Cervical cerclage in twin pregnancies: obstetric and neonatal outcomes

BACKGROUND

Although there have been significant improvements in prenatal and neonatal care in recent years, twin pregnancies account for 17-20% of all preterm births and are associated with an increased risk of perinatal mortality and morbidity.

AIMS

To evaluate the contribution of cerclage to the continuation of pregnancy in twin pregnancy cases required cervical cerclage.

METHODS

Cases of twin pregnancies who performed cervical cerclage with follow-up and deliveries between January 2010 and January 2022 in the Department of Obstetrics and Gynecology, Ege University Faculty of Medicine Hospital, were retrospectively analyzed. Obstetric and neonatal outcomes were evaluated.

RESULTS

A total of 23 women who performed cervical cerclage due to cervical insufficiency in twin pregnancies were evaluated retrospectively. The mean time between cerclage placement and delivery was 12.1 ± 7 weeks, maximum prolongation was in the obstetric history-indicated cerclage group. The gestational age at delivery was 20-38 (median 30) weeks. The rate of spontaneous preterm birth at < 34, < 32, < 28, and < 24 weeks was higher in the physical examination-indicated cerclage group. Overall neonatal survival was 82.5% (n = 33/40).

CONCLUSION

The time between cerclage placement and birth were considered as an important gain for twin pregnancies at the limit of viability. Further studies are needed to better understand the role of cervical cerclage in preventing premature birth and to determine the indications for cerclage.

Comparison of laparoscopic enclosed electromechanical morcellation and vaginal enclosed scalpel morcellation at laparoscopic myomectomy: A prospective randomized trial

AIM

This study aimed to compare the laparoscopic-enclosed electromechanical morcellation (LEM) with vaginal-enclosed scalpel morcellation (VSM) in laparoscopic myomectomy procedures.

METHODS

One hundred eighteen patients who underwent laparoscopic myomectomy were enrolled the prospective randomized interventional clinical study in tertiary university hospital. After myomectomy, tissue removal was accomplished via either LEM using the in-glove morcellation technique or VSM.

RESULTS

The median tissue removal time was longer in the LEM group (25 min [range: 14-55]) than the VSM group (20 min [range: 6-38] [p = 0.001]). Rescue analgesia requirement was significantly higher in the LEM group than the VSM group (mean rank: 56.92 vs. 40.92 doses, respectively; p < 0.001). There was no significant difference between preoperative and postoperative third month total scores of female sexual function index (FSFI) and subdomains in the LEM group. Conversely, all subdomains and total scores of FSFI (26.5 [16.7-34.8] vs. 22.7 [15.2-28.7]) except pain significantly worsened 3 months after operation in the VSM group.

CONCLUSIONS

LEM was associated with a longer tissue removal time and increased postoperative analgesic requirement. On the other hand, VSM was associated with worsened postoperative sexual function from baseline.

A prospective cohort study: can advanced ultrasonography replace magnetic resonance imaging in the diagnosis of placental adhesion disorders?

OBJECTIVES

To define and compare the diagnostic accuracy of ultrasonography (USG) and magnetic resonance imaging (MRI) for the placental adhesive disorder (PAD).

METHODS

A prospective study was conducted between January 2019 and February 2020 in a tertiary referral university hospital. A total of 115 placenta previa cases were included in the study during the third trimester of gestation. USG examination was performed, and the placenta was scanned in a systematic manner using gray-scale ultrasound, color Doppler flow mapping, and 3-D imaging for each participant. Thereafter, all participants underwent an MRI examination. USG and MRI findings were compared with histopathological findings.

RESULTS

Loss of the retroplacental sonolucent zone (71% [95% CI 47-88]) and an irregular retroplacental sonolucent zone (71% [95% CI 47-88]) were the most sensitive USG parameters. For MRI, the uterine bulging parameter was the most sensitive (60% [95% CI 36-80]) and specific (91% [95% CI 83-96]) findings, and it had the highest accuracy rate (85% [95% CI 77-91]). Overall, the USG sensitivity, specificity, and accuracy rates were 77% (95% CI 54-92), 87% (95% CI 79-93), and 85% (95% CI 77-91), respectively. The MRI sensitivity, specificity, and accuracy rates for all participants were 81% (95% CI 59-94), 85% (95% CI 76-92), and 84% (95% CI 76-90), respectively.

CONCLUSIONS

In the diagnosis of PAD, the specificity and accuracy of USG are higher than that of MRI, whereas the sensitivity of MRI is better than that of USG.

The role of fetal fibronectin and plasminogen activator inhibitor 1 biomarkers in antenatal prediction of placenta accreta spectrum

In this study, we aimed to assess the determining role of foetal fibronectin (FFN) and plasminogen activator inhibitor type (PAI-1) levels in the antenatal prediction of placenta accreta spectrum in cases with risk factors for placenta accreta spectrum. Singleton live pregnancies with placenta previa or low-lying placenta within 32-34 weeks of gestation were included in the study. The cases were divided into two groups after delivery as those with PAS and those with normal placentation. 54 cases diagnosed with placenta previa or low-lying placenta were included in the study. 17 of the cases underwent peripartum hysterectomy due to placenta accreta spectrum. 37 cases with normal placentation underwent caesarean delivery. Foetal fibronectin (p:.03) and PAI-1 (p:.02) levels were determined to be significantly different between cases with placenta accreta spectrum and cases with normal placentation. AUC for foetal FFN was calculated to be 0.69, while the AUC for, PAI-1was 0.66. Results for both FFN and PAI-1 were not found useful enough for the diagnosis of PAS. IMPACT STATEMENTWhat is already known on this subject? We lack biomarkers which can identify placenta accreta spectrum.What do the results of this study add? Maternal plasma levels of FFN and PAI-1 significantly altered in PASWhat are the implications of these findings for clinical practice and/or future research? If multiple of median values of FFN and PAI-1 levels in maternal blood are determined in future studies, it can be used in the antenatal diagnosis of PAS cases.

Prenatal diagnosis of a case with tetrasomy 9p confirmed by cytogenetics, FISH, microarray analysis and review

OBJECTIVE

Tetrasomy 9p is a rare fetal condition. Cases are usually mosaic. Here, we present a non-mosaic tetrasomy 9p case with cytogenetic analysis, fluorescence in situ hybridization, microarray data, ultrasound findings, and phenotypic presentation.

CASE REPORT

A pregnancy was referred to cytogenetic analysis because of increased nuchal translucency in prenatal ultrasound at 13 weeks of gestation. Prenatal laboratory analysis revealed an extra marker chromosome with a non-mosaic pattern. Ultrasonographic findings were unilateral cleft lip and palate, micrognathia, and atrioventricular septal defect at the 17th week; additionally, ventriculomegaly, left axis deviation of the fetal heart, and a single umbilical artery were determined at the 23rd week.

CONCLUSION

Phenotypic severity in non-mosaic tetrasomy 9p widely differs depending on the chromosomal content. We recommend performing appropriate genetic tests in those pregnancies with the suspicion of tetrasomy 9p, evaluating the mosaic state, and following those cases with detailed ultrasonographic examinations.

Evaluation of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in pregnant women with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is associated with a higher risk of complications in pregnancy. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been evaluated in numerous inflammatory diseases. We evaluated the possible role of these markers in SLE pregnancies. Forty-six pregnant patients with an already established diagnosis of SLE were included in the study. Complete blood counts were obtained upon admission for delivery. Seven patients were diagnosed with a flare and managed with multiple medications, whereas rest of the patients were not on any treatment or managed with monotherapy. NLR and PLR values were also evaluated between two groups and no statistically significant difference was found (p=.44 and p=.80, respectively). This study is the first to evaluate the possible role of NLR and PLR in pregnant SLE patients in the literature. Further studies are warranted for an elaborate evaluation of NLR and PLR in lupus pregnancies.Impact StatementWhat is already known on this subject? Pregnancy in the setting of SLE is associated with a higher risk of complications. Active disease increases the risk of adverse outcomes further.What the results of this study add? This study is the first to evaluate NLR and PLR in pregnancies complicated by SLE. No significant association between the course of the disease in pregnancy and NLR/PLR was documented.What the implications are of these findings for clinical practice and/or further research? Further studies on the markers to predict prognosis of SLE in pregnancy are required to improve the maternal and neonatal outcomes in this exclusive group of high-risk patients.

Pulmonary hypertension in pregnancy: experience from 45 cases at a tertiary care center

Objective: Pulmonary hypertension (PH) is a rare maternal cardiac disorder associated with high maternal and fetal mortality. The objective of our study was to evaluate the maternal and fetal outcomes in pregnant women with PH in a single health center.Study design: 45 pregnant patients with PH, who had undergone antenatal follow-up and delivery at the department of gynecology and obstetrics at a referral center were retrospectively investigated. Maternal and perinatal outcomes were evaluated and descriptive statistics were reported.Results: According to the WHO classification; 35 patients (78%) were in Group 1; 9 patients (20%) in Group 2 and one patient (2%) were in Group 3. Thirty-three of the cases (73%) had mild, 8 (18%) moderate and 4 (9%) severe PH. The mean delivery week was 35.5. Twenty-four of the cases (56%) delivered before the 37th week and the remaining 19 cases (44%) in the 37th week or later. Rate of cesarean section delivery was 88%. Only one case of maternal death was reported, who was initially diagnosed with PAH during pregnancy. This patient had severe PH and was in Group 1 according to the WHO classification.Conclusion: While the mortality rates related to PH were reported to be between 30% and 56% several decades ago, recent studies have reported the mortality rates between 5% and 25%. It is believed that the decline in the maternal mortality depended on the developments in the treatment alternatives and multidisciplinary management. However, PH is still a serious condition which requires a multidisciplinary approach and a well-planned obstetric management.

Comparison of indications and results of prenatal invasive diagnostic tests before and after the implementation of the use of cell-free fetal DNA: a tertiary referral center experience

PURPOSE

In this study, we aimed to compare the changes in the number, yield, and the percentage of karyotyping indications of the invasive prenatal diagnostic tests between the periods before and after cell-free fetal DNA was introduced to clinical use.

METHOD

The number of invasive prenatal diagnostic procedures such as amniocentesis and chorionic villus sampling, indication percentages and karyotype results in the periods before (January 1, 2009-December 31, 2010), (n = 1412) and after (January 1, 2016-December 31, 2017), and (n = 593) the introduction of cell-free fetal DNA was retrospectively evaluated.

RESULTS

When compared with the period before cell-free fetal DNA came into clinical use, the number of invasive prenatal diagnostic tests decreased by 58% while their yield was found to have increased (4.4% vs. 10.3%) in the period after cell-free DNA began to be used (p < 0.001). While there was a decrease in the indications due to advanced maternal age, an increase was found in ultrasonography indications for structural anomaly and the risk of a single-gene disorder (p < 0.001). Amniocentesis rate was found to have decreased in invasive prenatal diagnostic procedure types, while an increase was reported in CVS rates (p < 0.001).

CONCLUSIONS

Invasive prenatal diagnosis gradually decreases over the years, but the yield of invasive prenatal diagnostic tests increases. In parallel with the rapid development of modern molecular technologies and cheaper and easier access to the tests, we think that the number of invasive prenatal diagnostic tests will experience a more dramatic decrease in the following years.

Case Report of a Tubo-ovarian Abscess Caused by Candida kefyr

BACKGROUND

Candida species are harmless commensals of hosts, including humans, but they can cause infection when the immune system is compromised. Infections with non-albicans species can occur, ranging from urinary tract infections to sepsis, especially among patients in intensive care units.

CASE

The patient, a 37-year-old woman, presented with severe abdominal pain, fever, and vomiting. The patient's symptoms and fever continued in spite of treatment with antibiotics, and she underwent exploratory laparotomy. Cyst content culture results showed that Candida kefyr was present in the cyst.

CONCLUSION

To the best of our knowledge, this is the first case report of a tubo-ovarian abscess caused by C. kefyr. Rare pathogens can be found in patients with a tubo-ovarian abscess, so culture of the abscess material is important for determining subsequent treatment, particularly in women who require an operation for tubo-ovarian abscess.

Is there a relationship between age and side dominance of tubal ectopic pregnancies? --A preliminary report

OBJECTIVES

To determine whether there exists a relationship between age and side dominance of tubal ectopic pregnancies.

MATERIAL AND METHODS

One hundred twenty patients were retrospectively analyzed. The sides of the tubal ectopic pregnancies were recorded on the basis of laparoscopy or laparotomy findings. Five age groups were created: 20-24, 25-29, 30-34, 35-39, and > or = 40 years.

RESULTS

Of the patients who were > 30 years of age, 46 (69%) and 21 (31%) had tubal ectopic pregnancies on the right and left sides, respectively (p = 0.002). In the 35-39 years of age group, 17 of 20 patients (85%) had tubal ectopic pregnancies on the right, and 3 of 20 patients (15%) on the left side (p = 0.002). In the 30-34 years of age group, 26 of 39 patients (67%) and 13 of 39 patients (33%) had tubal ectopic pregnancies on the right and left sides, respectively (p = 0.037). In the > or = 40 years of age group, 3 of 8 patients (37%) had tubal ectopic pregnancy on the right side, while 5 patients (63%) on the left side (p = 0.48).

CONCLUSIONS

Patients who are between the age of 30-40 years have a right-sided dominance of tubal ectopic pregnancy however studies that involve larger numbers of subjects are needed to make definitive conclusions about women older than 40 years of age.