P-302 How adenomyosis changes throughout pregnancy

Study question

How do the ultrasound characteristics of adenomyosis modify during pregnancy?

Summary answer

Signs of adenomyosis are visible in pregnancy and progressively disappear through gestation; adenomyosis was associated with an increased risk of miscarriage in the 1st trimester.

What is known already

Women with uterine adenomyosis may be asymptomatic (35%) or report menorrhagia (50%), dysmenorrhea (30%) and metrorrhagia (20%). Several authors recently linked this condition to subfertility since many women with “unexplained infertility” were found to have adenomyosis. Being relatively inexpensive and accurate, ultrasound is now considered the imaging modality of choice for diagnosing adenomyosis. Although the increasing interest towards the adenomyosis there are no data on the identification of sign of adenomyosis among pregnant women and evaluating their changes throughout the pregnancy.

Study design, size, duration

This is a retrospective exploratory cohort study conducted between 2016 and 2020 including 254 women of which 66 were diagnosed as having focal or diffuse adenomyosis (according to the MUSA classification) before conception or during the 1st trimester of pregnancy. The remaining 188 women were used as controls.

Participants/materials, setting, methods

Women were included if they had at least one pre-conceptional transvaginal ultrasound scan documenting adenomyosis, at least one scan per trimester and known maternal and neonatal outcomes. Diagnosis of adenomyosis was based on the MUSA classification and the recent consensus classification system for adenomyosis. We evaluated if the signs of adenomyosis were visible later in pregnancy and post-partum. Obstetric and neonatal outcomes were compared between women with or without these signs.

Main results and the role of chance

The globular aspect of the uterus was reported in 79% women with adenomyosis in the 1st trimester: it progressively disappeared, being present in only 38% and 2% women in the 2nd and 3rd trimester respectively and again visible in the post-partum in 65% women. Asymmetrical thickening (30%) and cysts (23%) were reported in the 1st trimester and disappeared during pregnancy. Adenomyosis was associated with miscarriage (OR 5.9 95%CI 2.4-14.9, p < 0.001) also when considering only normal conception (OR 5.1 95%CI 1.8-14.2, p = 0.002) or when correcting for maternal age (aOR 5.9, CI95% 2.3-15.2, p < 0.001). Gestational age at delivery was lower in women with adenomyosis (p = 0.004); Caesarean Sections (CS) rate was higher than in controls (OR 2.5, CI95% 1.3-4.8, p = 0.007) and this was confirmed (OR 2.4 CI95% 1.1-5, p = 0.02) also excluding women with previous CS.

Limitations, reasons for caution

These findings are from a monocentric retrospective study including only patients with known obstetric outcomes diagnosed with adenomyosis. Analysis was not stratified according to the mode of conception because of the small sample size, possibly introducing a bias in pregnancy outcomes.

Wider implications of the findings

Despite their progressive disappearance, signs of adenomyosis can be clinically relevant since associated with an increased risk of miscarriage in the first trimester also when considering only women with normal conception. Adenomyosis per se might have an influence on endometrial molecular expression resulting in impaired implantation and early development.

Trial registration number

not applicable

Role of progesterone, cerclage and pessary in preventing preterm birth in twin pregnancies: A systematic review and network meta-analysis

OBJECTIVE

To determine the role of progesterone, pessary and cervical cerclage in reducing the risk of (preterm birth) PTB in twin pregnancies and compare these interventions using pairwise and network meta-analysis.

STUDY DESIGN

Medline, Embase, CINAHL and Cochrane databases were explored. The inclusion criteria were studies in which twin pregnancies were randomized to an intervention for the prevention of PTB (any type of progesterone, cervical cerclage, cervical pessary, or any combination of these) or to a control group (e.g. placebo or treatment as usual). Interventions of interest were either progesterone [vaginal or oral natural progesterone or intramuscular 17a-hydroxyprogesterone caproate (17-OHPC)], cerclage (McDonald or Shirodkar), or cervical pessary. The primary outcome was PTB < 34 weeks of gestation. Both primary and secondary outcomes were explored in an unselected population of twin pregnancies and in women at higher risk of PTB (defined as those with cervical length <25 mm). Random-effect head-to-head and a multiple-treatment meta-analyses were used to analyze the data and results expressed as risk ratios.

RESULTS

26 studies were included in the meta-analysis. When considering an unselected population of twin pregnancies, vaginal progesterone, intra-muscular17-OHPC or pessary did not reduce the risk of PTB < 34 weeks of gestation (all p > 0.05). When stratifying the analysis for spontaneous PTB, neither pessary, vaginal or intramuscular 17-OHPC were associated with a significant reduction in the risk of PTB compared to controls (all p > 0.05), while there was no study on cerclage which explored this outcome in an unselected population of twin pregnancies. When considering twin pregnancies with short cervical length (≤25 mm), there was no contribution of either pessary, vaginal progesterone, intra-muscular 17-OHPC or cerclage in reducing the risk of overall PTB < 34 weeks of gestation.

CONCLUSIONS

Cervical pessary, progesterone and cerclage do not show a significant effect in reducing the rate of PTB or perinatal morbidity in twins, either when these interventions are applied to an unselected population of twins or in pregnancies with a short cervix.

Early- and late-onset selective fetal growth restriction in monochorionic diamniotic twin pregnancy: natural history and diagnostic criteria

OBJECTIVES

To evaluate the natural history and outcome of selective fetal growth restriction (sFGR) in monochorionic diamniotic (MCDA) twin pregnancy, according to gestational age at onset and various reported diagnostic criteria, and to quantify the risk of superimposed twin-to-twin transfusion syndrome (TTTS).

METHODS

This was a cohort study of MCDA twin pregnancies that had their routine antenatal care from the first trimester at St George's Hospital, London, UK. Pregnancies had ultrasound examinations every 2 weeks at 16-24 weeks and then every 2-3 weeks until delivery. The diagnostic criteria for sFGR were estimated fetal weight (EFW) of one twin < 10^th centile and intertwin EFW discordance ≥ 25%. We also applied other diagnostic criteria reported in a recent Delphi consensus. Pregnancies in which the diagnosis of TTTS was made before that of sFGR were not included in the analysis. Pregnancies that underwent fetal intervention for sFGR were excluded. The incidence of sFGR was compared between the different diagnostic criteria, overall and according to gestational age at onset. In all subsequent analyses, cases of sFGR included those diagnosed according to any of the criteria. The Gratacós classification of sFGR was applied (Type I, II or III). Pregnancy outcomes included miscarriage, intrauterine death, neonatal death and admission to the neonatal unit. Comparisons between groups were carried out using the Mann-Whitney U-test for continuous variables and the chi-square or Fisher's exact test for categorical variables.

RESULTS

The analysis included 287 MCDA twin pregnancies. According to the International Society of Ultrasound in Obstetrics and Gynecology diagnostic criteria, the incidence of early (< 24 weeks) sFGR was 4.9%, while that of late sFGR was 3.8%. When applying the various diagnostic criteria, the incidence of early sFGR varied from 1.7% to 9.1% and that of late sFGR varied from 1.1% to 5.9%. In early-onset cases, the incidence of Type I sFGR was 80.8%, that of Type II was 15.4% and that of Type III was 3.8%. The corresponding figures in late-onset cases were 94.4%, 5.6% and 0%. The incidence of superimposed TTTS was 26.9% in cases affected by early-onset sFGR and 5.6% in those affected by late-onset sFGR. The incidence of perinatal death was 8.0% in early-onset sFGR and 5.6% in late-onset sFGR (P = 0.661). Admission to the neonatal unit occurred in 61.0% and 52.9% of cases, respectively (P = 0.484).

CONCLUSIONS

In MCDA twin pregnancies, early-onset sFGR is slightly more common than is late-onset sFGR, although this difference was not significant, and is associated with worse perinatal outcome. The incidence of Types II and III sFGR is higher in early-onset sFGR. The incidence also varies according to the diagnostic criteria used, which supports the use of standardized international diagnostic criteria. Superimposed TTTS is more common in early- than in late-onset sFGR. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Core outcome set for studies investigating management of selective fetal growth restriction in twins

OBJECTIVE

Selective fetal growth restriction (sFGR) occurs in monochorionic twin pregnancies when unequal placental sharing leads to restriction in the growth of just one twin. Management options include laser separation of the fetal circulations, selective reduction or expectant management, but what constitutes the best treatment is not yet known. New trials in this area are urgently needed but, in this rare and complex group, maximizing the relevance and utility of clinical research design and outputs is paramount. A core outcome set ensures standardized outcome collection and reporting in future research. The objective of this study was to develop a core outcome set for studies evaluating treatments for sFGR in monochorionic twins.

METHODS

An international steering group of clinicians, researchers and patients with experience of sFGR was established to oversee the process of development of a core outcome set for studies investigating the management of sFGR. Outcomes reported in the literature were identified through a systematic review and informed the design of a three-round Delphi survey. Clinicians, researchers, and patients and family representatives participated in the survey. Outcomes were scored on a Likert scale from 1 (limited importance for making a decision) to 9 (critical for making a decision). Consensus was defined a priori as a Likert score of ≥ 8 in the third round of the Delphi survey. Participants were then invited to take part in an international meeting of stakeholders in which the modified nominal group technique was used to consider the consensus outcomes and agree on a final core outcome set.

RESULTS

Ninety-six outcomes were identified from 39 studies in the systematic review. One hundred and three participants from 23 countries completed the first round of the Delphi survey, of whom 88 completed all three rounds. Twenty-nine outcomes met the a priori criteria for consensus and, along with six additional outcomes, were prioritized in a consensus development meeting, using the modified nominal group technique. Twenty-five stakeholders participated in this meeting, including researchers (n = 3), fetal medicine specialists (n = 3), obstetricians (n = 2), neonatologists (n = 3), midwives (n = 4), parents and family members (n = 6), patient group representatives (n = 3), and a sonographer. Eleven core outcomes were agreed upon. These were live birth, gestational age at birth, birth weight, intertwin birth-weight discordance, death of surviving twin after death of cotwin, loss during pregnancy or before final hospital discharge, parental stress, procedure-related adverse maternal outcome, length of neonatal stay in hospital, neurological abnormality on postnatal imaging and childhood disability.

CONCLUSIONS

This core outcome set for studies investigating the management of sFGR represents the consensus of a large and diverse group of international collaborators. Use of these outcomes in future trials should help to increase the clinical relevance of research on this condition. Consensus agreement on core outcome definitions and measures is now required. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Outcome of isolated fetal talipes: A systematic review and meta-analysis

INTRODUCTION

The aim of this systematic review was to explore the outcome of fetuses with a prenatal diagnosis of isolated talipes.

MATERIAL AND METHODS

Medline, Embase, Cinahl, and Clinicaltrials.gov databases were searched. The outcomes explored were: associated anomalies detected at follow-up ultrasound examination; fetal magnetic resonance imaging (MRI) and birth; chromosomal abnormalities detected with standard and chromosomal microarray analysis, intrauterine, neonatal, and perinatal death, and termination of pregnancy; rate of surgical and nonsurgical treatment; neurodevelopmental outcome; and false-positive rate of prenatal diagnosis. Meta-analyses of proportions were used to combine data.

RESULTS

Twenty-five studies (1567 fetuses) were included. Associated anomalies were detected in 7.8% (95% CI 0.1%-29.3%) of cases at follow-up ultrasound, and in 4.0% (95% CI 0.1%-13.2%) of cases, fetal MRI identified anomalies not detected at ultrasound assessment. Similarly, 7.0% (95% CI 3.4%-11.7%) of cases labeled as isolated talipes on prenatal imaging were found to have associated anomalies at birth. Abnormal karyotype was present in 3.6% (95% CI 1.7%-6.2%) of fetuses, whereas no anomaly was found at chromosomal microarray analysis, although this outcome was reported by only 1 study. Intrauterine death occurred in 0.99% (95% CI 0.4%-1.9%) of fetuses, whereas the corresponding figures for neonatal death and termination of pregnancy were 1.5% (95% CI 0.6%-2.6%) and 2.2% (95% CI 1.2%-3.4%), respectively. Surgical management of anomalies after birth was found in 41.7% (95% CI 27.0%-57.2%) of fetuses with isolated talipes, and 54.8% (95% CI 31.5%-77.0%) had nonsurgical management of the anomalies after birth. Abnormal neurodevelopmental outcome was reported in 7.6% (95% CI 1.0%-19.4%) of children, although this analysis was affected by the small number of included cases and short time of follow up.

CONCLUSIONS

Isolated talipes detected on prenatal ultrasound carries a generally good prognosis. The incidence of additional abnormalities detected on fetal MRI, aneuploidy, or neurodevelopmental disability is relatively low. However, longitudinal ultrasound assessment during pregnancy and a thorough postnatal evaluation are recommended to rule out associated anomalies that may significantly impact short- and long-term prognosis.

Variation in outcome reporting in randomized controlled trials of interventions for prevention and treatment of fetal growth restriction

OBJECTIVE

Although fetal growth restriction (FGR) is well known to be associated with adverse outcomes for the mother and offspring, effective interventions for the management of FGR are yet to be established. Trials reporting interventions for the prevention and treatment of FGR may be limited by heterogeneity in the underlying pathophysiology. The aim of this study was to conduct a systematic review of outcomes reported in randomized controlled trials (RCTs) assessing interventions for the prevention or treatment of FGR, in order to identify and categorize the variation in outcome reporting.

METHODS

MEDLINE, EMBASE and The Cochrane Library were searched from inception until August 2018 for RCTs investigating therapies for the prevention and treatment of FGR. Studies were assessed systematically and data on outcomes that were reported in the included studies were extracted and categorized. The methodological quality of the included studies was assessed using the Jadad score.

RESULTS

The search identified 2609 citations, of which 153 were selected for full-text review and 72 studies (68 trials) were included in the final analysis. There were 44 trials relating to the prevention of FGR and 24 trials investigating interventions for the treatment of FGR. The mean Jadad score of all studies was 3.07, and only nine of them received a score of 5. We identified 238 outcomes across the included studies. The most commonly reported were birth weight (88.2%), gestational age at birth (72.1%) and small-for-gestational age (67.6%). Few studies reported on any measure of neonatal morbidity (27.9%), while adverse effects of the interventions were reported in only 17.6% of trials.

CONCLUSIONS

There is significant variation in outcome reporting across RCTs of therapies for the prevention and treatment of FGR. The clinical applicability of future research would be enhanced by the development of a core outcome set for use in future trials. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Mirabegron in the treatment of overactive bladder

INTRODUCTION

Mirabegron is a selective β3-adrenergic receptor agonist recently developed for the treatment of patients with overactive bladder (OAB), which offers an alternative pharmacological option to the well-established treatment with antimuscarinics (AMs).

AREAS COVERED

This review offers an explanation of the mechanism of action, of the pharmacokinetics and pharmacodynamics of mirabegron and gives readers a complete overview of Phase II and III studies on the clinical efficacy, tolerability and safety of this agent in the setting of OAB treatment.

EXPERT OPINION

Both Phase II and III trials have shown that mirabegron is efficacious and safe in treating patients with OAB. Future research should focus on the assessment of mirabegron concentrations in the CNS and on the evaluation of the potential of the combination of mirabegron with AMs. Another field for future research is represented by the investigation of the interaction of mirabegron with CYP2D6 inhibitors. Furthermore, current literature completely lacks studies on the efficacy and safety of mirabegron in the pediatric population and such trials are awaited.

An alternative approach for the treatment of vaginal atrophy

AIM

The aim of this study was to determine the efficacy of a new topic non-hormonal treatment for postmenopausal women complaining of symptoms of vaginal atrophy.

METHODS

Patients included in the study were prescribed Sinecol gel (AM PHARMA Srl, Vimercate, Monza and Brianza, Italy) application once a day for 20 consecutive days. Sinecol gel is a topic compound for vaginal atrophy containing hyaluronic acid, that is known to improve vaginal elasticity, lactoperoxidase, Xantham gum and glucose oxidase, which have protective and antibacterial action. We evaluated each patient before and after treatment, both subjectively with the "Visual Analogical Scale" (VAS) and objectively with the "Vaginal Health Index" (VHI).

RESULTS

We observed a significant clinical improvement of the subjective and objective assessment of symptoms severity with a p value <0.001 at the end of the treatment compared to baseline.

CONCLUSION

Sinecol gel appears to be an effective and valid non-hormonal alternative to the estrogen therapy for vaginal atrophy.

[Surgical treatment of parathyroid hyperplasia]

BACKGROUND

To review a series of 11 patients affected by hyperplasia of parathyroid glands and to discuss diagnostic and therapeutic tools.

METHODS

A series of 11 patients out of 44 (= 25%) with primary hyperparathyroidism has been retrospectively reviewed. They underwent surgery in I surgical Department of OORR of Bergamo. All 11 patients were submitted to ultrasound and computed tomography examination before surgery, without any localisation of hyperplastic or adenomatous tissue. An exploring cervicotomy was performed with subtotal parathyroidectomy after the anatomopathological result of hyperplasia.

RESULTS

No adverse effects related to surgery were observed. All patients could be considered as cured with a median follow-up of 36 months.

CONCLUSIONS

Among hyperparathyroidism, hyperplasia is an underhand form and even if the laboratory diagnosis is simple, the imaging techniques cannot always localise the pathologic tissue. Personal experience shows the role of subtotal parathyroidectomy (removal of 3 parathyroid glands and a half of the last one) confirmed by the absence of adverse effects or relapse with a median follow-up of 36 months.

[Biliopancreatic bypass in the treatment of severe obesity: long-term clinical, nutritional and metabolic evaluation]

Biliopancreatic bypass surgery leads to considerable weight loss and the stabilisation over time of the newly acquired body weight. The aim of this study was to evaluate the long-term clinical and nutritional conditions of patients undergoing this operation. Thirty subjects who had undergone biliopancreatic bypass surgery (7 males and 23 females) aged between 20 and 55 years old, with body mass indexes between 35 and 80, were examined at yearly intervals (maximum follow-up 5 years). Tha following parameters were evaluated at each control: body weight, presence of collateral effects, support therapy, main hematochemical parameters, nutritional behavior and calorie intake. All patients recorded a significant reduction in body weight with a mean weight loss of 28% during the first year; these values were confirmed during the second year, whereas body weight tended to stabilise in the long-term. Laboratory data showed a significant reduction in triglycerides, cholesterol, glycemia in all patients; sideropenic anemia appeared in 50% of patients. Mean daily calorie intake was 2,200 kcal/day, broken down as follows: glucides 50%, lipids 33%, proteins 17%. The main collateral effects reported were: diarrhea, vomit, flatulence, onset of food intolerances. The following support therapies were used: iron in 90% of cases, calcium in 60% and 30% of patients also underwent surgery. In conclusion, biliopancreatic bypass surgery enables a significant weight loss to be achieved together with an improved glycolipid status without leading to nutritional deficiencies.(ABSTRACT TRUNCATED AT 250 WORDS)

New perspectives in medical management of hyperprolactinemia

We performed 113 new treatments in 98 patients (pts) (69 females and 27 males), 41 with macroprolactinoma, 26 with microprolactinoma, 5 with empty sella and 26 with idiopathic hyperprolactinemia. Parlodel LA was administered in 31/113, Parlodel LAR in 51/113, Parlodel SRO in 24/113 and Cabergoline in 8/113. In each pt the clinical effect, PRL plasma level CT-scan and visual field examination were monitored. PRL plasma levels normalized in 84/98 pts. In 13/41 macroadenoma pts a complete disappearance of the adenomatous mass was observed at CT-scan after 0.5-3 years' oral bromocriptine or Parlodel LAR therapy. The clinical features normalized in most of the pts. In conclusion, the new long acting dopamine agonists may represent the future of the management of hyperprolactinemic states because of their effectiveness, tolerability and good compliance.

Effects of a somatostatin derivative (SMS 201-995) on postprandial hyperglycemia in insulin-dependent diabetics studied by means of a closed-loop device

We studied the effects of a premeal sc injection of an analog of somatostatin (SMS 201-995, Sandoz) on the postprandial glycemic excursions, insulin requirement and hormone profiles (GH, glucagon and C-peptide) in 8 IDDM patients (diabetes duration 14.0 +/- 6.5 yr, daily insulin requirement 36 +/- 6.4 U) maintained normoglycemic by connecting them to a closed-loop insulin infusion system (Betalike, Genoa). The morning of the test the patients were connected to the Betalike and their glucose levels stabilized for at least 4 h. At 13:00 h the study was begun with a sc injection of 50 micrograms of SMS 201-995 or placebo (randomly) and a standardized mixed meal (800 Kcal) was given. Blood samples were obtained 0, 15, 30, 60, 120 and 180 min after the injection. Each patient was tested both with SMS 201-995 and placebo. Postmeal glycemic peaks were decreased after SMS 201-995 (119.6 +/- 5.4 mg/dl vs 149.1 +/- 4.2; p less than 0.05) as well as insulin requirements (3.2 +/- 0.8 U vs 13.3 +/- 1.9; p less than 0.01) for the 180 min postprandial period. Similarly, glucagon level was reduced 30 min postprandially (24 +/- 6 pg/ml vs 59 +/- 24; p less than 0.05) and so GH level only 180 min after lunch (p less than 0.05). The premeal injection of SMS decreases postprandial glycemic excursions and the corresponding insulin requirement. The action of SMS 201-995 may be mainly mediated by the suppression of postprandial glucagon peak.

Empty sella syndrome and growth deficiency in childhood

We describe four cases of empty sella syndrome in childhood associated with growth and neuroendocrine disorders. We note that empty sella syndrome probably presents with endocrine disorders more often in childhood than in adults and that its frequency seems to be underestimated.