Evaluation of Cesarean section scar using saline contrast sonohysterography in women with previous Cesarean scar pregnancy.

OBJECTIVE: To evaluate Cesarean scar defects using saline contrast sonohysterography (SCSH) in women with a history of Cesarean scar pregnancy (CSP). METHODS: A cohort of 38 non-pregnant women with a history of CSP treated with combined local and systemic methotrexate was investigated prospectively by SCSH. For the purpose of analysis, they were classified, according to the modified Delphi consensus criteria for CSP in early gestation, into three subgroups based on the depth of the gestational sac herniation in the midsagittal plane. Subgroup A included eight (21.1%) cases, in which the largest part of the gestational sac protruded towards the uterine cavity; Subgroup B included 20 (52.6%) cases, in which the largest part of the gestational sac was embedded in the myometrium; and Subgroup C included 10 (26.3%) cases, in which the gestational sac was located partially outside the outer contour of the cervix or uterus. RESULTS: SCSH revealed that all women in Subgroup C had a uterine niche. The median niche length (P = 0.006) and depth (P = 0.015) were significantly greater in Subgroup C than in Subgroups A or B. The median residual myometrial thickness (RMT) was significantly lower in Subgroup C than in Subgroups A or B (P = 0.006). CONCLUSIONS: Women with prior CSP who had a gestational sac protruding beyond the serosal line had a significantly greater niche length and depth, and lower RMT. This knowledge may guide individualized risk counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Adverse outcome following selective termination of presenting twin vs non-presenting twin.

OBJECTIVE: Data are lacking on the impact on pregnancy outcome of the position of the abnormal fetus in a discordant twin pregnancy undergoing selective termination (ST). Tissue maceration post ST of the presenting twin may lead to early rupture of membranes, amnionitis and preterm labor. The aim of this study was to evaluate pregnancy complications and outcome following ST of the presenting vs non-presenting twin. METHODS: This was a multicenter retrospective cohort study of dichorionic diamniotic twin pregnancies that underwent ST due to a discordant fetal anomaly (structural or genetic) between 2007 and 2021. The study population was divided into two groups according to the position of the reduced twin (presenting or non-presenting) and outcomes were studied accordingly. The primary outcome was a composite of early complications following ST, including infection, preterm prelabor rupture of membranes and pregnancy loss. RESULTS: A total of 190 dichorionic twin pregnancies were included, of which 73 underwent ST of the presenting twin and 117 of the non-presenting twin. The groups did not differ in either baseline demographic characteristics or mean gestational age at the time of the procedure. ST of the presenting twin resulted in a significantly higher rate of early complications compared with the non-presenting twin (19.2% vs 7.7%; P = 0.018). Moreover, the rates of preterm delivery (75.3% vs 37.6%; P < 0.001) and neonatal intensive care unit admission (45.3% vs 17.1%; P < 0.001) were higher, and birth weight was lower (P < 0.001), in those pregnancies in which the presenting twin was reduced. CONCLUSIONS: ST of the presenting twin resulted in a higher rate of adverse pregnancy outcome compared with that of the non-presenting twin. These findings should be acknowledged during patient counseling and, if legislation permits, taken into consideration when planning ST. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Obstetric outcomes of twin pregnancies presenting with a complete hydatidiform mole and coexistent normal fetus: a systematic review and meta-analysis.

BACKGROUND: Epidemiological data on obstetric and oncologic complications in twin pregnancies combining a complete hydatidiform mole (CHM) coexisting with a normal fetus and placenta are limited. OBJECTIVES: To evaluate perinatal and obstetric outcomes for mother and fetus and risk of gestational trophoblastic neoplasia (GTN) in twin pregnancies including a CHM. SEARCH STRATEGY: PubMed, MEDLINE and EMBASE and the grey literature were searched for articles published between May 1980 and May 2019 using a protocol designed a priori and registered on PROSPERO (CRD42018112524). SELECTION CRITERIA: Observational cohort studies of four or more cases confirmed by histopathology and providing data on pregnancy outcomes and GTN. DATA COLLECTION AND ANALYSIS: Two reviewers independently reviewed abstracts and full-text articles. The quality of the studies was assessed with the Newcastle-Ottawa scale and a meta-analysis was performed. MAIN RESULTS: Of the 344 abstracts identified, 14 studies (244 cases) met the eligibility criteria. The incidence of maternal complication in ongoing pregnancies was 80.8% and included vaginal bleeding, hyperthyroidism and pre-eclampsia. There were overall 91 (50%) live births in ongoing pregnancies and 83 (34%) of the total cases were subsequently diagnosed with GTN. Substantial and significant (P < 0.001) heterogeneity was found for the incidence of preeclampsia indicating variability in reporting the incidence of some obstetric complications between studies. CONCLUSIONS: Patients diagnosed with a twin pregnancy combining a CHM and an apparently normal fetus have a high risk of perinatal complications, low live-birth rates and around a third of them will develop a GTN and should be managed by specialised multidisciplinary teams. TWEETABLE ABSTRACT: Our study indicates a high rate of obstetric and oncologic complications in patients presenting with a complete hydatidiform mole and coexistent normal fetus.

Bedside risk estimation of morbidly adherent placenta using simple calculator.

PURPOSE: To construct a calculator for 'bedside' estimation of morbidly adherent placenta (MAP) risk based on ultrasound (US) findings. MATERIALS AND METHODS: This retrospective study included all pregnant women with at least one previous cesarean delivery attending in our US unit between December 2013 and January 2017. The examination was based on a scoring system which determines the probability for MAP. RESULTS: The study population included 471 pregnant women, and 41 of whom (8.7%) were diagnosed with MAP. Based on ROC curve, the most effective US criteria for detection of MAP were the presence of the placental lacunae, obliteration of the utero-placental demarcation, and placenta previa. On the multivariate logistic regression analysis, US findings of placental lacunae (OR = 3.5; 95% CI, 1.2-9.5; P = 0.01), obliteration of the utero-placental demarcation (OR = 12.4; 95% CI, 3.7-41.6; P < 0.0001), and placenta previa (OR = 10.5; 95% CI, 3.5-31.3; P < 0.0001) were associated with MAP. By combining these three parameters, the receiver operating characteristic curve was calculated, yielding an area under the curve of 0.93 (95% CI, 0.87-0.97). Accordingly, we have constructed a simple calculator for 'bedside' estimation of MAP risk. The calculator is mounted on the hospital's internet website ( http://www.assafh.org/Pages/PPCalc/index.html ). The risk estimation of MAP varies between 1.5 and 87%. CONCLUSIONS: The present calculator enables a simple 'bedside' MAP estimation, facilitating accurate and adequate antenatal risk assessment.

Prediction of morbidly adherent placenta using a scoring system.

OBJECTIVE: To evaluate the accuracy of an ultrasound-based scoring system for diagnosing morbidly adherent placenta (MAP). METHODS: This study included pregnant women referred to our ultrasound unit during 2013-2015 because of suspected MAP on a previous ultrasound examination or because they had at least one previous Cesarean delivery. All women were assessed using a scoring system based on the following: number and size of placental lacunae; obliteration of the demarcation between the uterus and placenta; placental location; color Doppler signals within placental lacunae; hypervascularity of the placenta-bladder and/or uteroplacental interface zone; and number of previous Cesarean deliveries. Each criterion was assigned 0, 1 or 2 points and the sum of points yielded the final score. Patients were classified into low, moderate or high probability for MAP based on the final score. The presence of MAP was determined by the surgeon at delivery and clinical descriptions were documented in the electronic patient file. Pathological diagnoses were available only in cases that underwent hysterectomy. RESULTS: In total, 258 pregnant women were included in the study, of whom 23 (8.9%) were diagnosed with MAP. There was a statistically significant difference in the prevalence of MAP when women were grouped according to the scoring system, with 0.9%, 29.4% and 84.2% in the low, moderate and high probability groups, respectively (P < 0.0001). All sonographic criteria of the scoring system were significantly associated with MAP (P < 0.0001). Receiver-operating characteristics (ROC) curves for prediction of MAP using the number of placental lacunae and obliteration of the uteroplacental demarcation yielded an area under the ROC curve of 0.94 (95% CI, 0.86-1.00). CONCLUSIONS: Our proposed scoring system is highly predictive of MAP in patients at risk. This allows an adequate multidisciplinary team approach for the planning and timing of delivery in such cases. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Fetal diagnosis of testicular torsion: what shall we tell the parents?

OBJECTIVES: The objectives of this study are to present our collective experience with the prenatal diagnosis of testicular torsion and to propose a possible prenatal management scheme. METHODS: We retrospectively collected and reviewed all medical records of cases that were diagnosed with perinatal testicular torsion in our medical center between the years 2002 and 2013. Prenatal torsion was categorized as torsion diagnosed in utero or on immediate newborn examination. RESULTS: A total of five unilateral prenatal torsions were diagnosed. Two fetuses were diagnosed in the third trimester of pregnancy. In both cases, cesarean section was performed immediately upon diagnosis. One newborn underwent immediate orchiectomy with contralateral orchiopexy. Torsion was confirmed by pathological examination. The other was managed conservatively, just as the three newborns who were diagnosed immediately after birth. On follow-up scan, the affected testicle was found atrophied with lack of blood flow on color Doppler examination. The unaffected contralateral testicle remained within the normal size with good blood flow. CONCLUSIONS: Prenatal diagnosis of unilateral testicular torsion is a coincidental rare finding. Because the twisted testicle cannot be salvaged, induced delivery and prompt surgery are not recommended.

[Prenatal diagnosis of trisomy 13 and trisomy 18: the experience of Assaf-Harofe Medical Center].

INTRODUCTION: Trisomy 18 and 13 are the most common autosomal trisomies, after trisomy 21, and their frequency is rising due to the increased maternal age of pregnant women. The fetuses suffer from multi-organ damage that may lead to many gestational complications as well as short life expectancy. OBJECTIVE: To assess the indications for prenatal karyotyping of trisomy 13 (T-13, Patau syndrome) and trisomy 18 (T-18, Edwards syndrome) during pregnancy in our medical center. METHODS: This retrospective cohort study involved all singleton pregnancies locally diagnosed or referred to our Institute because of T-13 and T-18, during the years 1998-2011. RESULTS: There were 1879 cases of termination of pregnancies (TOPs) because of fetal indications, of them 53 cases of T-18 and 10 cases of T-13. The main indications for prenatal karyotyping in our study group were abnormal sonographic findings during anomaLy scans. In addition, 7 newborns with T-18 and 3 infants with T-13 were born in our hospital during the same period of time. We examined all cases that led to the Live birth of newborns with chromosomal anomalies, stemming from the Lack of extraction of the tests mentioned above and/or ignoring findings that raise suspicion that requires performing prenatal karyotyping during pregnancy. DISCUSSION: Our findings corresponded with other studies and showed that prenatal diagnosis of T-13/T-18 due to abnormal sonographic finding is rising. CONCLUSIONS: Our study shows that it was possible to identify the vast majority of T-13/T-18 among the pregnant women who had an increased risk based on a combination of the routine screening tests applied in Israel.

Nuchal translucency in twins according to mode of assisted conception and chorionicity.

OBJECTIVES: The impact of nuchal translucency (NT) screening in twins conceived after use of assisted reproduction technology (ART) has not been addressed properly in the literature. The aim of the current study was to assess, in a large cohort from a single center, NT in twins following various modes of ART as compared with NT in spontaneously-conceived twins and to differentiate results with regard to chorionicity. METHODS: Retrospective data from 825 twin pregnancies were available for this study. All pregnant women underwent NT screening and chorionicity determination between 11 + 0 and 13 + 6 weeks' gestation in our center. Information about mode of conception and pregnancy outcome was obtained from hospital records and by telephone interviews. Twins were classified as having been conceived after in-vitro fertilization (IVF) with the woman's own or a donated embryo, after non-IVF ART or spontaneously. NT distribution in subgroups of fetuses was compared on the basis of the multiple of the normal median (MoM), SD of log10 MoM estimated by the 90(th) -10(th) centile range divided by 2.563 and the proportion of NT values exceeding the normal 95(th) centile which was 1.641 MoM in the singletons. RESULTS: NT values were statistically significantly higher in ART pregnancies as compared with spontaneously-conceived pregnancies (Wilcoxon rank-sum test, P < 0.05) with medians of 1.073 and 1.038 MoM, respectively, but the proportion with values above the normal 95(th) percentile did not differ (chi-square test, P = 0.89). Among the ART twins, NT values were significantly higher for those conceived using IVF methods (P < 0.005), with a median of 1.082 MoM, compared with a median of 1.022 MoM using other methods. However, although a greater proportion exceeded the 95(th) centile (7.3% compared with 4.8%) this difference did not reach statistical significance (P = 0.17). There were no differences in NT values according to chorionicity (Wilcoxon rank-sum test, P = 0.75). The standard deviation of log10 NT was similar for all subgroups of twins. The correlation coefficient between fetuses in ART pregnancies was statistically significantly lower than that in spontaneously-conceived pregnancies (P < 0.05) but no significant differences were found between types of ART or according to chorionicity. CONCLUSIONS: There was a small but significant increase in NT levels among ART pregnancies, which appeared to be confined to those conceived using IVF, and a small reduction in the correlation between fetuses. These effects probably have little impact on the estimated risk based on algorithms in use today.

Long-term outcomes of children with umbilical vein varix diagnosed prenatally.

OBJECTIVES: The current study aims were to assess the long-term outcomes of children who were diagnosed with umbilical vein varix (UVV) prenatally. METHODS: The study included fetuses with UVV diagnosed in the community between the years 2005 and 2011. They all have been refereed to our Ultrasound Unit for diagnosis' confirmation. This has been conducted locally by a single operator. After delivery, they were matched by gestational age at birth with a set of newborns from a random list. Developmental delay was assessed by telephone interview using a questionnaire based on Ages and Stages Questionnaire. If the child's score (both in the study and control group) was below the cut-off in one or more domain(s), the families were offered an examination by a child developmental health care team. RESULTS: There was no perinatal mortality in both groups. A low-development score was found in 41.7% (15/36) and 3.7% (4/108) in UVV and control group, respectively (P < 0.05). In 10 out of 15 (67%) children in the UVV group with low scores, formal developmental assessment was performed. Four (40%) were diagnosed having developmental delay. Among the four controls with low score, two families refused additional assessment and one child died. The remaining child was found to have normal development. CONCLUSIONS: A possible association between UVV diagnosed prenatally and child developmental delay was found. However, the clinical implications of these findings are still premature; thus, additional studies are needed.