Treatment with valacyclovir during pregnancy for prevention of congenital cytomegalovirus infection: a real-life multicenter Italian observational study

BACKGROUND

Valacyclovir is the only treatment demonstrated to be effective for the prevention of vertical transmission of cytomegalovirus within a clinical randomized, placebo-controlled trial and has been reimbursed by the Italian National Health System since December 2020.

OBJECTIVE

This study reported the results of a real-life Italian multicenter observational study on cytomegalovirus infection in pregnancy evaluating the effect of the introduction of valacyclovir in the clinical practice for the prevention of vertical transmission of cytomegalovirus.

STUDY DESIGN

The outcomes of women who received valacyclovir treatment and their fetuses or newborns were compared with those of a retrospective cohort observed between 2010 and 2020 who did not receive the antiviral treatment. The inclusion criterion was the diagnosis of cytomegalovirus primary infection occurring in the periconceptional period or up to 24 weeks of gestation. The primary outcome was the transmission by the time of amniocentesis. The secondary outcomes were termination of pregnancy, transmission at birth, symptomatic infection at birth, and a composite outcome (termination of pregnancy or transmission at birth).

RESULTS

A total of 447 pregnant women from 10 centers were enrolled, 205 women treated with valacyclovir (called the valacyclovir group, including 1 twin pregnancy) and 242 women not treated with valacyclovir (called the no-valacyclovir group, including 2 twin pregnancies). Valacyclovir treatment was significantly associated with a reduction of the diagnosis of congenital cytomegalovirus infection by the time of amniocentesis (weighted odds ratio, 0.39; 90% confidence interval, 0.22-0.68; P=.005; relative reduction of 61%), termination of pregnancy (weighted odds ratio, 0.36; 90% confidence interval, 0.17-0.75; P=.0021; relative reduction of 64%), symptomatic congenital cytomegalovirus infection at birth (weighted odds ratio, 0.17; 90% confidence interval, 0.06-0.49; P=.006; relative reduction of 83%). The treatment had no significant effect on the rate of diagnosis of congenital cytomegalovirus infection at birth (weighted odds ratio, 0.85; 90% confidence interval, 0.57-1.26; P=.500), but the composite outcome (termination of pregnancy or diagnosis of congenital cytomegalovirus infection at birth) occurred more frequently in the no-valacyclovir group (weighted odds ratio, 0.62; 90% confidence interval, 0.44-0.88; P=.024). Of note, the only symptomatic newborns with congenital cytomegalovirus infection in the valacyclovir group (n=3) were among those with positive amniocentesis. Moreover, 19 women (9.3%) reported an adverse reaction to valacyclovir treatment, classified as mild in 17 cases and moderate in 2 cases. Lastly, 4 women (1.9%) presented renal toxicity with a slight increase in creatinine level, which was reversible after treatment suspension.

CONCLUSION

Our real-life data confirm that valacyclovir significantly reduces the rate of congenital cytomegalovirus diagnosis at the time of amniocentesis with a good tolerability profile and show that the treatment is associated with a reduction of termination of pregnancy and symptomatic congenital cytomegalovirus infection at birth.

Brain cortical assessment by MRI in fetuses with left congenital diaphragmatic hernia Brain development in left congenital diaphragmatic hernia

OBJECTIVE

To evaluate fetal brain development using MRI (magnetic resonance imaging) in CDH (congenital diaphragmatic hernia).

METHODS

52 isolated left CDH and 104 control fetuses were imaged using MRI. Brain morphometry (Biparietal diameter - BPD, brain fronto-occipital diameter - BFOD, third ventricle, posterior ventricles, transcerebellar diameter - TCD, anteroposterior and craniocaudal cerebellar vermis diameter - AP and CC) and cortical structures (bilateral cingulate fissure - CF, insular fissure - IF, insular depth - ID) were compared with controls using Mann-Whitney test .

RESULTS

Median gestational age at MRI was comparable (p=0.95), as well as was the median biparietal diameter (p=0.737). Among morphometric parameters only the brain fronto-occipital diameter was significantly smaller in CDH (p= 0.001) and the third ventricle was significantly greater in CDH (<0.0001). Among cortical structures, the cingulate and insular fissure were significantly deeper in CDH fetuses (p<0.0001), as the insular depth ID was smaller in CDH (p< 0.03).

CONCLUSIONS

CDH fetuses have a smaller fronto-occipitaldiameter, reduced insular depth, and deeper cingulate and insular fissure, and greater third ventricle width as compared to controls. These findings suggest that left CDH may have an impact on fetal brain development with an overall reduction of brain volume. This article is protected by copyright. All rights reserved.

Using IOTA terminology to evaluate fetal ovarian cysts: analysis of 51 cysts over 10-year period

OBJECTIVES

To describe ultrasound features of fetal ovarian cysts as reported by the original ultrasound examiner, to apply International Ovarian Tumor Analysis (IOTA) terminology after retrospective analysis of the images and to describe patient management and evolution of fetal cysts during pregnancy and after delivery.

METHODS

This retrospective observational study included pregnant women diagnosed on ultrasound examination with a fetal ovarian cyst at the Prenatal Diagnosis Division of the Bambino Gesù Children's Hospital, in Rome, between March 2011 and May 2020. Cysts were classified by the original ultrasound examiner as 'simple' (unilocular anechoic cyst) or 'complex' (cyst with other morphology). In addition, three ultrasound examiners, experienced in gynecologic ultrasound, classified retrospectively the fetal ovarian cysts according to IOTA terminology, by reviewing stored ultrasound images. The evolution of these fetal ovarian cysts during pregnancy and after birth was recorded.

RESULTS

Included were 51 ovarian cysts in 48 fetuses. Of the 51 cysts, 29 (56.9%) had been classified by the original ultrasound examiner as 'simple', and 22 (43.1%) as 'complex'. Of the simple cysts, the majority (20/29 (69.0%)) resolved spontaneously after delivery, 2/29 (6.9%) resolved following intrauterine aspiration, 2/29 (6.9%) resolved after postnatal aspiration and 5/29 (17.2%) underwent surgery due to persistence after delivery; in all five, normal ovarian parenchyma without signs of necrosis was observed at histology. Of the complex cysts, 7/22 (31.8%) resolved spontaneously. The other 15/22 (68.2%) were removed surgically and, at histology, necrosis was observed in most (12/15 (80.0%)), while a benign epithelial cyst with normal ovarian parenchyma was observed in 3/15 (20%). After reviewing the ultrasound images and applying IOTA terminology, all 51 (100%) fetal cysts were described as unilocular; 29/51 (56.9%) cysts showed anechoic content (described as simple cysts by the original ultrasound examiner), and 10/51 (19.6%) had low-level, 1/51 (2.0%) had ground-glass, 9/51 (17.6%) had hemorrhagic, 1/51 (2.0%) had mixed and 1/51 (2.0%) had undefined content (all described as complex by the original ultrasound examiner). Among the 29 anechoic ovarian cysts, resolution was observed in most (24/29, 82.8%) cases. Similarly, resolution was observed in 7/10 (70.0%) cysts with low-level content. Resolution was not observed in any of the other 12 cysts and all of these cases underwent surgery, with evidence of necrosis being observed in 11 (91.7%).

CONCLUSIONS

Applying IOTA terminology provided a more detailed and accurate description of fetal ovarian cysts compared with the original classification into 'simple' and 'complex' categories. Anechoic cysts (described as simple cysts by the original ultrasound examiner) and cysts with low-level content (described as complex by the original ultrasound examiner) frequently resolved spontaneously. Cysts with ground-glass, hemorrhagic, mixed or undefined content were frequently associated with necrosis at histology following surgery. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Intrafetal Laser Therapy Is a Feasible Treatment for Different Fetal Conditions: A Systematic Review

INTRODUCTION

Over the past years, intrafetal laser (IFL) therapy has been increasingly used in the management of various prenatal conditions. The aim of our research was to clarify the effectiveness and safety of this technique.

METHODS

A systematic review of the literature was carried out using MEDLINE/PubMed over a period of 20 years (2001-2021).

RESULTS

A total of forty-one articles were selected in the literature search, including 194 cases of twin reversed arterial perfusion (TRAP) sequence, 56 cases of bronchopulmonary sequestrations (BPSs), 5 cases of placental chorioangiomas (PCA), 11 cases of sacrococcygeal teratoma (SCT), and 103 cases of embryo reduction (ER) managed using IFL. In TRAP sequence, perfusion of the acardiac twin was successfully disrupted in all cases. However, preterm premature rupture of membranes (P-PROMs) occurred in 6 out of 79 pregnancies (7.5%), and preterm birth (PTB) occurred in 36 out of 122 pregnancies (29.5%). In BPS, IFL was successfully performed in all cases with no significant fetal-maternal complications. The rates of P-PROM and PTB were, respectively, 3.2% and 12.5%. All PCA IFL-treated cases resulted in successful pregnancy outcomes; no cases of P-PROM were reported, but the rate of PTB reached a peak of 60% due to complications such as severe fetal growth restriction and fetal Doppler abnormalities. In SCT cases, complete cessation of blood flow was achieved in 4 patients (36.4%); P-PROM occurred in 2 cases (18.2%), whereas the rate of PTB was 87.5%. In ER, no intraoperative or major maternal complications were described in the literature. Rates of miscarriage and PTB differed between initial trichorionic triamniotic and dichorionic triamniotic triplet pregnancies.

CONCLUSION

Our analysis suggests that IFL is a safe and feasible technique for the management of different fetal conditions. However, the overall risk of PTB, and its related morbidity and mortality, ranges from 12.5% in BPS to 87.5% in SCT IFL-treated cases. This information could aid in decision-making during prenatal counseling. However, final perinatal outcome depends on the severity of the disease itself.

Hemodynamic Assessment of a Large Pulmonary Arteriovenous Malformation in a Neonate: Case Report and Review of Literature

Herein we report the case of a neonate with a prenatally diagnosed large pulmonary arteriovenous malformation, managed with minimally invasive hemodynamic monitoring in our Neonatal Intensive Care Unit. The combination of Near-Infrared Spectroscopy and Pressure Recording Analytical Method could guide neonatal management of critical cases of vascular anomalies: immediate data are offered to clinicians, from which therapeutic decisions such as timing of surgical resection are made to achieve a positive outcome. We also systemically collected and summarized information on patients' characteristics of previous cases reported in literature to data, and we compared them to our case.

Prevalence of Maternal Psychological Distress in pregnant women who receipt prenatal diagnosis of fetal Central Nervous System (CNS) anomalies

Introduction

Women receiving a prenatal diagnosis of fetal anomalies are a high-risk population for psychological distress leading to mood disorders. Even so, to date we have no evidence of studies who investigated the levels of maternal anxiety and depression in pregnant women receiving a prenatal diagnosis of fetal CNS anomalies.

Objectives

The aim of this study was to assess the prevalence of anxiety and depression levels in a pilot sample of pregnant women at the Prenatal Diagnostic Unit of the Bambino Gesù Children Hospital.

Methods

We collected data among 43 women who receipt fetal brain anomaly diagnosis (mean age: 35 yrs, SD ± 6.3, range 19-48 yrs; mean week at first access 26w, SD ± 3.9, range 18-33w). Prenatal diagnosis including: ventriculomegaly (37.2%), posterior cranial fossa (23.3%), choroid plexus cysts (11.6%), anomalies of CC (7%) and other (20.9%). Pregnancies with assisted reproductive technology were 14%. We use the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorders (GAD-7) questionnaires to assess anxious-depressive symptoms.

Results

showed a rate of mild-to-severe anxious depressive symptoms by 60.5% and 48.8% respectively. In detail: 41.9% mild, 14% moderate and 4.7% of severe anxiety. Meanwhile, 41.9% mild and 7% moderate depression. The prevalence of comorbid depressive and anxiety symptoms was 39.5% among the entire sample.

Conclusions

Preliminary data showed a high prevalence of anxious depressive symptoms and comorbidity among pregnant with CNS fetal anomalies. Women receiving a fetal CNS anomaly diagnosis may need additional psychological support or counselling.

Disclosure

No significant relationships.

Pregnancy and viral infections: Mechanisms of fetal damage, diagnosis and prevention of neonatal adverse outcomes from cytomegalovirus to SARS-CoV-2 and Zika virus

Some maternal infections, contracted before or during pregnancy, can be transmitted to the fetus, during gestation (congenital infection), during labor and childbirth (perinatal infection) and through breastfeeding (postnatal infection). The agents responsible for these infections can be viruses, bacteria, protozoa, fungi. Among the viruses most frequently responsible for congenital infections are Cytomegalovirus (CMV), Herpes simplex 1–2, Herpes virus 6, Varicella zoster. Moreover Hepatitis B and C virus, HIV, Parvovirus B19 and non-polio Enteroviruses when contracted during pregnancy may involve the fetus or newborn at birth. Recently, new viruses have emerged, SARS-Cov-2 and Zika virus, of which we do not yet fully know the characteristics and pathogenic power when contracted during pregnancy.

Viral infections in pregnancy can damage the fetus (spontaneous abortion, fetal death, intrauterine growth retardation) or the newborn (congenital anomalies, organ diseases with sequelae of different severity). Some risk factors specifically influence the incidence of transmission to the fetus: the timing of the infection in pregnancy, the order of the infection, primary or reinfection or chronic, the duration of membrane rupture, type of delivery, socio-economic conditions and breastfeeding. Frequently infected neonates, symptomatic at birth, have worse outcomes than asymptomatic. Many asymptomatic babies develop long term neurosensory outcomes.

The way in which the virus interacts with the maternal immune system, the maternal-fetal interface and the placenta explain these results and also the differences that are observed from time to time in the fetal‑neonatal outcomes of maternal infections. The maternal immune system undergoes functional adaptation during pregnancy, once thought as physiological immunosuppression. This adaptation, crucial for generating a balance between maternal immunity and fetus, is necessary to promote and support the pregnancy itself and the growth of the fetus. When this adaptation is upset by the viral infection, the balance is broken, and the infection can spread and lead to the adverse outcomes previously described. In this review we will describe the main viral harmful infections in pregnancy and the potential mechanisms of the damages on the fetus and newborn.

Assisted Reproductive Technology and Anorectal Malformation: A Single-Center Experience

Background: Assisted reproductive technologies (ART) are becoming widespread, accounting for approximately 2% of all births in the western countries. Concerns exist on the potential association of ART with congenital anomalies. Few studies have addressed if a relationship exists between ART and the development of anorectal malformation (ARM). Our aim was to analyze the relationship between ARM and ART. Methods: Single-center retrospective case control study of all patients treated for ARM between 2010 and 2017. Patients with bronchiolitis treated since 2014 were used as controls. Variables analyzed include the following: prevalence of ART, gestational age, birth weight, and maternal age. Patients with ARM born after ART were also compared with those naturally conceived for disease complexity. Fisher's exact and Mann-Whitney U-tests were used as appropriate. Results: Three hundred sixty-nine patients were analyzed (143 cases and 226 controls). Prevalence of ART was significantly higher in ARM patients than in controls [7.6 vs. 3.0%; odds ratio: 2.59 (95% CI, 0.98-0.68); p = 0.05]. Among ARM patients, incidence of VACTERL association (17%) is more frequent in ART babies. Conclusion: Patients with ARM were more likely to be conceived following ART as compared with controls without congenital anomalies. Disease complexity of patients with ARM born after ART seems greater that those born after nonassisted conception.

Vertical Transmission of SARS-CoV-2 (COVID-19): Are Hypotheses More than Evidences?

In spite of the increasing, accumulating knowledge on the novel pandemic coronavirus severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), questions on the coronavirus disease-2019 (COVID-19) infection transmission from mothers to fetuses or neonates during pregnancy and peripartum period remain pending and have not been addressed so far. SARS-CoV-2, a RNA single-stranded virus, has been detected in the amniotic fluid, in the cord blood and in the placentas of the infected women. In the light of these findings, the theoretical risk of intrauterine infection for fetuses, or of peripartum infection occurring during delivery for neonates, has a biological plausibility. The extent of this putative risk might, however, vary during the different stages of pregnancy, owing to several variables (physiological modifications of the placenta, virus receptors' expression, or delivery route). This brief review provides an overview of the current evidence in this area. Further data, based on national and international multicenter registries, are needed not only to clearly assess the extent of the risk for vertical transmission, but also to ultimately establish solid guidelines and consistent recommendations. KEY POINTS: · Questions on the COVID-19 infection transmission from mothers to fetuses or neonates during pregnancy and peripartum period remain pending so far.. · The theoretical risk of intrauterine infection for fetuses, or of neonatal infection during delivery for neonates, has a biological plausibility.. · A caution is recommended in the interpretation of clinical and laboratory data in neonates..

Comparison of mediastinal shift angles obtained with ultrasound and magnetic resonance imaging in fetuses with isolated left sided congenital diaphragmatic hernia

Objectives: To compare ultrasound (US) and magnetic resonance imaging (MRI) in the assessment of mediastinal shift angles (MSAs) in fetuses affected by isolated left congenital diaphragmatic hernia (CDH). The use of MRI-MSA and US-MSA as prognostic factor for postnatal survival in fetal left CDH was also explored.Methods: This was an observational study of 29 fetuses with prenatally diagnosed isolated left CDH, assessed with both US and MRI examinations between January 2015 and December 2018. The US-MSA measurements performed within 2 weeks from the MRI assessment were considered for the analysis. The primary outcome was the postnatal survival rate.Results: No significant difference between US and MRI MSAs was detected (p = .419). Among the 29 cases, there were 21 alive infants, for an overall postnatal survival rate of 72.41%. After stratifying for postnatal survival, the best cutoffs with the highest discriminatory power in terms of sensibility and specificity were 42.1° for the US-MSA and 39.1° for the MRI-MSA. The performance of MRI-MSA in predicting postnatal survival was close to that of US-MSA in terms of sensitivity (62.5 versus 50.0%), specificity (80.9 versus 90.5%), positive predictive value (55.6 versus 66.7%), negative predictive value (85.0 versus 82.6%) and accuracy (75.9 versus 79.3%). There was no statistically significant difference between the two modalities (p > .05 for all).Conclusions: MRI and US can be interchangeably used for the assessment of MSA in prenatally diagnosed isolated left CDH. Moreover, MSA measured by both US and MRI was confirmed to be correlated with perinatal outcome in terms of survival.

Fetal MRI assessment of mediastinal shift angle in isolated left congenital diaphragmatic hernia: A new postnatal survival predictive tool?

OBJECTIVE

To quantify the mediastinal shift angle (MSA) in fetuses with isolated left congenital diaphragmatic hernia (CDH) by magnetic resonance imaging and evaluate survival.

METHOD

Fetuses from singleton pregnancies with isolated left CDH were matched for gestational age with controls without thoracic malformations. For all fetuses the MSA was determined by two operators and inter-operator variability and differences between cases and controls were investigated. For all cases total fetal lung volume (TFLV) was calculated and the correlation between MSA and TFLV was assessed, and its predictive value towards survival was determined.

RESULTS

Thirty-four fetuses were included as cases and 42 as controls. The mean gestational age for assessment of CDH fetuses was 32 weeks (range 27-38). Twenty-four fetuses survived until discharge and 10 did not. There was an excellent inter-operator reliability for measuring the MSA and a significant difference between MSA in cases and controls. There was an inverse correlation between MSA values and survival, a correlation between TFLV and survival and an inverse correlation between MSA and TFLV. The area under the ROC curve for MSA in predicting survival was 0.931 (95% CI 0.851-1.000).

CONCLUSION

The MSA measured late in gestation correlates with postnatal survival in patients with isolated left CDH.

Ultrasonographic assessment of mediastinal shift angle (MSA) in isolated left congenital diaphragmatic hernia for the prediction of postnatal survival

Objectives: To quantify mediastinal shift in isolated congenital diaphragmatic hernia (CDH), by the introduction of a new ultrasonographic (US) marker, defined as mediastinal shift angle (MSA) and to evaluate its ability in predicting postnatal survival at discharge.Methods: Twenty-four consecutive fetuses from singleton pregnancies with isolated left-sided CDH were included in the study group and then subdivided into group A (16 survivors) and group B (8 nonsurvivors). The study group was matched with a control group of 95 fetuses from singleton pregnancies free from structural and/or chromosomal anomalies. On the same US stored images commonly used for lung-to-head ratio (LHR) measurement, a landmark line was drawn from a point on the posterior face of the vertebral body, splitting it into two equal parts, to the mid-posterior surface of the sternum. Another landmark line was then traced from the same point of the vertebral body to touch tangentially the lateral wall of the right atrium. The angle between these two lines was used to quantify mediastinal shift and called "mediastinal shift angle" (MSA).Results: Median MSA was significantly different between group A (34.3° range 29.3-45.9°) and group B (42.7° range 34.1-58.9°) (p < .001) and between study group as a whole and the control group (19° range 13.8-25.9°) (p < .001). Statistical analysis confirmed an inverse correlation between MSA values and survival (p = .004). The best cutoff value for MSA was 43.7°, which demonstrated the highest discriminatory power (sensitivity 63%; specificity 93.75%).Conclusions: In fetuses with isolated CDH, the mediastinal shift may be quantified using mediastinal shift angle (MSA) and this US marker, similarly to the widely accepted and used US prenatal prognostic indicators (LHR and O/E LHR), seems to reliably predict survival.

Uterine Artery Velocity Waveforms as Predictors of Pregnancy Outcome in Patients with Antiphospholipid Syndrome: A Review

In pregnant women, antiphospholipid syndrome (APS) is associated with an increased risk for preeclampsia, fetal intrauterine growth restriction, and other complications related to uteroplacental insufficiency. In normal pregnancy, impedance to flow in the uterine arteries decreases with gestation, as the likely consequence of the physiologic change of spiral arteries into low-resistance vessels. The presence of antiphospholipid antibodies can impair this vascular adaptation, resulting in a reduced placental perfusion. Doppler investigation provides a noninvasive method for the study of uteroplacental blood flow. Several studies were performed to detect the predictive role of uterine artery Doppler velocimetry in relation to pregnancy outcome in APS patients. In some studies, a high resistance index in the uterine arteries strongly predicted the subsequent development of obstetric complications. In other studies, persistent bilateral uterine artery notches identified the risk of preeclampsia and fetal intrauterine growth restriction. To date, the uterine artery Doppler velocimetry resulted to be a useful tool for identifying APS pregnancies at risk for adverse pregnancy outcome. These findings might have important implications for the management of these patients.

Resistin regulates human choriocarcinoma cell invasive behaviour and endothelial cell angiogenic processes

Resistin is a novel hormone that is secreted by human adipocytes and mononuclear cells and is probably associated with insulin resistance. Recently, resistin has been postulated to play a role in pregnancy, and resistin gene expression has been observed in placental tissues. However, it is still not known if resistin is able to affect trophoblast functions and development. Therefore, we investigated the hypothesis that resistin might regulate trophoblast production of matrix metalloproteinases (MMPs), the tissue inhibitors of metalloproteinases (TIMPs), trophoblast invasive behavior and the angiogenic processes. In human choriocarcinoma cells (BeWo), resistin (10-100 ng/ml) enhanced both MMP-2 protein and mRNA expression, significantly reduced TIMP-1 and TIMP-2 and increased trophoblast-like cell invasiveness. We analyzed the effect of resistin on an in vitro angiogenesis system for endothelial cells (HUVEC) and we evaluated its ability to modulate the secretion of an angiogenic factor, vascular endothelial growth factor (VEGF). Our data showed that resistin induced VEGF production and we observed that the addition of resistin stimulated endothelial cell tube formation. These findings suggest that resistin might be able to induce BeWo cell invasiveness and to contribute to the control of placental vascular development.

Successful Treatment of Post-Cesarean Hemorrhage Related to Placenta Praevia Using an Intrauterine Balloon

The authors report a positive experience in controlling severe postpartum hemorrhage after cesarean section performed for placenta praevia by using an inflated intrauterine balloon and avoiding any further invasive surgery.

Cardiovascular risk factors in healthy women with previous gestational hypertension

CONTEXT

Epidemiological studies indicate that gestational hypertension (Gh) during pregnancy is associated with increased risk of cardiovascular disease in later life. However, it is unclear whether particular metabolic and hemodynamic characteristics are related to this risk.

OBJECTIVE

The objective of this study was to investigate endothelial function and carbohydrate and lipid metabolism in healthy, normotensive women with previous pregnancy complicated by Gh.

DESIGN, SETTING, AND PARTICIPANTS

Brachial artery flow-mediated dilatation (FMD; endothelium dependent) and nitroglycerin-induced dilatation (endothelium independent) were measured in 15 subjects with previous Gh and in 15 controls with previous normal pregnancies. Lipid panel, glucose, insulin, homocysteine, and androgens were also measured.

RESULTS

FMD was significantly reduced in women with previous Gh compared with controls (P < 0.0001), whereas nitroglycerin-induced dilatation was comparable in both groups. Gh women showed increased fasting insulin (P = 0.011), insulin resistance measured by homeostasis model assessment (P = 0.018), free fatty acids (P = 0.0018), and testosterone (P = 0.0012) and decreased high-density lipoprotein cholesterol (P = 0.0017) compared with controls. Across all subjects, FMD showed a strong independent negative correlation with testosterone and homeostasis model assessment and a positive correlation with high-density lipoprotein cholesterol (r = -0.60, P = 0.0003; r = -0.43, P = 0.016; and r = 0.58, P = 0.0005, respectively).

CONCLUSIONS

Endothelial dysfunction and early alteration of carbohydrate and lipid metabolism are present in otherwise healthy women with previous Gh. These abnormalities along with a relative hyperandrogenism could explain, at least in part, the increased risk for cardiovascular disease in later life in these women.

Rectal cancer in pregnancy: a new management based on blended anesthesia and monitoring of fetal well being

Colorectal carcinoma presenting during pregnancy is an extremely rare condition associated with a poor prognosis. In this report we studied a patient referred to our hospital at 26 weeks of gestation with the diagnosis of rectal adenocarcinoma. Tumor resection with a colostomy was planned in the attempt to preserve pregnancy until fetal viability could be reached. Blended anesthesia (general and epidural) was chosen to avoid surgical and anesthesiological risks; in fact this technique allows either an optimal block of neurohormonal response or a good control of surgical stress to be obtained. In order to monitor fetal well being during surgery, Doppler evaluations of fetal heart rate and umbilical artery flow velocity waveforms were performed. The patient was dismissed in good health and then rehospitalized at 32 weeks of gestation in order to perform an elective cesarean section. In conclusion we suggest that, with the choice of a good anesthesiological technique and monitoring of fetal well being, surgical treatment in case of rectal cancer could be performed without affecting the course of pregnancy.

Predictive value of uterine artery velocimetry at midgestation in low- and high-risk populations: a new perspective

OBJECTIVE

The aim of this study was to assess the value of uterine artery Doppler velocimetry performed at 18-20 and 22-24 weeks of gestation in predicting preeclampsia and adverse pregnancy outcome in low- and high-risk patients.

METHODS

865 pregnant women were evaluated: 335 and 530 pregnant women represented the high- and low-risk groups, respectively. Doppler ultrasound examination of the uterine arteries was performed at 18-20 weeks of gestation in 385 patients and at 22-24 weeks of gestation in 659 patients. Pregnancy outcome was evaluated in terms of: onset of preeclampsia; birth weight <2,500 g; birth weight <1,750 g; delivery before 36 weeks, and delivery before 32 weeks.

RESULTS

At 18-20 weeks of gestation the sensitivity for the prediction of preeclampsia was 100 and 94% in low- and high-risk groups, respectively. Excellent negative predictive values towards birth weight <1,750 g (97% in low-risk and 93% in high-risk groups) and delivery prior to 32 weeks of gestation (99% in low-risk and 95% in high-risk groups) were obtained. At 22-24 weeks of gestation the sensitivity for the prediction of preeclampsia was 100 and 97% in low- and high-risk groups, respectively. Negative predictive values towards birth weight <1,750 g were 97% in low-risk and 94% in high-risk groups, whereas towards delivery prior to 32 weeks of gestation they were 98% in low-risk and 94% in high-risk groups.

CONCLUSION

Doppler evaluation of the uterine artery at 18-20 and 22-24 weeks of gestation represents a useful predictive test in high-risk pregnancy and can also be used in prenatal surveillance of a low-risk population.

Conventional ultrasonography and color Doppler velocimetry of uterine leiomyomas

The role of uterine leiomyomas as causative factor of sterility is controversial. Submucosal myomas, in particular, can interfere with fertility and be associated to obstetric complications as abruption of placenta, post-partum metrorrhagia and puerperal sepsis. With ultrasonography, immediate and long-term information can be drawn on changes in the features of myomas. However, to-date, there are no reliable noninvasive exams to assess the nature and growth pattern of myomas. With Doppler velocimetry in ovarian malignancies a vascularization significantly different from that observed in benign tumors, is detected. It has been hypothesized that within benign tumors, as myomatous masses, tissues with different cell proliferation rates could be characterized by different vascular patterns. In a group of myomas shown to have central arterial vessels at Doppler examination, significant correlations were assessed between resistance indices of analyzed vessels and percentage of cell in the proliferative phase evaluated with cytofluorimetry. The myomatous tissue with high cell proliferation rate seems to have higher vascular resistances.

Short-term maternal oxygen administration in fetuses with absence or reversal of end-diastolic velocity in umbilical artery: pathophysiological and clinical considerations

BACKGROUND

The aim of our study was to evaluate the hemodynamic response to acute maternal hyperoxygenation (O2 test) in a group of growth retarded fetuses with absence or reversal of end-diastolic velocity (AREDV) in the umbilical artery (UA) and to correlate this response to a series of feto-placental velocimetric parameters and clinical variables.

METHODS

In 25 singleton pregnancies, feto-maternal Doppler velocimetry was performed before and after acute maternal hyperoxygenation.

RESULTS

Ten fetuses (40%) exhibited an increase of middle cerebral artery Pulsatility Index (PI) >20% after O2 (Responders), while in 15 fetuses PI did not change relevantly (Nonresponders). Non-responder fetuses showed a higher prevalence of reverse flow in umbilical artery (6/15 vs 0/10: p<0.03) and a slight, but not significant, higher percentage with reversed flow in inferior vena cava (% of A). Also the prevalence of a % of A greater than 95th confidence interval was higher in Non-responders (13/15 vs 4/10; p<0.04). Finally the Responder fetuses showed higher peak velocities in the cardiac outflows, even if the difference reached a statistical significance only for the pulmonary artery. The outcome of the two groups did not differ significantly.

CONCLUSIONS

Our results seem to prove an ability of O2 test in selecting a group of AREDV fetuses characterized by a higher degree of hemodynamic deterioration and hence 'placed' in a more advanced step of the pathological process leading to overt cardiac decompensation, even if the clinical application of such a test seems to be still of limited value.

[Usefulness of color Doppler in the differential diagnosis of adnexal masses]

BACKGROUND

The aims of this study were to verify the predictive performance of color-Doppler analysis in the differential diagnosis of adnexal masses and to evaluate the prognostic value of a new "vascular score".

METHODS

One-hundred-ninety-six patients referred to our Institute for adnexal masses were evaluated with color and pulsed Doppler within 2-3 days from surgery, and the velocimetric results were compared to histopathological data. On the basis of histopathology, patients were classified in 166 with benign and 30 with malignant ovarian tumors.

RESULTS

The predictivity obtained with color Doppler analysis ("vascular score") was compared to that of some "morphological scores" commonly used in the literature. The sensitivity was 100% for all the techniques used, but Doppler analysis had a higher specificity with respect to the others (95% vs max 76% for echographic techniques). The introduction of a new "vascular score" based on the introduction of the acceleration of flow in another score system previously presented, was not able to improve the predictive performance of color Doppler analysis.

CONCLUSIONS

Color Doppler ultrasonography of ovarian tumors seems to be a reliable method in the differential diagnosis of adnexal masses, and its potential use in the choice of a less-invasive surgical approach in selected cases (those negative to the "vascular score") should be considered.

Transvaginal color Doppler ultrasonography in the presurgical characterization of adnexal masses

The aim of our study was to evaluate flow-velocity waveforms from ovarian tumors with color Doppler, in order to test the predictivity of malignancy and to compare the Doppler technique with some morphological scoring systems. Color Doppler examination of ovarian neoplasms was performed in 122 patients within 2-3 days from surgery and, based on vascular characteristics and on Doppler resistance index, a "vascular" score was calculated. One hundred one women had benign and 21 had malignant tumors on histopathology. In all of the malignant lesions color Doppler was able to detect vascular patterns, whereas only 43% of the benign tumors showed recognizable vessels (P < 0.001). Malignant masses showed significantly greater vascular scores than those of benign tumors (P < 0.001). Doppler ultrasonography achieved better specificity and PPV when compared to morphological scores (96% vs 61-75% and 82% vs 35-48%). Color Doppler ultrasonography of ovarian tumors seems to be a reliable method in the presurgical characterization of ovarian neoplasms.

Chronic hypertension in pregnancy: color Doppler investigation of uterine arteries as a predictive test for superimposed preeclampsia and adverse perinatal outcome

To determine if uterine artery Doppler velocimetry is useful in identifying chronic hypertensive pregnancies at risk for superimposed preeclampsia and adverse perinatal outcome. Resistance index (RI) was assessed by color velocimetry at the level of uterine arteries at 23-24 weeks of gestation in 42 women with chronic hypertension. The "lowest", the "highest" and the "average" values were compared to select the most predictive index for superimposed preeclampsia, intrauterine growth retardation (IUGR), birth weight lower than 2500 g and gestational age at delivery less than 36 weeks. Nine patients developed superimposed preeclampsia (21%) and 15 delivered before the 36th week of gestation (36%); 4 babies were IUGR (10%) and in 18 cases birth weights were below 2500 g (43%). Statistical analysis of Doppler findings showed that abnormal values of "lowest RI" were significantly correlated with adverse pregnancy outcome. Color Doppler analysis of uterine arteries is able to select chronic hypertensive pregnant women at risk of superimposed preeclampsia and poor perinatal outcome.

Pregnancy outcome in relation to uterine artery flow velocity waveforms and clinical characteristics in women with antiphospholipid syndrome

OBJECTIVE

To determine whether uterine artery velocimetry is a useful tool for identifying pregnancies with antiphospholipid syndrome at risk for adverse outcome.

METHODS

Twenty-four women with antiphospholipid syndrome, who had experienced 56 fetal losses in 63 previous pregnancies (88.9%), were treated with prednisone (40 mg/day) and aspirin (100 mg/day) during 28 pregnancies. Color Doppler ultrasound was performed at 18-24 weeks' gestation to investigate the resistance index of the uterine arteries.

RESULTS

Treated women delivered 23 live infants in the 28 pregnancies (82.1%). Three infants weighed less than the tenth percentile (13%). Five pregnancies were complicated by preeclampsia and ten by nonproteinuric gestational hypertension. Positive results for all three assays for antiphospholipid antibodies (anticardiolipin antibodies, lupus anti-coagulant, VDRL) at conception identified pregnancies destined to have poor fetal outcome and a significantly lower birth weight compared to pregnancies not having all three assays positive. An abnormal resistance index of the uterine arteries predicted pregnancies with poor fetal outcome in terms of week of delivery, birth weight, and birth percentile, as well as four of five cases of preeclampsia.

CONCLUSIONS

Three assays positive for antiphospholipid antibodies at conception and an abnormal resistance index of the uterine arteries at 18-24 weeks' gestation predicted pregnancies at major risk for obstetric complications. Future studies should determine whether treatment can be modulated based on the Doppler findings.

Behavioural state transitions in healthy and growth retarded fetuses

The transitions, i.e. time intervals between two different behavioural states, were studied in 10 healthy and 10 growth retarded fetuses (IUGR) in near term pregnancies. In healthy fetuses, transitions usually lasted less than 3 min whereas IUGR fetuses showed a longer duration when compared to healthy fetuses. Moreover, a significant trend in the change of state variables (fetal heart rate, fetal eye movements and fetal gross body movements) was evident in healthy fetuses: fetal heart rate was the first variable to change in transitions from 1F to 2F and the last variable to change in transitions from 2F to 1F. On the other hand IUGR fetuses showed a random sequence in order of change. These findings were substantiated by the intraindividual consistency evidenced in repeated recordings. In conclusion the analysis of transitions differentiates between healthy fetuses and those affected by IUGR.

Development of behavioral states in hydrocephalic fetuses

Behavioral states observations were carried out in 12 hydrocephalic fetuses by means of a computerized system. Recordings of behavioral parameters, including fetal heart rate, gross body movements, breathing movements and eye movements, were performed at 2-week intervals from 30 weeks of gestation onwards. The hydrocephalic fetuses showed quantitative and qualitative differences in their motor behavior in comparison to healthy fetuses of equivalent gestational age. Similarly the appearance of behavioral states was delayed in hydrocephalic fetuses. Furthermore, an increased discordance between the behavioral parameters was evidenced. The degree of discordance seems to be related to the severity of neonatal outcome suggesting a possible estimation of CNS dysfunction by means of behavioral state analysis.