewed to the left with a median of 34 mm. The rate of spontaneous labor and delivery before 33 weeks increased exponentially with decreasing cervical length at 23 weeks from 8% at 36-48 mm, to 11% at 26-35 mm, 33% at 16-25 mm and 67% at 15 mm or less. Cervical length was < or = 30 mm, < or = 25 mm and < or = 15 mm in 37%, 16% and 8% of cases, respectively, and the corresponding sensitivities in the prediction of spontaneous delivery before 33 weeks were 67%, 50% and 33%.

CONCLUSIONS

In triplet pregnancies, measurement of cervical length provides a useful prediction of risk for spontaneous early preterm delivery.

Cervical assessment at the routine 23-weeks' scan: problems with transabdominal sonography

OBJECTIVES

To compare transabdominal and transvaginal sonographic measurements of cervical length in pregnancy and examine the factors that may influence these measurements.

METHODS

The study population consisted of 149 women with singleton pregnancies attending for routine ultrasound examination at 23 weeks of gestation. In all women the cervix was successfully visualized by transvaginal sonography and cervical length was measured after emptying of the bladder. This measurement was compared to that obtained by transabdominal sonography. In addition the ability to visualize the cervix transabdominally was examined in relation to body mass index (BMI), bladder volume and cervical length.

RESULTS

The percentage of cases in which the cervix could be seen transabdominally increased from 42% for bladder volume of < 50 ml to 73% for volumes > 150 ml, and 13% for cervical length < 20 mm to 51% for lengths > 40 mm. The ability to visualize the cervix was unrelated to BMI. Although there was a significant association between measurements taken transabdominally with those made transvaginally, measurements taken with a full bladder were significantly longer than those with an empty bladder.

CONCLUSION

The aim of cervical assessment in pregnancy is to identify women with a short cervix because they are at high risk of preterm delivery. This aim can not be fulfilled by transabdominal sonography. Such a scan fails to visualize the cervix in a high proportion of cases and in particular those with a short cervix. Furthermore, successful visualization requires a full bladder which falsely increases cervical length.