Ultrasonographic evaluation of equine fetal growth throughout gestation in normal mares using a convex transducer

Prediction of Gestational Age in Warmblood, Standardbred and Thoroughbred Horses Based on the Table Established in Light Breed Horses Using Foetal Ultrasonographic Measurements of Four Biometric Parameters

Using the equation of Hartwig et al. and the table established for light breed horses, day of gestation was predicted in 108 Warmblood (WB) and 59 racehorses (Thoroughbred [TB] and Standardbred [STB]) pregnant mares. In WB, gestational ages were predicted within 2 weeks from 100 to 200 days of gestation using biparietal diameter (BPD), aortic diameter (AortD) or femur length (FL); within 2 weeks from 100 to 250 days using BPD or AortD; within 2 weeks from 100 to 300 days using BPD alone; and within 3 weeks from 100 to 350 days using eye approximated volume (EyV) alone. In the racehorse group, gestational ages were predicted within 2 weeks from 100 to 200 days of gestation using BPD or AortD; within 3 weeks from 100 to 250 days of gestation using BPD or FL; and within 3 weeks after 300 days of gestation using EyV. Across breeds including Quarter Horses (QH), WB, STB and TB, BPD was the best foetal age predictor from 100 to 200 days of gestation and from 200 to 300 days of gestation with accuracies within 2 and 3 weeks, respectively. After 300 days of gestation, EyV was found to be the best predictor with an accuracy of within 3 weeks. Overall, in the two groups, the breed of the foal nor the breed of the dam (except for short days increments), had any effect on foetal age prediction. Therefore, the table established for light breed horses can be used to assess the foetal age of foetuses carried by recipient mares whether they are WB or STB. Using the same anatomical landmarks but a different ultrasound machine, both ultrasonographers determined foetal age with similar accuracy.

Real-time transrectal ultrasonographic measurement of the fetal eye (vitreous body) to predict parturition in bucking horse mares

Monitoring gestation and predicting parturition in mares with unknown breeding dates is challenging, especially in pasture bred herds of bucking horses. Transrectal ultrasonographic measurement of fetal vitreous body length is a validated predictor of foaling dates, but previous research suggested a need for breed-specific parameters to develop accurate indices for respective breeds. This study aimed to develop a scale associating fetal vitreous body length with days before parturition (DBP) in bucking horses. Biannual data collection over 2 years identified 199 pregnancies out of 240 reproductive examinations, of which 155 fetal eyes were successfully identified and measured (78 %). Foaling dates confirmed for 131 successful fetal eye examinations (n = 131) enabled DBP calculation. A single transrectal ultrasonographic measurement was collected of the length of the fetal eye measured to the maximum dimensions of the vitreous body at the level of the lens, ranging from 9 to 35 mm. Multilevel mixed-effects linear regression methodology yielded the curvilinear equation DBP= -0.163(fetal eye length measurement in mm) 2 + 268.949 (r = 0.881, p < 0.001, concordance=0.994, average difference -0.077±17.214 days), which accurately calculates DBP in bucking horses based on transrectal ultrasonographic measurement of the fetal eye. Although this newly developed equation is similar to a previously reported equation for use in small ponies, applying the equation used for DBP prediction in small ponies to bucking horse pregnancies resulted in a small, but significant underestimation in predicting bucking horse DBP.

Assessment of fetal development during mid and late term pregnancies by standard B-Mode ultrasonography in Shetland ponies

Transrectal and transabdominal ultrasonography is an established method to monitor pregnancy, fetal growth and wellbeing in different species. Growth charts with multiple bio-morphometric parameters to estimate days of gestation and days before parturition exist in small companion animals, sheep and goats, riding type horses and large ponies but not in small horse breeds like Shetland ponies. The aim of this study was to apply fetal biometric assessment and detailed description of physiologic fetal development to mid and late term pregnancies in Shetland mares and to generate reference data for clinical practice and for future research. Fetal parameters were collected starting on day 101 of pregnancy in five Shetland mares. The fetal biometric parameters determined consisted of aortic diameter, eye diameter, combined rib and intercostal distance (CRID), stomach length and width and different heart morphology parameters in sagittal and frontal plane. Additionally, fetal activity and organ development in terms of differentiation and changes in echogenicity were recorded. Considering reliably assessable parameters, fetal CRID was the best predictor for gestational age with ± 13.6 days and fetal aortic diameter the most accurate for prediction of days until parturition with ± 16.2 days.

Twin Pregnancy in the Martina Franca Donkey Breed Managed by Natural Reduction and Post-Fixation Manual Crushing

In Equids, undetected twin pregnancy represents the most important cause of abortion and is also associated with high neonatal mortality rates. Therefore, the detection and management of twin pregnancies is pivotal to allow the continuation of single pregnancies. Although pre-fixation manual crushing of one embryo is the most common management of twin pregnancies, and the impact of natural reduction has been reported in mares, very little is known about donkeys. The present study aimed to report results on the natural reduction occurrence and post-fixation manual crushing management of twin pregnancies in the Martina Franca donkey breed.

METHODS

Twenty-five twin pregnancies were detected at 11-13 days after ovulation. At 16 days after ovulation, twin pregnancies were classified as unilateral or bilateral and left untreated. The occurrence of natural reduction of one embryo was assessed at 20-21 days after ovulation, and post-fixation manual crushing of one embryo was performed in those cases in which natural reduction did not occur. The pregnancy rate at 28 days after ovulation and live foal rate were recorded.

RESULT

Sixteen out of 25 twin pregnancies were unilateral and nine bilateral. At 20-21 days after ovulation, the natural reduction of one embryo occurred in 87.5% of the unilateral and in none of the bilateral twin pregnancies. The remaining twin pregnancies were treated by post-fixation manual crushing of one embryo. The 28-days-after-ovulation single embryo pregnancy rate was 93.8% for unilateral twin pregnancies and 88.9% for bilateral twin pregnancies, with an overall pregnancy rate of 92%. The live foal rate was 87%.

CONCLUSIONS

The success rate of natural reduction within 20-21 days after ovulation, the 28-days-after-ovulation pregnancy rate, and the live foal rate suggest that waiting for the natural reduction of one embryo and choosing the post-fixation manual crushing of one embryo could be considered as an alternative to traditional early pre-fixation manual crushing in the Martina Franca donkey breed.

Use of Transabdominal Ultrasound and Maternal Hormone Testing for the Prenatal Monitoring of Equine Fetal Enlarged Bladder

Ultrasound examination during late gestation is one of the best methods for monitoring potential pregnancy risks. Enlarged bladder is a urological disorder rarely observed in equine fetuses. This clinical case report aimed to present a case illustrating the development of equine fetal enlarged bladder using transabdominal ultrasound examinations and maternal hormone evaluation during gestation. An 8-year-old Hokkaido native pony was impregnated by embryo transfer, and at 215 days of gestation, abnormalities of the fetal bladder were detected. The bladder volume increased with gestational age, and a second bladder was observed at 257 days of gestation. No abnormalities were observed in the fetal kidneys. Moreover, the maternal plasma progesterone concentration was measured throughout the gestation period. The progesterone concentration was elevated from 36 weeks of gestation until parturition. At 363 days of gestation, parturition induction was conducted, and a foal successfully delivered. This case report is the first to describe the development of equine fetal enlarged bladder and record the corresponding ultrasound and hormone profiles.

First Description of Fetal Cystic Hygroma Associated With Early Equine Pregnancy Loss

Cystic hygroma (hygroma cysticum) is a malformation that has not yet been described as a cause of early pregnancy loss in equines. The condition is a congenital anomaly occurring during embryogenesis due to a failure in which the primitive lymphatic sac does not reach the venous system at the jugular vein, resulting in a lymphatic stasis that starts in the neck region and continues to the rest of the body. From 2015 to 2020, a total of 5,730 ultrasound examinations were performed in mares from 43 different horse farms and embryo transfer farms when sexing pregnancies. In 12 pregnant mares, a suspected fetal cystic hygroma was diagnosed via transrectal ultrasound performed from day 52 to 75 of pregnancy. Six fetuses were collected and fixed to conduct histopathological and karyotyping. Macroscopic and microscopic analysis supported the suggested diagnosis being the first description of cystic hygroma in equine fetuses and concluded as a cause of pregnancy loss around 65 days of gestation.

Equine Stomach Development in the Fetal Period: An Anatomical, Topographical, and Morphometric Study

Studies of equine stomach prenatal development are very rare, and descriptions usually focus on the processes taking place in the embryonic period. Only general information about gastric organogenesis in the fetal period is available in embryology textbooks on domestic mammals. The material for our study included twenty half-breed horse fetuses divided into three age groups on the basis of known fetal age (verified using the CRL method). Our study consists of the topographical, morphological, and morphometrical description of stomach development between the 4th and 11th months of gestation. Even though the skeletotopy, syntopy, and holotopy of the stomach in the fetal period seems to be relatively unchanged, the organ shape and the proportions between its anatomical parts differed in fetuses from the three age groups. The achieved results were statistically elaborated to estimate the dynamics of the stomach shape. This can be described as changing from medium-wide to wide and from slightly bent to sharply bent. A nonlinear correlation of all metric values with CRL in all age groups was observed. A positive allometric growth rate of different intensity was seen in all metric parameters. All the values increased as the fetal period progressed. Only the parietal surface growth rate gradually changed from strongly positive allometric in the first age group to strongly negative allometric in the third age group. A difference between the non-glandular and glandular mucosa of the stomach was visible in the first group. Development of a well-distinguishable plicated edge margin began in the second age group together with gastric pits and gastric areas. The third age group showed a well-developed gastric groove and angular incisura.

Fertility restoration of racing mare with persistent corpus luteum

Background and Aim:

Persistent corpus luteum (PCL) causes anestrus in mares. This study aimed to determine the effect of intrauterine prostaglandin F2α (PGF2α) treatment on PCL of racing mares to restore fertility.

Materials and Methods:

Twelve racing mares suspected with PCL were diagnosed using transrectal palpation and confirmed by serum progesterone (P4) concentration measurement. PGF2α was infused intrauterine, followed by serum collection at 24, 48, and 72 h after. Estrous symptoms were monitored, and mating was conducted on day 3 of estrus with an earlier injection of 8.4 μg gonadotropin-releasing hormone twice a day. Transrectal palpation was performed on days 21-30 to observe the corpus luteum. Pregnancy diagnosis was performed rectally on 40-45 days post-mating and confirmed using Doppler ultrasound scanning.

Results:

Eleven of the 12 mares had PCL. There was a dramatic reduction in the P4 concentration following PGF2α treatment of mares with PCL. All mares exhibited estrus 2.6±0.55 days post-treatment with a P4 concentration of 0.12±0.12 ng/mL. Rectal palpation and P4 concentration on 21-30 days after estrous onset showed that all mares were ovulating. The evaluation of P4 concentration on days 40-45 post-mating showed that all mares were still in the luteal phase. However, the pregnancy rate was only 54.5% based on rectal palpation and Doppler ultrasound scanning.

Conclusion:

Treatment of PCL in racing mares with an intrauterine infusion of PGF2α restored the estrous cycle and induced ovulation and pregnancy.

Ultrasonographic examination of equine fetal growth parameters throughout gestation in pony for Equine-Assisted Therapy

Equine-Assisted Therapy (EAT) is gaining popularity. Ultrasound examination is used to decrease the abortion rate in horses. In this study, to monitor fetal well-being throughout the gestation for EAT, we measured fetal heart rate (FHR), fetal eye orbit (FEO), fetal gonad length (FGL), fetal kidney length (FKL), and the combined thickness of the uterus and placenta (CTUP) by ultrasonography in pony mares. Additionally, we measured the plasma progesterone (P₄) and estradiol (E₂) concentrations in pregnant horses using enzyme immunoassay. The FGL peaked at week 32 and then decreased to term, and a strong correlation (r=0.72, P<0.001) between the FGL and E₂ concentration was observed. A strong correlation with gestational age was detected among the FEO (r=0.96, P<0.001), FKL (r=0.85, P<0.001), and CTUP (r=0.96, P<0.001). The P₄ concentration peaked at week 10, decreased to low levels (below 5 ng/ml), and peaked before parturition. In conclusion, this study provides information on fetal growth throughout gestation in pony mares for EAT. In addition, it revealed the relationship between ultrasonographic profile and plasma hormone concentrations during gestation.

Pregnancy obtained in a late gestational mare by in vitro embryo production

Recently, the demand for invitro embryo production in the horse has increased worldwide. Most clinical transvaginal ultrasound-guided ovum pick-up (OPU) procedures are performed in non-pregnant donor mares, and few experimental studies have described invitro embryo production from oocytes of pregnant donors 21-150 days in gestation. This report discusses OPU, follicular growth and invitro embryo production in a pregnant mare during late gestation.

Ultrasonographic findings associated with normal pregnancy and fetal well-being in the bottlenose dolphin (Tursiops truncatus)

Reproductive success is vital in sustaining free‐ranging and managed bottlenose dolphin (Tursiops truncatus) populations. Ultrasonography is an invaluable, non‐invasive tool in assessing the fetomaternal unit in humans and animals, including dolphins and horses. The purpose of this prospective longitudinal cohort study was to develop a protocol for fetomaternal ultrasonographic monitoring in dolphins and to report normal measurements and descriptive findings correlated with a positive outcome. From 2010 to 2017, serial ultrasonographic evaluations of 12 healthy dolphins were performed over the course of 16 pregnancies. A total of 203 ultrasound examinations were included in the study. Several metrics were accurate in predicting fetal age. Fetal biparietal diameter (BPD), thoracic width in dorsal and transverse planes, thoracic height in a sagittal plane, aortic diameter, and blubber thickness all demonstrated high correlation with gestational age (r > 0.94, P < .00001). Regional uteroplacental thickness significantly increased with each trimester (range 0.22–0.40 cm; P < .00011 cranial uterus, P < .00057 mid, and P < .000011 caudal). Lung:liver mean pixel intensity was 2.57 ± 0.46 (95% confidence interval 2.47‐2.67). Ultrasonographic characteristics of normal pregnancy in dolphins are described and an equation for prediction of parturition date in Tursiops is reported: days to parturition = 348.16 − (26.03 × BPD(cm)) (R² = 0.99). Future applications of these normal data will help identify in utero abnormalities indicative of fetal morbidity, and improve understanding of reproductive failure in wild and managed populations.

A regression model including fetal orbit measurements to predict parturition in Standardbred mares with normal pregnancy

In the mare, foaling is a critical unpredictable event due to a wide range of gestational length and the absence of clear signs of impending parturition. To predict foaling, pH, inversion sodium potassium and increase of calcium concentration in mammary secretions are used. The aim of this study was to find how many days are left until parturition knowing mare's age (A) and parity (P) combined with ultrasonographic measurements of the fetal orbit in Standardbred mares with normal pregnancy. Eighty healthy Standardbred mares with normal pregnancy were hospitalized for attended delivery. Information about mare's age, parity and breeding date were recorded at admission. Transrectal ultrasonography were routinely performed at admission and every 10 days until parturition using a B-mode real time portable unit equipped with a 5-7.5 MHz linear transducer. The images of the fetal orbit were acquired when cornea, anterior and posterior chamber, vitreous body, lens and optic nerve were visible. Longitudinal diameter (LD) was considered as the distance between the two ocular poles, within the vitreous body; transverse diameter (TD), perpendicular to LD and bisecting the lens, was measured as the distance between cornea and retina. At delivery, length of pregnancy and gestational age at each exam were registered. For each ultrasound examination, days before parturition (DBP) were calculated. Seventy-eight Standardbred mares with normal pregnancies were included in the study. Mares' mean age was 9 ± 5 years old (range 4-20 years) and mean gestation length was 341 ± 7 days (range 327-366 days). Thirty-three mares were primiparous and 45 mares were multiparous. Data were analyzed using a regression tree: P, A, LD and TD were used as covariates. DBP was used as the variable of interest. Nine terminal nodes were identified based on the selected covariates. The first split is produced by the TD: fetuses with TD greater or equal than 2.97 cm are further split according to LD, with a threshold of 3.28 cm. The next split is dictated by A; after a further split on LD, the first terminal node is built, containing 34 fetuses with average DBP equal to 10 days. If the A is ≥ 9.5 years a further split is on P: when mares are multiparous, the TD built two different nodes. Since prediction of mare's foaling date is an important factor in stud farm management, the regression model developed may help the veterinarian to estimate the DBP in Standardbred mares with normal pregnancy.

Transrectal three-dimensional fetal volumetry and crown-rump length measurement during early gestation in mares: Intra- and inter-observer reliability and agreement

The aim of this study was to investigate if transrectal three-dimensional (3D) ultrasound is a reliable technique to measure equine fetal volume (FV) during early gestation in mares. In total 149 warmblood mares were examined once transrectally on days 45 ± 1 of pregnancy with a portable 3D ultrasound device (Voluson^® i, GE Healthcare, Zipf, Austria). The following measurements were performed: Two-dimensional (2D) and 3D crown-rump length (CRL), FV using Virtual Organ Computer-aided AnaLysis (VOCAL™) software with rotational angles of 6° and 30°. To analyze intra- and inter-observer reliability (intraclass correlation coefficient (ICC)) and agreement (Bland-Altman's limits of agreement (LoA)) of FV measurements, images from 60 horse fetuses were selected and repeatedly analyzed by the same examiner (A) and by a second examiner (B). The time for each ultrasound examination (2D and 3D) and for the FV measurements was recorded. The 3D measured CRL was larger (P < 0.001) than the 2D CRL. Repeated measurements of 3D CRL showed a higher reliability (ICC = 0.91 (0.88-0.94), P < 0.001) and agreement (mean = 0.13%, 95% LoA: 7.45 to +7.19) compared to reliability (ICC = 0.50 (0.36-0.61), P < 0.001) and agreement (mean = -1.54%, 95% LoA: 23.29 to +20.21) of the CRL measurement in 2D mode. For intra-observer examinations, reliability was highest when using a rotational angle of 30° (ICC = 0.98 (0.97-0.99), P < 0.001). The inter-observer reliability of 3D measurements was good (ICC = 0.85 (0.67-0.92), P < 0.001). The extra time needed to perform the 3D scan ranged from 1 to 9 min and FV measurements lasted 03:30 ± 00:46 and 08:10 ± 01:05, for rotational angles of 30° and 6°, respectively. In conclusion, this study showed a high level of intra- and inter-observer reliability and agreement for FV measurements using VOCAL™. Furthermore, the 6° and 30° rotational angles can be used interchangeably, but test duration, reliability and agreement were better with the 30° rotational step method. The CRL measurements obtained with 3D mode probably reflects the true CRL, compared to the 2D measured CRL.

Introduction of a new fetal examination protocol for on-field and clinical equine practice

Prepartum fetal surveillance techniques have been widely used in both human and veterinary obstetrics, although these tests differ in their sensitivity for the assessment of fetal well-being. In equine reproduction, the 'gold standard' examination technique is the equine biophysical profile (EBP) described by Virginia Reef in 1995. Although this fetal assessment has many benefits, its accuracy, sensitivity and specificity have not been evaluated so far. In this study, 129 late-term pregnant mares were scanned twice in their last month of gestation using two different protocols (the EBP and a new, rapid examination protocol, REP) in order to determine the accuracy of these tests. The REP included the determination of fetal heart rate, fetal aortic diameter and the combined thickness of the uteroplacental unit. Twenty-seven fetuses proved to be compromised and 102 mares had healthy asymptomatic foals. Statistical analyses showed slight differences in test sensitivity (81.48% and 85.19%), specificity (83.3% and 87.25%) and accuracy (82.95% and 86.82%) for EBP and REP, respectively. Furthermore, a statistically significant interchangeability could be demonstrated between the two methods. It is concluded that, depending on the prevalence of the disease (here: compromised state), both methods are useful for the diagnosis of fetal abnormalities and make it possible to provide satisfactory care for broodmares and their fetuses.

Combined thickness of the uterus and placenta and ultrasonographic examinations of uteroplacental tissues in normal pregnancy, placentitis, and abnormal parturitions in heavy draft horses

The combined thickness of the uterus and placenta (CTUP) and ultrasonographic images of uteroplacental tissues were investigated in 35 pregnant heavy draft horses in Months 7–12 of pregnancy. The mares were divided into three groups: those pathologically diagnosed as placentitis (placentitis group, n=3); those who had abortion, premature birth, or fetal malformation (abnormal group, n=7); and those who had no abnormal findings (normal group, n=25). In the normal group, CTUP increased as pregnancy progressed from Months 7 (median, 7.08 mm; range, 5.68–11.27) to 12 (13.31 mm; 7.44–16.31 mm) (P<0.05) and was higher than those reported previously in Thoroughbred, quarter, and American paint horses. Values of CTUP greater than the 75th percentile of the normal group from Months 7 (7.54 mm) to 12 (15.19 mm) were detected in 100% of the placentitis group (3/3) and in 86% of the abnormal group (6/7). Ultrasonographic images showing placental separation were obtained in 67% of the placentitis group (2/3), 29% of the abnormal group (2/7), and 20% of the normal group (5/25). Pathological placental edema and ultrasonographic images showing uteroplacental roughness or distinguishability were observed even in the normal group. These findings suggest that increased CTUP and placental separation would reflect placentitis and abnormal pregnancies and may help to detect them in heavy draft horses.

Aborted fetal sizes of Thoroughbred horses in Hidaka, Japan, between 2005 and 2015

The degree of fetal growth restriction has been unclear in equine reproduction. In this study, 2,195 fetuses from 2,137 abortions during 11 seasons were examined to determine the causes of abortion, and fetal size dimensions (crown rump length and body weight) were measured. In total, 900 cases (42.1%) of abortion were identified as caused by viral infection (215, 10.1%), bacterial infection (156, 7.3%), fungal infection (25, 1.2%), circulation failure (406, 19.0%), multiple causes (66, 3.1%), deformity (13, 0.6%), placental abnormality (12, 0.6%), and other causes (7, 0.3%). All viral infections originated from equine herpes virus. Of all abortions, 94.3% occurred between 181–360 days of pregnancy, and the gestational ages at abortion were different based on the causes. Fetal sizes in viral abortions were considerably larger than those due to other reasons. Compared with viral infection, the crown rump length size dimension of fetuses aborted from multiple and fungal infection was affected. In addition, bacterial infection, circulation failure, and unknown causes of abortions also contributed to growth restriction in terms of body weight. In conclusion, the present study showed details of equine abortion and the relationships between causes of abortion and fetal size. Most of the aborted fetuses showed restrictions in their growth. The manifestations of growth restriction were more related to weight than skeletal length.

Animal welfare aspects in respect of the slaughter or killing of pregnant livestock animals (cattle, pigs, sheep, goats, horses)

This scientific opinion addresses animal welfare aspects of slaughtering of livestock pregnant animals. Term of Reference (ToR) 1 requested assessment of the prevalence of animals slaughtered in a critical developmental stage of gestation when the livestock fetuses might experience negative affect. Limited data on European prevalence and related uncertainties necessitated a structured expert knowledge elicitation (EKE) exercise. Estimated median percentages of animals slaughtered in the last third of gestation are 3%, 1.5%, 0.5%, 0.8% and 0.2% (dairy cows, beef cattle, pigs, sheep and goats, respectively). Pregnant animals may be sent for slaughter for health, welfare, management and economic reasons (ToR2); there are also reasons for farmers not knowing that animals sent for slaughter are pregnant. Measures to reduce the incidence are listed. ToR3 asked whether livestock fetuses can experience pain and other negative affect. The available literature was reviewed and, at a second multidisciplinary EKE meeting, judgements and uncertainty were elicited. It is concluded that livestock fetuses in the last third of gestation have the anatomical and neurophysiological structures required to experience negative affect (with 90-100% likelihood). However, there are two different possibilities whether they perceive negative affect. It is more probable that the neurophysiological situation does not allow for conscious perception (with 66-99% likelihood) because of brain inhibitory mechanisms. There is also a less probable situation that livestock fetuses can experience negative affect (with 1-33% likelihood) arising from differences in the interpretation of the fetal electroencephalogram, observed responses to external stimuli and the possibility of fetal learning. Regarding methods to stun and kill livestock fetuses at slaughter (ToR4), sets of scenarios and respective actions take account of both the probable and less probable situation regarding fetal ability for conscious perception. Finally, information was collated on methods to establish the dam's gestational stage based on physical features of livestock fetuses (ToR5).

A clinical case of equine fungal placentitis with reference to hormone profiles and ultrasonography

Fungal placentitis is an infectious disease inducing abortion in pregnant mares. In the present report, we describe a field case of abortion caused by fungal placentitis with consecutive examinations. The progesterone level and combined thickness of the uterus and placenta (CTUP) were abnormal before the onset of clinical signs. Additionally, the estradiol level started to change before the appearance of clinical signs. Abnormal serum amyloid A values and an abnormal fetal heart rate were observed after the onset of clinical signs. The present report demonstrates that the progesterone level and CTUP may be adequate as early diagnostic markers of fungal placentitis and bacterial infection. Endocrinological evaluation based on cutoff values or serial measurements were also useful for early diagnosis.