TIMER: A Clinical Study of Energy Restriction in Women with Gestational Diabetes Mellitus.

Medical nutrition therapy is an integral part of gestational diabetes mellitus (GDM) management; however, the prescription of optimal energy intake is often a difficult task due to the limited available evidence. The present pilot, feasibility, parallel, open-label and non-randomized study aimed to evaluate the effect of a very low energy diet (VLED, 1600 kcal/day), or a low energy diet (LED, 1800 kcal/day), with or without personalized exercise sessions, among women with GDM in singleton pregnancies. A total of 43 women were allocated to one of four interventions at GDM diagnosis: (1) VLED (n = 15), (2) VLED + exercise (n = 4), (3) LED (n = 16) or (4) LED + exercise (n = 8). Primary outcomes were gestational weight gain (GWG), infant birth weight, complications at delivery and a composite outcomes score. Secondary outcomes included type of delivery, prematurity, small- for-gestational-age (SGA) or large-for-gestational-age (LGA) infants, macrosomia, Apgar score, insulin use, depression, respiratory quotient (RQ), resting metabolic rate (RMR) and middle-upper arm circumference (MUAC). GWG differed between intervention groups (LED median: 12.0 kg; VLED: 5.9 kg). No differences were noted in the type of delivery, infant birth weight, composite score, prevalence of prematurity, depression, RQ, Apgar score, MUAC, or insulin use among the four groups. Regarding components of the composite score, most infants (88.4%) were appropriate-for-gestational age (AGA) and born at a gestational age of 37-42 weeks (95.3%). With respect to the mothers, 9.3% experienced complications at delivery, with the majority being allocated at the VLED + exercise arm (p < 0.03). The composite score was low (range 0-2.5) for all mother-infant pairs, indicating a "risk-free" pregnancy outcome. The results indicate that adherence to a LED or VLED induces similar maternal, infant and obstetrics outcomes.

Implementation of Fetal Cardiac Guidelines for the Routine Second-Trimester Heart Examination: A Feasibility Study.

PURPOSE: This study aimed to explore the feasibility of implementation of the ISUOG 2013 guidelines on routine second-trimester examination of the fetal heart. MATERIALS AND METHODS: This was a prospective study in 357 women with singleton pregnancy undergoing their routine second-trimester scan. The fetal heart was examined using B-mode in different planes according to the guidelines. Potential maternal and fetal factors that can affect the rates of diagnostic-quality imaging for each of the recommended views were tested, using regression analysis. The intra- and interobserver agreement was analyzed in stored video loops. RESULTS: Most cardiac structures could be successfully examined with rates at or close to 100 %. Structures with a successful examination rate of ≤ 85 % included the ventricular wall fine details (55.2 %), tricuspid valve insertion (82.6 %), aortic root with clear walls (77.9 %), pulmonary artery walls (65.8 %) and clear view of the great artery walls (66.7 %). Common factors affecting the likelihood of successful examination of these structures included maternal BMI, skin-to-crux distance and the orientation of the cardiac axis. A post-hoc analysis indicated that a lack of pre-defined criteria for diagnostic quality was a constant reason for the interobserver variation. CONCLUSION: Most of the cardiac views can be consistently and reliably obtained, with maternal habitus being the primary factor limiting the quality of visualization. As offline interpretation may be subjective, using pre-defined quality criteria for the assessment of the images might improve interrater agreement.

Safety and efficacy of intravenous iron administration for uterine bleeding or postpartum anaemia: a narrative review.

The management of iron deficiency anaemia (IDA) consists of oral or intravenous administration of iron supplements. The aim of this narrative review is to summarise information regarding the treatment of IDA in women who have postpartum anaemia or uterine bleeding with intravenous (IV) or oral iron supplements. Fourteen randomised control studies comparing IV to oral iron treatment for IDA in 2913 women with uterine bleeding or postpartum haemorrhage are included. All reviewed studies suggest that IV iron administration is important in treating the IDA in such women and in improving their physical performance and quality of life. Comparisons among intravenous iron supplements show advantages of ferric carboxymaltose over others in time of reaching desired haemoglobin and ferritin values and in adverse reactions. Despite the limitation that the above evidence emerges from not systematically collected data, our review highlights that new forms of IV iron supplements seem safe and efficient in treating IDA.

Divergence of estimated fetal weight and birth weight in singleton fetuses.

OBJECTIVE: To evaluate differences in distribution of estimated fetal weight (EFW) and birth weight (BW) of ongoing fetuses and neonates of the same gestational age. METHODS: Reference curves for EFW (Hadlock BPD-HC-AC-FL formula, N = 1191) and BW (N = 1036) in singleton pregnancies from 24+0 to 40+6 gestational weeks were calculated. Multiple pregnancies, fetuses with major or multiple abnormalities or syndromes and iatrogenic preterm deliveries due to preeclampsia or abnormal fetal Doppler were excluded. The standardized residuals for EFW and BW were calculated and compared. RESULTS: EFW and BW can be accurately described by quadratic equations (R2 = 0.944 and 0.807, respectively). The distribution of standardized residuals for BW using the EFW formula was negative from 28+0 to 35+6 weeks. The 50th and 5th centiles of BW were lower than those of EFW throughout prematurity, and they converged at approximately 38 gestational weeks. The 5th centile for BW was 30% lower than the 5th centile for EFW at 27 weeks, 27.5% lower at 30 weeks and 19.4% at 34 weeks. CONCLUSIONS: Preterm infants have lower BW distribution compared to the expected EFW of ongoing pregnancies of the same gestational age, supporting the concept of hidden intrauterine morbidity for a proportion of these infants.

Prenatal diagnosis of X-linked myopathy associated with a VMA21 gene mutation afforded through a novel targeted exome sequencing strategy applied in fetuses with abnormal ultrasound findings.

Fetal malformations detected through routine prenatal ultrasound examination comprise a heterogeneous group potentially associated with genetic disorders where the underlying cause is difficult to establish. We present the prenatal diagnosis of a rare X-linked myopathy involving a new VMA21 gene mutation, detected through a novel prenatal exome sequencing-based approach.

Is there a role for single-port laparoscopy in the treatment of endometriosis?

Endometriosis is among the most common benign gynecological conditions, and it affects 6-15% of women of reproductive. During recent decades, minimally invasive surgical techniques, and especially laparoscopy, have gained significant ground concerning the treatment of gynecological disorders. To date, laparoscopy is considered the gold standard for the diagnosis and treatment of endometriosis. Available English-language papers in PubMed and Scopus databases have been used for the current narrative review. Data from all relevant literature regarding single-port laparoscopy and treatment of endometriosis have been extracted. The main key words used by the authors for the search were: single-port laparoscopy, endometriosis and laparoscopy. Two authors (A.D. and K.C.) performed the data base search and extraction of relevant studies, and a third author (E.A.) consented to the study selection of the 23 relevant papers, consulted and approved the final presentation of the results and conclusions. To date, the laparo-endoscopic single-site surgery (LESS) technique has been used for a variety of procedures in gynecology as well as for a variety of diagnoses. Thus, adhesiolysis, ovarian endometrioma enucleation and salpingo-oophorectomy can be easily performed using the LESS approach. Novel single-site trocars as well as appropriate curved instruments are being designed and produced to facilitate the surgeon utilizing such a demanding technique. However, single-site surgery does not seem to have a place to date in the treatment of deep infiltrating endometriosis due to the complicated surgical maneuvers required for the treatment of this condition combined with technical difficulties posed by the loss of triangulation, and the instrument crowding when LESS is implemented. Apart from being feasible, LESS has also proven to be non-inferior in terms of surgical safety and efficacy, and according to most, but not all, reports, better in terms of cosmetics and postoperative body image perception. Currently, it has been shown that most of the gynecologic operations are feasible using the LESS approach. So, this approach has a role to play in the treatment of endometriosis too, especially concerning the most common manifestations of the disease. However, more extensive research is required to properly evaluate single-port access techniques to conventional minimally invasive ones in the treatment of the different manifestations of endometriosis, concerning short term as well as long term outcomes of the treatment, including the ones associated to fertility.

Screening performance of different methods defining fetal nasal bone hypoplasia as a single and combined marker for the detection of trisomy 21 in the second trimester.

OBJECTIVE: To evaluate different methods of defining fetal nasal bone hypoplasia in the second trimester for the detection of trisomy 21. METHODS: Prospective study in Greek women undergoing anomaly scan between 18 + 0 and 23 + 6 weeks. The following methods of defining nasal bone hypoplasia were evaluated, either as a single marker or in combination with others: (1) BPD to nasal bone length (NBL) ratio; (2) multiples of the median (MoM) of NBL, according to normal curves from a Greek population; (3-4) NBL < 2.5 percentile according to normal curves (3) commonly used internationally curves and (4) curves from a Greek population. RESULTS: In total, 1301 singleton fetuses were evaluated - 10 with trisomy 21. The best detection rate of trisomy 21 was achieved when the applied method was nasal bone percentiles adjusted to maternal ethnicity, in combination with other markers (<2.5 percentile according to normal curves from a Greek population; p < 0.001; sensitivity 50%; specificity 94.8%; false-positive rate 5.2%; positive likelihood ratio 9.6). CONCLUSION: Screening performance of fetal nasal bone hypoplasia in detecting trisomy 21 varies according to the method applied. The best screening performance is achieved by using percentiles adjusted to maternal ethnicity in combination with other markers of aneuploidy.

Fetal growth impairment after first-trimester chorionic villus sampling: a case-control study.

OBJECTIVE: The objective of this study is to test if chorionic villus sampling (CVS) is associated with fetal growth impairment, after controlling for maternal and fetal factors. STUDY DESIGN: Case-control study of singleton fetuses whose mothers had undergone CVS (N = 442) and 2969 controls. The primary outcomes were the prevalence of birthweight < 10th centile and birthweight <3rd centile; the prevalence of preeclampsia was the secondary outcome. Tested predictors in logistic regression analysis included CVS, free beta-hCG MoMs, PAPP-A MoMs, first-trimester mean uterine artery pulsatility index (PI) z-scores, maternal height, BMI, age, and smoking. RESULTS: The proportion of newborns with birthweight <10th centile (7.9 versus 6.2%), and <3rd centile (1.6 versus 1.1%) did not differ between the two groups. Maternal age, smoking during pregnancy, PAPP-A MoMs, and mean first-trimester uterine PI z-score were significant predictors for these outcomes. Although the prevalence of preeclampsia was higher in the CVS group (3.2 versus 1.3%, OR 2.62, 95% CI 1.41-4.89), the association was abolished in the regression analysis, in which maternal body mass index, free b-hCG levels, and mean first-trimester uterine PI z-score were the only significant predictors. CONCLUSIONS: CVS is not associated with fetal growth impairment, possibly because the resulting mechanical disruption is compensated by the developing placenta, without significantly impairing its function.

Fetal nasal bone length in the second trimester: comparison between population groups from different ethnic origins.

OBJECTIVE: To compare normal ranges of ultrasonographically measured fetal nasal bone length in the second trimester between different ethnic groups. METHOD: A prospective, non-interventional study in order to establish normal ranges of fetal nasal bone length in the second trimester in a Greek population was conducted in 1220 singleton fetuses between 18 completed weeks and 23 weeks and 6 days of gestation. A literature search followed in order to identify similar studies in different population groups. Fetal nasal bone length mean values and percentiles from different population groups were compared. RESULTS: Analysis of measurements in the Greek population showed a linear association, i.e., increasing nasal bone length with increasing gestational age from 5.73 mm at 18 weeks to 7.63 mm at 23 weeks. Eleven studies establishing normal ranges of fetal nasal bone length in the second trimester were identified. Comparison of fetal nasal bone length mean values between the 12 population groups showed statistically significant differences (P<0.0001). CONCLUSION: Normal ranges of fetal nasal bone length in the second trimester vary significantly between different ethnic groups. Hence, distinct ethnic nomograms of fetal nasal bone length in the second trimester should be used in a given population rather than an international model.

Neurodevelopmental fetal assessment using KANET scoring system in low and high risk pregnancies.

OBJECTIVE: To assess and compare fetal behavior and neurodevelopment (KANET) between low and high risk pregnancies. METHODS: Prospective, comparative, cohort study. One hundred and fifty-two consecutive pregnant women presenting for routine 2nd trimester and 3rd trimester scan had four dimensional ultrasound examinations (4D US) in order to assess fetal behavior and neurodevelopment. This was achieved by the study of: (1) isolated head movements, (2) isolated hand movements, (3) isolated leg movements, (4) cranial sutures, (5) hand to face/head movements, (6) finger movements, (7) yawning - mouthing, (8) facial expressions, (9) isolated eye blinking, (10) "Gestalt" perception. According to the maternal background risk, the population of the study was classified in low risk pregnancies (n = 78) and high risk pregnancies (n = 74) with IUGR fetuses (n = 12), diabetes mellitus (n = 24), and pre-eclampsia (n = 38). RESULTS: The neurodevelopmental score was statistically significant higher in the low risk group compared to the high risk group (p < 0.0004). The diabetes subgroup score was statistically significantly higher compared to the IUGR and the pre-eclampsia subgroup (p = 0.0001). CONCLUSIONS: The neurodevelopment fetal assessment by 4D ultrasound appears to be a feasible technique in the evaluation of high risk pregnancies. Further studies where any association between KANET score and neurological outcome of the childhood are warranted.

Correlation of 2nd trimester amniotic fluid amino acid profile with gestational age and estimated fetal weight.

OBJECTIVES: Our aim was to identify and quantitate free amino acids in human amniotic fluid (AF) specimens collected during 2nd trimester amniocentesis and determine the correlation between amino acid concentrations, gestational age, and estimated fetal weight. METHODS: Seventy-eight AF samples were retrieved between 18 and 22 weeks of gestation. Fetal weight estimation was based on fetal biometric measurements. RESULTS: Twenty-one amino acids were quantified. The concentration of glutamine exhibited the greatest correlation with gestational age (r = 0.477, p < 0.01). Additionally, significant negative correlations were recorded between gestational age and levels of alanine, proline, lysine, valine, taurine, leucine, glutamic acid, tyrosine, phenylalanine, isoleucine, ornithine, methionine, and tryptophane (p < 0.05). After adjusting for maternal age, fetal gender, intervals between consecutive pregnancies, pre-pregnancy body mass index, and smoking during pregnancy the strength of the correlation for proline and lysine decreased. A stepwise multiple linear regression model including gestational age as a first level predictor of fetal weight indicated that lysine and cysteine concentrations were additional predictors. CONCLUSIONS: Our results suggest that AF amino acids are crucial for fetal growth. Our purpose was not to establish an immediate diagnostic application. However, further exploration is likely to be fruitful, especially in high-risk pregnancies.

Ectopia cordis in a fetus with mosaic trisomy 16.

Ectopia cordis and mosaic trisomy 16 are two rare fetal anomalies, which have not been reported in association. We report a case of an isolated ectopia cordis at 11(+3) weeks. Subsequent embryological examination confirmed thoracic ectopia cordis with normal heart structure and array comparative genomic hybridization of fetal tissue detected trisomy 16 mosaicism.

Sonographic changes after laparoscopic cystectomy compared with three-stage management in patients with ovarian endometriomas: a prospective randomized study.

BACKGROUND: Laparoscopic surgery is the gold standard treatment for ovarian endometriomas. The aim of this study was to evaluate the impact of two different laparoscopic methods on sonographic indicators of ovarian reserve in the treated ovary. METHODS: In this prospective randomized clinical trial, 20 patients with endometriomas were randomly assigned to undergo either laparoscopic cystectomy (Group 1) or the 'three-stage procedure' (Group 2). All patients underwent ultrasound examination preoperatively and 6 months after laparoscopy. Another ultrasound examination was performed 12 months after intervention in order to detect any recurrence. We investigated the alterations in the residual ovarian volume, ovarian vascular supply and antral follicle count (AFC) on the ovary with the endometriotic cyst by transvaginal color Doppler ultrasonography. RESULTS: The residual ovarian volume and the lowest pulsatility and resistance indexes were found to be similar between the two groups before and 6 months after laparoscopic intervention. The AFC of the operated ovary was increased significantly (P = 0.002) in Group 2 compared with Group 1 after 6 months. One year after laparoscopy, two recurrences of endometriomas were detected in Group 2, although none were detected in Group 1 (P = 0.47). CONCLUSIONS: Ovarian volumes and vascularization were comparable among the two laparoscopic methods. On the contrary, functional ovarian tissue as determined by AFC was higher after the 'three-stage' procedure.

Embryo with XYY syndrome presenting with clubfoot: a case report.

Talipes equinovarus (clubfoot) is a skeletal anomaly of the embryo's legs, with a frequency of 1-3:1000 living born babies. It may occur as an independent anomaly, or as part of a syndrome with concomitant chromosomal abnormalities.XYY syndrome is a quite rare sex chromosomal abnormality with 47, XYY karyotype. Prenatal diagnosis is usually accidental because the syndrome is not associated with increased prevalence of sonographically detectable defects. The possibility of co-existence of skeletal anomalies in embryos with 47, XYY karyotype is scant, with only a few cases reported in the literature.An amniocentesis was performed in an embryo at the 21(st) week of gestation because clubfoot was detected in the 2(nd) trimester scan, and the embryo was found to have abnormal karyotype of 47, XYY. Current opinions and management dilemmas are discussed.

Failure of ultrasound to diagnose a giant ovarian cyst: a case report.

Ultrasonography is the method of choice in the diagnosis of ovarian cysts. In this case report, a cyst of enormous volume (>35 litres) was limiting the application of ultrasound techniques giving the false impression of ascites. A 55-year-old woman was finally diagnosed as having a giant ovarian mucosal-serosal cystadenoma of borderline potential after undergoing a total abdominal hysterectomy with salpingo-oophorectomy and excision of the cyst. In the literature, similar conditions have been described with the term 'empty abdomen'.

Women's expectations and intention to terminate pregnancy in case of abnormal findings at the second trimester level II ultrasound scan. A prospective, questionnaire-based, cross-sectional survey.

OBJECTIVE: The aims of this study were: (1) to explore pregnant women's background knowledge and expectations of 2nd trimester ultrasound screening, and (2) to investigate women's intentions to proceed to pregnancy termination if fetal anomaly is detected at the 2nd trimester ultrasound screening. METHODS: A prospective, cross-sectional, questionnaire-based study. 300 consecutive pregnant women served as a convenience sample for this study. All the women had had a detailed, 2nd trimester, fetal anomaly scan. The questionnaire was a standardized but not validated, purpose-built structure consisting of five parts: (a) demographics, (b) anamnesis and obstetric history, (c) perceived aim of the scan, (d) expectations from the scan, and (e) intention to terminate pregnancy in case of fetal malformation diagnosis. Statistical analysis was performed with the SPSS 12.0 for Windows. RESULTS: The participants' mean age was 31.3 (21-45) years. 89.3% of the women filled in the questionnaire. The main reasons for the scan, according to the women, were to exclude fetal abnormalities and to assess the fetal karyotype. The main maternal expectations from the scan were to reduce maternal anxiety and to identify fetal malformations. 75.3% of the women were willing to terminate their pregnancy if fetal abnormalities were detected. Older women more commonly opted for pregnancy termination. CONCLUSION: The majority of participants have a correct notion about the aim of the ultrasound scan, their expectation is mainly anxiety reduction and a high percentage would proceed to pregnancy termination in the event of the detection of a fetal abnormality.

Comparison between 20G and 22G needle for second trimester amniocentesis in terms of technical aspects and short-term complications.

OBJECTIVE: To compare short-term complications of amniocentesis using 20G versus 22G needle. METHODS: A total of 200 women referred for mid-trimester amniocentesis were randomized to a 20G (Group I, n = 100) or 22G amniocentesis needle (Group II, n = 100). The primary outcome was intrauterine bleeding at needle insertion. The operator reported technical aspects and patient's reactions immediately after the procedure. Women's perception of discomfort 30 min after the procedure and complications after 2 weeks were recorded. RESULTS: Intrauterine bleeding at needle insertion was similar between groups (4/100 vs 8/100). When only transplacental taps were analyzed, bleeding was significantly lower in Group I (4/20 vs 8/14, p = 0.035). Fluid retrieval was faster in Group I (9.6 vs 26.8 sec, p < 0.001). In all, 65% of women in Group I versus 30% in Group II reported discomfort during the procedure, although discomfort 30 min after the procedure and complications within 2 weeks after the procedure were similar in the two groups. CONCLUSION: Amniocentesis with 20G needle is associated with lower risk of intrauterine bleeding in case of transplacental needle insertion and allows for faster fluid retrieval, as compared with 22G needle. Nevertheless, 20G needle is associated with more immediate discomfort during the procedure.

Aggressive angiomyxoma of the vulva extending into the pelvis: report of two cases.

Aggressive angiomyxoma is a rare soft-tissue neoplasm found mainly in the female pelvis. Approximately 130 cases have been reported in the literature to date. In most cases treatment consists of surgical resection, but local recurrence rates remain high (36-72%). Therefore, long-term follow up is necessary and magnetic resonance imaging seems to be the preferred method for detecting recurrence. We report our experience of a primary and a recurrent aggressive angiomyxoma.