The first trimester combined test for aneuploidies – a single center experience

Purpose: We present the results of the systematic application of the first trimester combined test for aneuploidies, in a Romanian center.

Methods: Since October 2009, in Filantropia Hospital in Bucharest, we have systematically been using the FMF (Fetal Medicine Foundation) combined first trimester test to screen for common aneuploidies at 11 to 13?+?6 weeks of gestation. We assessed the crown to rump length (CRL), nuchal translucency, fetal heart rate as well as PAPP-A, and free β-hCG in maternal serum. We evaluated additional first trimester ultrasound markers in most of the cases. The individual risk for aneuploidies was calculated using the FMF algorithm.

Results: Pregnancy outcome is known for 6030 euploid fetuses and 42 aneuploid fetuses from our screening population. The detection rate for trisomy 21 of the combined test was 87.5% for a screen positive rate of 1.96%. All of the trisomy 18 and trisomy 13 cases were detected prenatally. Some of the trisomy 18 cases proved not to be symptomatic in the first trimester.

Conclusions: Our results are similar to those of the main studies on the FMF method of first trimester screening for aneuploidies. Our numbers are small because of limited availability of the very specialized resources involved.     

Combined vaginal-cesarean delivery of twins: risk factors and neonatal outcome – a single center experience

Objective: We aimed to characterize risk factors for combined twin delivery and assess neonatal outcome.

Methods: This was a retrospective cohort study of all women admitted for trial of labor (TOL) with twin gestation, in a single, tertiary, university-affiliated medical center. Eligibility was limited to gestations with twin A delivered vaginally.

Results: During the study period, 44?263 women delivered in our center, of whom 1307 (2.9%) delivered twins. Overall, 221 out of 247 women (89.5%) undergoing TOL delivered twin A vaginally. Parturients who delivered twin B by cesarean delivery (n?=?23) were compared with those delivered twin B vaginally (n?=?198). Multivariate analysis demonstrated that risk factors combined delivery were included non-cephalic twin B at admission (aOR 11.5, 95% CI 3.8–34.9, p?<?0.001) or after delivery of twin A (aOR 17.7, 95% CI 6.6–47.2, p?<?0.001), and dichorionic–diamniotic (DCDA) twins (aOR 8.9, 95% CI 1.8–44.0, p?=?0.008). Spontaneous version of a cephalic twin B was not found to increase the risk (above the baseline risk of non-cephalic twin B) for combined delivery. Combined delivery was associated with slightly higher risk for hemorrhagic-ischemic encephalopathy of twin B (4.3% versus 0%, p?=?0.003).

Conclusion: Non-cephalic twin B at admission or following delivery of twin A poses higher risk for combined delivery. Neonatal outcome of twin B following combined delivery are comparable with those of vaginal delivery.     

Clinical and radiological findings for early diagnosis of Herlyn–Werner–Wunderlich syndrome in pediatric age: experience of a single center

Objective: The authors present their experience in the management of pediatric patients with Herlyn–Werner–Wunderlich syndrome (HWWS) considering clinical classification and anatomical characteristics of the malformation.

Methods: All the data of the patient presented at our Pediatric Surgery Unit from February 2010 to August 2015 were collected. According to the type of malformations, patients were divided in 3 groups: A (completely obstructed hemivagina), B (incompletely obstructed hemivagina), and C (communication between the duplicated cervices).

Results: Six patients were treated in the study period. The mean age was 9?years (2?months–15?years). According to the characteristics of the HWWS, we had 5 patients in group A, 1 in group B, and none in group C. One-stage surgical treatment was performed in all cases of complete obstruction, but in one case a second look was necessary for a better resection of the septum. At a mean follow-up of 18?months all patients were symptoms free.

Conclusions: Prognosis of this malformation is good in case of early diagnosis and treatment. We suggest that when a renal agenesia is diagnosed, the patient needs an ultrasonographic follow-up of the contralateral kidney but also of the genital tract to find each minimal abnormalities, furthermore, a MRI scanning before the onset of menstruation can be necessary.     

The incidence and risk factors for retained placenta after vaginal delivery – a single center experience

Abstract

Objective: We aimed to determine the incidence and risk factors for retained placenta immediately after vaginal delivery in a single, university-affiliated tertiary center.

Methods: A case-control study. Women who delivered vaginally and diagnosed with suspected retained placenta were compared to control group of women with spontaneous vaginal delivery with spontaneous non-complicated placental separation between the years 2007 and 2012. Eligibility was limited to singleton fetuses in vertex presentation with no history of more than one cesarean section, stillbirth or major fetal anomaly.

Results: Overall, 33?925 women delivered vaginally, of them, 491 (1.4%) underwent revision of uterine cavity due to suspected retained placenta. Women with retained placenta were characterized by a higher rate of previous cesarean section (OR 1.71, 95% CI 1.23–2.36), previous abortions, lower parity (OR 0.79, 95% CI 0.68–0.91), lower gestational age at delivery. Hypertensive disorders, oligohydramnios and labor and delivery interventions as induction of labor (OR 1.84, 95% CI 1.30–2.59), neuro-axial analgesia (OR 1.60, 95% CI 1.27–2.00) and vacuum delivery (OR 1.89, 95% CI 1.48–2.41) were independently associated with uterine revision for retained placenta.

Conclusion: Risk factors for manual revision due to retained placenta can be recognized. This data should be taken into consideration in the assessment of women immediately after delivery.     

Trial of vaginal delivery for twins – is it safe? a single center experience

Purpose: This study assessed our hospital protocol of vaginal delivery for twins and evaluated whether trial of vaginal delivery (unless contraindicated) was as safe as elective cesarean. Risk factors leading to failed trial of labor (TOL) were characterized to improve our ability to advise patients and select cases for TOL.

Methods: This retrospective, cohort study included women >32 weeks gestation, with twin A in cephalic presentation and no contraindications for vaginal delivery. Controls were women with twin pregnancy and planned cesarean delivery (PCD). Maternal and neonatal morbidity between TOL and PCD were compared. TOL group was subcategorized by vaginal or cesarean delivery to characterize pre-labor risk factors for failed TOL.

Results: Of the 411 twins, 215 had TOL and 196 had PCD. Among TOL, 196/215 (91%) delivered vaginally. TOL was more likely to have spontaneous pregnancy, pregnancy complications and tended to deliver earlier. More TOL had postpartum hemorrhage (p?Conclusions: The results support the contemporary practice of TOL for twins at term when the first is in cephalic presentation with no other contraindications.     

Extraovarian conditions mimicking ovarian cancer: a single center experience of 15 years

Objective  

This study aims to review cases of extra-ovarian conditions that resembled ovarian malignancy and thus, to evaluate the distribution of primary pathology mimicking ovarian malignancy.     

Congenital heart defects according to the types of the risk factors – a single center experience

Objective: The main aim of this study was to compare the prevalence of congenital heart defects (CHDs) between pregnant women with and those without the risk factors. The secondary aim was to determine the influence of the specific risk factors, divided into subgroups, on the development of the CHD.

Methods: The presented results were obtained over the course of a 15-year study between years 2002 and 2016. Fetal echocardiography was performed as a planned screening examination during the second trimester of gravidity. A total of 35,831 singleton pregnancies were examined at our center. Risk factors for the development of CHDs were analyzed and divide into the following groups: (i) maternal age ≥35 years; (ii) mother-related risk factors; (iii) pregnancy- and fetus-related risk factors; (iv) pregnancy after in vitro fertilization (IVF); (v) history of CHDs in the first-degree family member; (vi) history of CHDs in the second-degree family member; and (vii) positive genetic family history.

Results: The risk factors were identified in 25% (8990/35,831) of pregnancies. In total, CHDs were detected in 1.1% (394/35,831) of fetuses. The prevalence rate of CHDs was higher in the pregnancies with than in those without the risk factors (2.5% [221/8990] versus 0.6% [173/26,841]; p?Conclusions: The presence of specific risk factors is related to the increasing prevalence of CHDs. Pregnancy- and fetus-related risk factors and in vitro fertilization were found to be the independent risk factors of CHD.     

The effect of anesthetic agents for oocyte pick-up on in vitro fertilization outcome: A retrospective study in a tertiary center

ObjectiveGeneral anesthesia is used in most in vitro fertilization (IVF) clinics for oocyte pick-up (OPU), however, there is no consensus on type of anesthetic agent use among clinicians performing OPU. Therefore, we aimed to evaluate the effects of propofol, ketamine, or combination of propofol and ketamine (P + K) for OPU on IVF outcome.Material and methodsThree hundred and thirty three women (n = 333) undergoing IVF treatment were retrospectively included and were evaluated in three groups depending on whether they received propofol (n = 217), or ketamine (n = 60), or P + K (n = 56) for anesthesia during OPU.ResultsBaseline characteristics and duration of anesthesia of each group were comparable except lower motile sperm percentage in the ketamine group compared to the propofol group (p = 0.002). Fertilization rate (FR) was decreased with ketamine compared to propofol (p = 0.013) and P + K (p = 0.008). After adjustment for sperm motility, this negative effect of ketamine on FR persisted. Implantation, clinical pregnancy, take-home baby rates, and oocyte retrieval parameters (number of total retrieved oocyte, metaphase II oocytes, embryo and methaphase II rate, and embryo quality) did not differ between the groups. Extended anesthesia duration (>30 min) was associated with low implantation (p = 0.04) and clinical pregnancy rates (p = 0.02).ConclusionKetamine use during OPU can affect FR compared to propofol and P + K. Long durations of anesthesia also seem to decrease implantation and clinical pregnancy rates.     

Women’s well-being after Manchester procedure for pelvic reconstruction with uterine preservation: a follow-up study

Purpose

This study describes the outcomes of a modified Manchester procedure on the quality of life and sexual functioning of women with elongation of the uterine cervix with or without pelvic organ prolapse (POP).

Methods

Data on medical and demographic variables were collected from medical files and then women were invited to for follow-up examination and data collection.

Results

Follow-up data were collected from 53 out of 87 women who underwent reconstructive surgery with modified Manchester procedure (60.9% of the women). Prior the surgery, all women in this sample (n?=?53) were medically examined and found to have uterine cervix elongation, 40/53 (75.4%) women also had cystocele, 10/53 women (18.8%) had uterine prolapse and 8/53 women (15.1%) had rectocele (all stages II–IV). On follow-up examination, all the cervical stumps were satisfactorily situated, recurrent cystocele was found among 12/53 women (22.6%) women; 13/53 (24.5%) had rectocele; and none of these women had uterine prolapse. Women with POP (cystocele and rectocele) (24/53) had less operative satisfaction (p?=?0.004), lower quality of life (p?p?=?0.03) compared to women without POP (29/53).

Conclusion

The modified Manchester procedure including reconstructive surgery for women with cervix elongation, with or without POP, prevented recurrent uterine prolapse and was well received in terms of patient’s satisfaction, quality of life, and sexual function.     

Prehysterectomy embolisation of uterine arteries for large uterine fibroids—a report

Hysterectomy for large uterine fibroids can prove to be a technically difficult procedure. The irregular shape of the uterus filling the pelvis may make access to the pedicles difficult. The larger the size of the uterus, the greater the risk of significant blood loss and trauma to the surrounding structures. Uterine artery embolisation (UAE) has been in use since 1991 as a noninvasive treatment for uterine fibroids and has had encouraging results. Various workers have reported success rates between 86% and 100%. We present here our experience with two patients who underwent embolisation of the uterine arteries, followed by hysterectomy. In both cases, patients had symptomatic uterine fibroids and no desire to conceive. The patients were counselled about the combined treatment and other treatment alternatives available to enable them make an informed choice.     

Short-term outcomes of fetoscopic laser surgery for severe twin–twin transfusion syndrome from Taiwan single center experience: Demonstration of learning curve effect on the fetal outcomes

ObjectiveTo evaluate the learning curve effect on fetal outcomes while using fetoscopic laser photocoagulation (FLP) for twin–twin transfusion syndrome (TTTS) as managed by a newly established single center in Taiwan.Materials and MethodsBetween October 2005 and October 2010, women diagnosed to have TTTS before 26 weeks of gestation were offered FLP surgery. Cases were divided into first-half and second-half groups to evaluate the learning effect on fetal outcomes including at least one survival rate, two survival rate, and gestational age of delivery.ResultsA total of 44 cases with a median gestational age of 20.1 weeks (range 16–25) at operation were included in the study. Overall, both twins survived in 22 (50.0%) cases, whereas only one twin was born alive in 13 (29.5%), and neither was born alive in the remaining nine cases (20.5%). The total survival rate was 64.8%. When comparing the first-half 22 cases and the second-half 22 cases, there were significant improvements in total survival rate (54.7% vs. 75.0%, p = 0.045), a prolonged interval between operation and delivery (62.1 vs. 89.1 days, p = 0.042), and more advanced gestational age of delivery (28.3 vs. 33.0 weeks, p = 0.008) in the second-half 22 cases.ConclusionsWith increasing experience in using fetoscopic guide laser therapy for TTTS, the fetal survival rate could be improved with advanced gestational age at delivery.     

Fertility in young patients following treatment for Hodgkin’s lymphoma: a single center survey

Purpose

The purpose of this study was to determine the fertility rates following treatment by means of the BEACOPP regimen (regular and escalated) (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) as compared to the ABVD regimen (doxorubicin, vinblastine, dacarbazine, bleomycin) in Hodgkin lymphoma patients under the age of 40 at the time of treatment.

Methods

A questionnaire was sent to 180 Hodgkin lymphoma (HL) patients. The questionnaire was composed of questions concerning reproduction and also menopausal and aging symptoms in females and males. The analyses were made using data collected from 123 patients (76 females and 47 males) who returned the questionnaire. All of the patients were treated between 1999 and 2012.

Results

In comparing the ABVD and BEACOPP groups of female patients, the frequency of the therapy-induced amenorrhea and the restored menses following treatment were found to be significantly different statistically (p?=?0.002 and p?=?0.012, respectively). The secondary amenorrhea statistically appeared more often in the BEACOPP group (p?=?0.003) while the cases of achieving pregnancy and having children after chemotherapy were not significantly different (p?=?0.630, p?=?0.070, respectively). In comparing the ABVD and BEACOPP treatments in male patients, the only significant difference was in the number of artificially inseminated or in vitro pregnancies achieved in the BEACOPP and escalated BEACOPP group, p?=?0.008 and p?=?0.002, respectively. In total, 45.2 % of patients in the ABVD female group, 34.6 % in the BEACOPP female group, 52.6 % in the ABVD male group, and 33.3 % in the male BEACOPP group, respectively, of patients attempting conception post-therapy, had children after chemotherapy.

Conclusions

Based on these high rates of childbirth following BEACOPP chemotherapy, we have concluded that intensified chemotherapy is not a definite predictor of reduced fertility in young HL patients.

     

Congenital abnormalities at a tertiary center in Jamaica: An 18-month maternal–fetal medicine experience

Objective: The objective of this study was to compare outcomes of patients with prenatally versus postnatally diagnosed congenital abnormalities seen during the first 18 months of a recently established MFM unit. Methods: Hospital charts of all congenital abnormalities diagnosed between July 2008 and December 2009 were reviewed. Data collected included: maternal demographics, perinatal outcome, neonatal mortality and morbidity as defined in the Radius trial. Results: Fifty-five pregnancies with 57 anomalous fetuses were identified: 13 (23%) postnatally and 44 (77%) prenatally. Most frequent postnatally diagnosed anomalies were gastrointestinal (33%), central nervous system (CNS) (16%) and cardiac (16%); whereas prenatally diagnosed were CNS (29%) and genitourinary (23%). Mothers postnatally diagnosed had a 12?kg (17%) greater mean weight; 12 (92%) had anomaly scans reported as normal; birth weight and moderate neonatal morbidity were statistically greater (2.8 vs. 2.13?kg, p?<?0.02) and (9/12 vs. 11/29, p?<?0.03), respectively. Neonatal morbidity was 6.2 times more likely in the postnatally diagnosed group adjusting for birth weight, gestational age and route of delivery [OR (95% CI) 6.2, (1.2–32.4), p?=?0.03]. Conclusions: Most abnormalities were diagnosed prenatally; however, the majority of postnatally diagnosed had false negative anomaly scans and experienced significantly more moderate neonatal morbidity.     

Misoprostol and termination of pregnancy: is there a need for ultrasound screening in a general population to assess the risk for adverse outcome in cases of uterine anomaly?

Purpose and methods

We reviewed the existing literature on medical termination of pregnancy in cases of congenital uterine malformation. Is medical termination of pregnancy safe in the presence of a uterine anomaly? Can termination of pregnancy still be performed when information concerning the presence of congenital uterine malformation is not available?

Results

The risk of adverse outcome, i.e. uterine rupture, was high in class 2 uterine anomalies, whereas the risks in classes 3–6 were negligible. However, the very low incidence of class 2 anomalies in pregnant women results in a calculated risk of uterine rupture in medical termination of pregnancy on the basis of this anomaly of 1 in 300,000 pregnancies. Ultrasound scanning is of limited diagnostic value to diagnose congenital uterine malformations.

Conclusions

The implications of uterine anomalies are not an argument in the discussion whether to use misoprostol for termination of pregnancy in developing countries with scarce diagnostics tools.

     

Endometriosis: the consequence of uterine denervation–reinnervation

Difficult intrapartum episodes and persistent straining during defecation cause injuries to uterine nerves and uterosacral ligaments. Injuries to uterine nerves (denervation) result in loss of fundocervical polarity, uterotubal dysmotility and retrograde menstruation. Ectopic endometrium, delivered by retrograde menstruation, adheres to injuries to uterosacral ligaments and peritoneal surfaces. Difficult vaginal deliveries result in laparoscopic appearances of asymmetry of uterosacral ligaments with, or without, ectopic endometrium. Straining during defaecation causes the “classic” appearances of nulliparous endometriosis including hypertrophy of the uterosacral ligaments often with large volumes of ectopic endometrium. Laparoscopic appearances depend on the site, nature, extent, and timing of tissue injury, as well as the presence of available endometrium. Tissue repair, including reinnervation in the uterine isthmus, cervix, vagina and uterosacral ligaments, contributes to chronic pelvic pain, dysmenorrhea, dyspareunia and subfertility some time after the primary injuries.     

Comparison of “sandwich chemo-radiotherapy” and six cycles of chemotherapy followed by adjuvant radiotherapy in patients with stage IIIC endometrial cancer: a single center experience

Objective

To compare “sandwich chemo-radiotherapy” with six cycles of chemotherapy followed by adjuvant radiotherapy with respect to tolerability and acute toxicity.

Materials and methods

Twenty-five women with surgically staged IIIC endometrial cancer were included. Treatment consisted of either three cycles of paclitaxel (175 mg/m²) and carboplatin (AUC 6) on a q21-day schedule followed by irradiation (45–50.4 Gy) or six cycles of the same chemotherapy followed by radiotherapy. Acute toxicity related to either chemotherapy or radiotherapy was evaluated.

Results

Median age was 61.5 years (range 36–83 years). Eleven patients had sandwich chemo-radiotherapy, and the other 14 patients had 6 cycles of chemotherapy followed by radiotherapy. Three out of the five patients who could not complete all the cycles in the sandwich chemo-radiotherapy group had pelvic and para-aortic radiotherapy. Acute radiotherapy related grade 1–2 gastrointestinal system (GIS) and genitourinary system (GUS) toxicities were observed in 72.8 and 63.6 % of patients, respectively, for sandwich group. Undesired treatment breaks in the course of radiotherapy were observed in six patients for sandwich chemo-radiotherapy and in one patient receiving six cycles of chemotherapy followed by radiotherapy. All the patients who had undesired treatment breaks in the sandwich chemo-radiotherapy group had pelvic and para-aortic radiotherapy.

Conclusion

Sandwich chemo-radiotherapy seems to be more toxic particularly for patients who had pelvic and para-aortic irradiation. Therefore, it might be more convenient to delay radiotherapy after six cycles of chemotherapy for patients with the indication of pelvic para-aortic radiotherapy.     

Sarcomas and the conservative management of uterine fibroids: a cause for concern?

The introduction of conservative management options has further increased the choices available to clinicians treating women with symptomatic uterine fibroids. However, in the absence of a tissue diagnosis, the possibility of mismanaging an underlying uterine sarcoma is still present, placing these patients at potential risk of a delayed diagnosis of this serious pathology. Evidence suggests that 1 in 250-400 women presenting with what are thought to be symptomatic fibroids, will in fact have an underlying sarcoma, making this an important clinical issue. This paper therefore reviews the methods currently available for the assessment of women in whom conservative management of symptomatic fibroids is contemplated.     

Endoscopic stapling of large uterine vessels at laparoscopic hysterectomy for uterine fibroid masses of 500 g or more: a pilot study

From December 1996 to March 2004, 27 consecutive patients (both private and public) presented with large uterine fibroid masses to be removed, which subsequently weighed 500 g or more. All were scheduled for a laparoscopic hysterectomy procedure where the uterine vessels are secured laparoscopically using a linear cutter-stapling device. The data from these cases was collected prospectively. Twenty-six of the large uterine fibroid masses were successfully removed by planned laparoscopic hysterectomy without major complication. One case had to be opened because of dense pelvic adhesion, and it was the case with the largest mass in the series (1,280 g). The mean weight of the removed masses was 704.6 g (range: 500–1,280 g). Operating times were long (mean 220 min), but the postoperative stay was short (mean 2.26 days). Laparoscopic hysterectomy a using linear cutter-stapling device to secure the uterine vessel pedicles for large uterine fibroid masses is a useful and effective procedure in most cases with fast patient recovery.