The postpartum uterine ultrasonographic scale in assessment of uterine involution after cesarean section in treated thrombophilia pregnant patients at term.

BACKGROUND: Pregnancy is a prothrombotic condition which can be abnormally exaggerated in women with thrombophilia. METHODS: In a prospective study, patients who delivered at term, by cesarean section, between 1 October 2017 and 1 December 2021, who already had a diagnosis of thrombophilia before coming to our hospital, were included in the study group (n = 80). A similar number of nonthrombophilia patients (n = 80) without any history of thrombotic events, age- and para-matched with the study group, were included in the control group. The postpartum uterine ultrasonographic scale (PUUS) values, in the first 24-48 h, were correlated with the patients' data. RESULTS: The P-LCR (platelet large cell ratio), was significantly higher in the treated thrombophilia group (p = 0.042). There was no correlation between PUUS and complete blood count values, coagulation factors, maternal characteristics, or fetal outcomes, except for postpartum neutrophils (p = 0.047) and postpartum platelet count (p = 0.046). CONCLUSIONS: Postpartum uterine involution was not significantly different, after cesarean section, between treated thrombophilia patients and nonthrombophilia patients. Involution correlated only with postpartum neutrophils and postpartum platelet count.

Risk management of vaginal birth after cesarean section (Review).

The increasing number of patients who desire to experience vaginal birth after cesarean (VBAC) and the optimized protocols for trial of labor after cesarean (TOLAC) has led to a shift of old obstetrical paradigms. The VBAC trend is accompanied with numerous challenges for healthcare professionals, from establishing suitability of each pregnant patient profile for TOLAC to active labor management, and ethical or legal issues, which occasionally are not included in specific guidelines. That is why an individualized risk assessment and management can serve obstetricians as a useful tool for improving outcomes of patients, satisfaction, and also for avoiding legal or moral liabilities. The risk management concept aims to reduce foreseen risks and to emulate strategies for prediction and prevention of unwanted events. In obstetrics, and particularly for the VBAC topic, this concept is relatively new and undefined, and thus its features are disparate between guideline recommendations and clinical studies. This narrative review intends to offer a new and organic perspective over clinical aspects of TOLAC and VBAC risk management.

Professional ethics, VBAC and COVID-19 pandemic: A challenge to be resolved (Review).

Since the declaration of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic by the World Health Organization (WHO) on March 11, 2020, the entire healthcare system is trying to adapt its capabilities to a challenge that induces a deep and continuous metamorphosis of people, strategies and policies. The right to proper health care is universal, and the patient's autonomy must be respected even in ambiguous times. In the context of increased Cesarean section (CS) rates, the women's desire to achieve vaginal birth after Cesarean section (VBAC) is becoming more articulate, and healthcare professionals need to adapt their approaches regarding the mode of delivery. But how to balance this aspect with respect to the paucity of resources during the pandemic, without infringing the fundamental rights and ethical principles is a demanding question. This article describes a clinical ethical decision-making framework for recommending trial of labor after Cesarean section (TOLAC), and individualized management of VBAC cases tailored upon the new circumstances dictated by the SARS-CoV-2 pandemic.

Vaginal birth after Cesarean experience in Romania: A retrospective case-series study and online survey.

The high Romanian Cesarean delivery rates have led to an increase in a women's desire to achieve vaginal birth after Cesarean delivery (VBAC), but certain impediments make this process difficult. We retrospectively evaluated the VBAC cases in a tertiary maternity hospital from Romania, and assessed the Romanian women's opinion about VBAC using a questionnaire that was distributed to three specific Facebook groups. We evaluated 63 patients who achieved VBAC between January 2014 and August 2020. In addition, an online survey with 41 open and closed questions assessed the participants' opinion regarding VBAC in Romania. The results are summarized and discussed. The results revealed that VBAC rates were under 1%. The main observed complications that followed VBAC were postpartum hemorrhage (15.8%), and uterine atony (7.93%), while the most frequent types of lesions encountered after VBAC were cervical tear (12.6%), followed by labial fissure (9.5%) and vaginal tear (7.9%). The patient's confidence in the health care system is low, and many women decide to try TOLAC at home. In conclusion, VBAC is an important topic in the context of high Romanian Cesarean rates, and the decision factors must provide consistent strategies that promote this mode of delivery.

Anosmia and ageusia associated with coronavirus infection (COVID-19) - what is known?

In 2020 a new pandemic caused by the SARS-CoV-2 coronavirus is affecting the lives of millions of patients and healthcare workers worldwide. The clinical picture of this infection is in a dynamic process of discovery, and more symptoms emerge as the clinicians observe and diagnose manifestations that affect multiple organs. Anosmia (loss of smell), and ageusia (loss of taste) become more frequently cited as independent symptoms or in association with the most common manifestations of the disease, such as fever, cough and dyspnea. A thorough screening program will prevent most nosocomial and community-acquired infections by promoting efficient triage and specific measures such as isolation of the patients. Therefore, it is important to include frequent symptoms in the anamnesis and questionnaires to select those patients who might benefit from testing, isolation, and treatment. This study summarizes the existing data regarding the association of anosmia and ageusia with the SARS-CoV-2 infection. It also aims to describe manifestations of these, particularly in the clinical picture of all symptomatic patients.

Conservative in utero treatment of fetal dyshormonogenetic goiter with levothyroxine, a systematic literature review.

Fetal goitrous hypothyroidism is a rare condition associated with important obstetrical, neonatal complications, and neurodevelopmental impairments. Prenatal treatment remains controversial, and the risk to benefit ratio must be accurately assessed and considered for individualized management. The objective of this review was to evaluate the feasibility, safety, and effectiveness of the conservative in utero treatment of fetal goitrous hypothyroidism. In total, 25 reports that met our inclusion criteria were selected and the management of 38 cases was analyzed. Prenatal diagnosis consisted mainly of ultrasonographic findings. Fetal thyroid status was assessed by cordocentesis. Prenatal treatment varied widely in terms of levothyroxine (LT4) route of administration, dosage, number of injections, and frequency. Although different regimens and routes of administration were proposed, they seem to have similar results regarding fetal goiter reduction and thyroid status at birth. At birth, most babies had hypothyroidism, but the long-term follow-up indicated a normal psycho-neuromotor development. Our data confirm the feasibility of conservative treatment with LT4 for fetal goitrous hypothyroidism. Further studies are needed to determine the optimal management of this disorder.

Anatomical and functional changes in arteries of uterine circulation after modified laparoscopic transabdominal cerclage in pregnancy: A case report and review of the literature.

Modified laparoscopic transabdominal cerclage (LTAC) was developed as a safer approach for the treatment of cervical insufficiency in pregnancy, with the cerclage tape placed lateral to the uterine vessels. We describe and review the evolution of a woman who successfully underwent an LTAC at 12 weeks of gestation, whose fetus developed growth retardation after 32 weeks. Three-dimensional power Doppler reconstruction viewed both uterine arteries (UtAs) inside of the cerclage until the second trimester. Thereafter, the visualization of UtAs showed the development of a rich array of collateral vascularization, adaptation supported by the findings of low velocity and pulsatility of blood flow in the UtAs. The appearance of the UtAs varies throughout the gestation. There is a moderate variation of the shape and curvature that could result due to their elongation. Furthermore, the cervical length increased during gestation, from 20 to 30 mm. We speculate that this is a mechanical modeling during the late gestation. More studies are needed to understand the hemodynamic and mechanical effects as well as the impact on fetal growth and development of modified LTAC in women with a short cervix or cervical incompetence.

Reference ranges for the fetal mesencephalon to occiput measurement at 11 to 13+6 weeks of gestation.

The objective was to have a quantitative description of the normal position of the fetal midbrain in the first trimester, through defining the reference ranges for the mesencephalon to the occipital bone distance, in the axial plane. This was a prospective study that included normal fetuses screened between 11 and 13 weeks of gestation. The distance was measured between the posterior limit of the mesencephalon to the occipital bone in the same axial view as the one required for the biparietal diameter (BPD) assessment, at this gestational age (GA). The reference ranges using quantile regression, according to the crown-rump length (CRL), BPD, and GA were fitted. Data analysis included 428 ultrasound measurements. A good, linear correlation was observed between mesencephalon to occiput (MO) distance and CRL, BPD, or GA. It increased linearly with advancing gestation (log10MO = -0.1834 + 0.0092 x CRL, R2=0.48, P<0.0001) and was independent of maternal demographic characteristics and intracranial translucency (IT). In our study, the 1st percentile of the normal MO distance varies from 1.31 mm at a CRL of 45 mm to 2.08 mm at a CRL of 84 mm. The intraclass correlation coefficient (ICC) was 0.89 for intraobserver variability. A significant increase in the MO distance was found in the patients who did not receive folic acid in the first trimester of pregnancy [1.056 vs. 1.008 multiple of median (MoM), P=0.014]. A simple measurement is described between the midbrain and the occipital bone, obtained in the same axial view. It increases linearly with advancing gestation. Integration of this measurement into the routine ultrasound screening in association with the 'crash sign' and recognizing the lower extreme values could lead to an early diagnosis of open spina bifida (OSB).