Malnutrition in pregnancy following bariatric surgery: three clinical cases of fetal neural defects.

OBJECTIVE: Bariatric surgery results in decreased food intake and a variable degree of malabsorption. Without adequate supplementation, the most common complications of this surgery are nutritional disorders. Pregnancy following surgery for obesity is a particular condition requiring strict monitoring of nutrient intake necessary for fetal development and a favourable neonatal prognosis. PATIENTS: Malnutrition in pregnancy and congenital neural malformations are reported in three women who had previously undergone bariatric surgery (1, 5 and 18 years before pregnancy, respectively). Two patients underwent the Roux en Y bypass and one bilio-pancreatic diversion with gastroplasty. None of the three received pre-conceptional nutritional counselling. Patients 1 and 2 did not undergo postoperative nutritional surveillance; nutrient supplementation was started at 22 and 20 weeks gestation, respectively. In patient 3, supplementation was stopped at six weeks gestation. RESULTS: Newborns 1 and 2 presented with dorsal myelomeningocele and ventricular dilation. Both underwent surgery and a ventriculo-peritoneal shunt was inserted in the first month of life. Newborn 3 had microcephaly, bilateral microphthalmia and sensorineural deafness. CONCLUSIONS: Diet and nutritional status, before and during pregnancy, play an important role in the early processes of fetal development and neonatal outcome. Women of childbearing age who have had bariatric surgery, should be encouraged to follow a well-balanced diet as part of a weight management strategy. They should be advised to take recommended maternal supplements.

Candida glabrata and pre-term premature rupture of membrane complicating in vitro pregnancy: case report and confirmation of mother to neonate transmission.

CASE REPORT: We report a case of Candida glabrata infection in an in vitro fertilization-assisted pregnancy complicated by pre-term pre-labor rupture of the membranes. We found C. glabrata in gastric fluid, amniotic fluid and maternal vaginal swab. Neonatal and maternal isolates showed indistinguishable molecular patterns analyzed by fingerprint DNA multilocus. DISCUSSION: Strong consideration should be given to perform a screening test C. glabrata. Multiple treatments, even in pregnancy, should be considered in women who have positive cultures results.

Cerebroplacental Doppler ratio and placental histopathological features in pregnancies complicated by fetal growth restriction.

OBJECTIVE: To correlate placental pathologic lesions, as defined by the Society for Pediatric Pathology, to the severity of the ratio of the pulsatility Doppler index (PI) of the fetal middle cerebral artery to that of the umbilical artery (cerebroplacental ratio, CPR). STUDY DESIGN: A cohort-study of 176 singleton pregnancies complicated by fetal growth restriction (FGR). RESULTS: The mean values of gestational age, birth weight and CPR of the entire cohort were 33.9±3.6 weeks, 1552±561 g, and 1.33±0.68, respectively. In ordered logistic regression analysis, after adjustment for potential confounders, muscularised arteries (Odds Ratio [OR]=3.14; 95% confidence intervals [CI]=1.58-6.28, P=0.001), mural hypertrophy (OR=2.35; 95% CI=1.26-4.4, P=0.008), immature intermediate trophoblast (OR=2.0; 95% CI=1.07-3.71, P=0.03) and maternal vascular underperfusion (OR=2.32; 95% CI=1.25-4.23, P=0.007) were the only parameters associated with severity of CPR. CONCLUSIONS: The correlation between placental histological findings indicating maternal underperfusion and placental occlusion suggest that forced centralization of fetal circulation in FGR could be at least partially attributable to the hemodynamic consequences of increased placental vascular resistance.

Placental histopathological correlates of umbilical artery Doppler velocimetry in pregnancies complicated by fetal growth restriction.

OBJECTIVE: The objective of the study was to evaluate the association between placental histological patterns and umbilical artery (UA) Doppler velocimetry in pregnancies complicated by fetal growth restriction (FGR). METHODS: A cohort of 126 FGR pregnancies was followed according to a standard protocol. Placental lesions were diagnosed according to consensus nomenclature and standardized criteria. RESULTS: Pulsatility index was normal in 45 (35.7%) and increased in 44 (34.9%) women. End-diastolic UA Doppler flow was absent in 27 (21.4%) and reversed in 10 (7.9%). Fifty-four women (42.9%) had preeclampsia. In preeclampsia, increasing Doppler abnormalities, from normal to reversed UA end-diastolic flow, were directly associated only with an increased number of placental syncytial knots. In normotensive pregnancies, Doppler abnormalities were associated with increased intervillous fibrin deposits, villous hypoplasia, syncytial knots, placental site giant cells, immature intermediate trophoblast, and with pattern of lesions indicating superficial implantation and maternal vascular underperfusion. In the whole cohort, increase of syncytial knots [odds ratio (OR) = 28.7; 95% confidence interval (CI) = 2.75-298.5], intervillous fibrin deposits (OR = 2.1; 95% CI = 1.04-4.28), placental site giant cells (OR = 3.0; 95% CI = 1.05-8.84), and patterns suggesting maternal underperfusion (OR = 2.9; 95% CI = 1.0-7.1) were independently associated with increased rates of absent/reversed UA end-diastolic flow. CONCLUSIONS: In pregnancies complicated by FGR, abnormalities of UA Doppler velocimetry were associated with placental lesions indicating superficial implantation and maternal vascular underperfusion.

The impact of first-trimester serum free beta-human chorionic gonadotropin and pregnancy-associated plasma protein A on the diagnosis of fetal growth restriction and small for gestational age infant.

OBJECTIVE: To evaluate the risk of fetal growth restriction (FGR) associated with first-trimester maternal serum concentrations of pregnancy-associated plasma protein A (PAPP-A) and free beta-human chorionic gonadotropin (beta-hCG). METHODS: A longitudinal study of 2,178 women who underwent first-trimester evaluation of serum PAPP-A and free beta-hCG. FGR was defined as a decrement of the fetal abdominal circumference to below the 10th percentile of our standard growth curve in the presence of Doppler signs of impaired placental perfusion. Logistic regression was used to compute multivariable odds ratios and the estimated prevalences of outcomes associated with first-trimester serum marker concentrations. RESULTS: The prevalences of small for gestational age (SGA, <10th percentile birth-weight) neonates and FGR were significantly higher among women with serum PAPP-A concentrations below the 10th percentile than in controls: 40/206 compared to 183/1,928, for SGA, adjusted odds ratio = 2.1, 95% confidence intervals (CI) 1.4-3.03; 24/75 compared to 182/1,900, for FGR, adjusted odds ratio = 3.9, 95% CI 2.3-6.5. The adjusted prevalences of FGR and SGA among women with simultaneous low first-trimester values of PAPP-A and free beta-hCG were 0.21 (95% CI 0.13-0.33) and 0.26 (95% CI 0.17-0.36), respectively. CONCLUSION: Low first-trimester maternal serum PAPP-A concentrations are significantly associated with reduced fetal size and increased risk of FGR with Doppler signs of impaired placental perfusion.

Long-term results of sigmoid vaginoplasty in a consecutive series of 62 patients.

We performed a historical cohort study of 62 consecutive patients who underwent abdomino-perineal vaginal re-construction with a segment of the sigmoid colon during a 25-year period. A dedicated database was reviewed for the aetiology of vaginal malformation, surgical complications and post-operative follow-up. Follow-up visits were scheduled 2, 6 and 12 months after discharge from hospital and annually thereafter. Fifty-eight (93.5%) patients were diagnosed as having Mayer-Rokitansky-Kuster-Hauser syndrome (MRKHS) and four (6.5%) had undergone previous demolitive surgery for gynaecologic malignancy. The mean operating time was 145 min (range 95 to 250 min). The mean hospital stay was 8.3 days (range 5 to 23 days). Post-operative complications requiring additional surgery occurred in 3 (4.8%) patients and were a case of necrotising fascitiis with leakage of the bowel anastomosis, a case of bowel occlusion and a case of neovaginal prolapse. The mean follow-up was 11.3 years (range 3 months to 24 years). We recorded 5 cases (8.1%) of sigmoid graft shrinkage treated successfully by dilation. The time interval between sigmoid vaginoplasty and first intercourse was 4 months (range 2 months to 4 years). During the follow-up, 32 (51.6%) women reported regular and 30 (48.4%) women reported occasional sexual intercourse; 80.6% (50/62) were "satisfied" with the surgical procedure. In this large series, laparotomic sigmoid vaginoplasty was a safe and acceptable technique to treat congenital absence of the vagina. This procedure allowed early sexual intercourse and was associated with a low incidence of shrinkage and a high rate of patients' satisfaction.