Fetal Sacrococcygeal Teratoma: A Case Report of a Giant Tumor withan Excellent Outcome.

Sacrococcygeal teratoma (SCT) occurs in approximately 1 per 20,000-40,000 births and is the most frequently encountered fetal teratoma, with 75% of cases observed in female fetuses. SCT can be detected on ultrasound as early as the first trimester, presenting as a large mass originating from the sacrococcygeal area, with or without an intrapelvic component. The prenatal course for most fetuses with SCT is generally uneventful, with only a few cases experiencing obstetric and fetal complications. We present the case of a 19-year-old woman who was in good health and had no relevant family or medical history. She was gravida 2 and para 1. During the first trimester scan, an examination revealed a heterogeneous mass in the presacral area with a predominantly multicystic appearance, measuring 12 mm in diameter. At 21+6 weeks of gestation, the Type 2 fetal SCT showed an increase in volume with the size of 49×37×36 mm and contiune to increase in size. The male fetus was delivered by elective Cesarean section at 38 weeks of gestation. The resection of the tumor and coccyx was performed when the newborn was 7 days old. The tumor measured 190×160×100 mm and weighed 1100 g. Pathological examination confirmed the diagnosis of a mature teratoma (Grade 0), and the resection margins were negative. Our case report highlights a fetus with a large and rapidly growing SCT, yet the outcome was excellent.

Does a Caesarean Section Scar Affect Placental Volume, Vascularity and Localization?

Caesarean section is associated with an increased risk of abnormal placental implantation and adverse pregnancy outcomes in subsequent pregnancies. Besides the placenta accrete spectrum, only a few of the previous studies focused on other placental development alterations in the scarred uterus. We assessed placental development deviations in the uterus with a Caesarean section scar by evaluating placental volume (PV) and vascular flow indexes. From 1 January 2021 until 31 March 2022, placental volumes and vascularization indexes (VI, FI, VFI) were prospectively measured by 3D power Doppler and VOCAL techniques in 221 patients attending the first trimester screening program. We also calculated the placental quotient to standardize PV to the gestational age. No statistically significant differences in the values of placental volume, placental quotient and placental vascularization indexes were detected between women with previous Caesarean section delivery or women with vaginal delivery. FI was significantly lower in nulliparous in the first trimester. The results of our study suggest that 3D placental evaluation was not able to detect placental development alteration in the uterus with a Caesarean section scar. Future research needs to verify whether 3D power Doppler and Vocal techniques can provide more information if used in an earlier gestational age.

Large Angiomyxoma of the Umbilical Cord-Uncomplicated Rupture of Tumor Membranes at 32 Weeks of Gestation.

BACKGROUND: When a tumor of the umbilical cord is prenatally visualized, it is possible to propose the diagnosis depending on the sonographic appearance of the tumor. Angiomyxoma of the umbilical cord appears as a complex solid-cystic mass that is made of angiomatous component and myxoid stroma. When the tumor is diagnosed, serial ultrasound and doppler examinations are used to monitor the tumor's size and the overall fetal well-being including doppler investigations and fetal growth. Angiomyxomas are not associated with fetal chromosomal pathologies. The cases of intrauterine rupture and fetal death was described in the literature. CASE PRESENTATION: A 28 years-old pregnant woman was referred to our clinic for second opinion because of visualized umbilical cord tumor during second trimester ultrasound screening. The tumor gradually increased in size until 34th week of gestation, when the rupture of the cystic component was observed. The fetal doppler studies was normal during the course of pregnancy, we observed decreased AC and decreased estimated fetal weight. At the gestational age of the 37 weeks the labor was induced and heathy male infant was born. CONCLUSIONS: For the first time to our knowledge, we demonstrate the case of uncomplicated rupture of the cystic component of the angiomyxoma that lead to the possibility to manage the pregnancy conservatively without any compromise of the fetus.

Literature Review of Cervical Regeneration after Loop Electrosurgical Excision Procedure, and Study Project (CeVaLEP) Proposal.

OBJECTIVE: To compile existing knowledge on the level of cervical regeneration (detected by ultrasound) after loop electrosurgical excision procedure (LEEP) and to suggest research protocol for further studies. METHODS: We conducted a literature search of Medline, Web of Science, Scopus, and Cochrane databases using the keywords "cervix" and "regeneration" without year restrictions. Our eligibility criteria included studies that analysed cervical volume and length regeneration using ultrasound. A literature review was conducted following PRISMA guidelines and registered in PROSPERO (reg. no. CRD42021264062). Information about the studies was extracted from each analysed study on an Excel datasheet and the average regeneration with standard deviation was calculated. All included studies' possible biases were assessed by the National Institutes of Health's (NIH) quality assessment tool. RESULTS: The literature search identified 802 papers and four trials (n = 309) that met our criteria. They investigated cervical length and volume regeneration after LEEP using ultrasound, concluding that there is a profound regeneration deficit. Average cervical length regeneration after 6 months was 83.4% (±10.8%) and volume regeneration was 87.4% (±6.1%). All analysed studies had their biases; therefore, based on the conducted studies' protocols, we present a CeVaLEP research protocol to guide high-quality studies. CONCLUSION: After LEEP, there is a cervical regeneration deficit. There is a lack of high-quality studies that assess cervical volume regeneration and its relation to obstetrical outcomes. There is a gap in the field and more research is needed to define the prenatal risks related to cervical regeneration.

Ultrasound Simulation for Training Trainees when the Luxury Becomes Essential: Opinion and Evidence Obtained during the Latvian Research Council Project Implementation.

Background: Simulation as a proxy tool for conditional clinical training became a powerful technique for introducing trainees to the ultrasound imaging world, allowing them to become a trained sonographer taking into consideration different rates of progress in completing a specific task against the time and ensuring the long-lasting maintenance of the obtained practical skills. Adding a costly, but effective high-fidelity simulator to the residency program justified the expense, demonstrating efficiency of training for improving the clinical performance and confidence of trainees. Materials and methods: A pilot study in Riga Maternity Hospital within the framework of the study "Role of metabolome, biomarkers and ultrasound parameters in successful labor induction" (Fundamental and Applied Research Programme lzp-2021/1-0300) was performed between March 1st 2022 and 31st April 2022. A virtual-reality simulator (ScanTrainer, MedaphorTM, Cardiff, UK) was used with the teaching module for assessment of the uterine cervix. Five trainees in obstetrics and two young specialists included in the study. None of them had Fetal Medicine Foundation certificate of competence in the assessment of the uterine cervical lenght before. The time used on the simulator, the number of simulations and a mean confidence in cervical length assessment before and after simulation were recorded. Results: The study on assesment of uterine cervical lenght demonstrated statistically significant increase in confidence (p=0.008) and statistically significant decrease in time needed to complete correctly the same tasks for the trainees (p=0.008) that shows a positive learning curve over the time of training on ScanTrainer, Medaphor. Conclusions: The simple task allows to become a certified specialist in uterine cervical assessment in the short period of time. That support the productiveness of the simulation-based education. The training program should be updated taking into consideration simulation curriculum.

The outcomes after transfers of embryos with chromosomal mosaicism: a single reproductive medicine center experience at iVF Riga clinic.

Aim: The aim of this study is to summarize the outcomes of transfers of mosaic embryos, which were classified according to guidelines and in strong collaboration of reproductologists, clinical geneticists and patients approved as suitable for transfer. Material and Methods: Retrospective data were collected from 70 patients from a private IVF center to whom embryos with mosaic changes in chromosomal material were transferred from 2015 to 2019. Results and Conclusion: Implantation outcomes and continuing pregnancies showed slight differences, when compared to fully normal embryos. Artifacts have to be differentiated from undeniable aberrations, and correct interpretation of results must be done with following patient counselling and prenatal testing if necessary.

The Correlation Between Abnormal Uterine Artery Flow in the First Trimester and Genetic Thrombophilic Alteration: A Prospective Case-Controlled Pilot Study.

INTRODUCTION: Evaluation of the first trimester uterine artery flow can predict the development of obstetrical complications. A genotype, making women prone to microthrombi. constitutes the main known susceptibility factor for anomalous development of placenta. Our aim was to study whether polymorphisms of 10 genes leading to blood clotting abnormalities are related to abnormal uterine artery blood flow in the first trimester, and may predict placenta-related diseases. MATERIAL AND METHODS: In primary analyses we included 19 singleton pregnancies with abnormal blood flow in the uterine arteries during the first trimester of gestation, and 24 matched control with normal flow patterns. All patients were genotyped for sequence variations in F5, F2, F11, MTHFR, SERPINE-1, CYP4V2, SELE, GP6, angiotensinogen (AGT) and fibrinogen gamma (FGG) genes and followed up until delivery. RESULTS: There were no differences between groups regarding selected sequence variations in any of these genes. The co-occurrence of several polymorphisms in the same patient was also not related to the blood flow patterns in the uterine arteries. CONCLUSIONS: Although we found certain trends of genetic polymorphisms being related to preeclampsia and fetal growth, we failed to find an association between clotting gene polymorphisms, single or in combination, with the abnormal uterine flow in the first trimester.

Case of Inherited Partial AZFa Deletion without Impact on Male Fertility.

Male factor infertility accounts for 40-50% of all infertility cases. Deletions of one or more AZF region parts in chromosome Y are one of the most common genetic causes of male infertility. Usually full or partial AZF deletions, including genes involved in spermatogenesis, are associated with spermatogenic failure. Here we report a case of a Caucasian man with partial AZFa region deletion from a couple with secondary infertility. Partial AZFa deletion, involving part of USP9Y gene appears to be benign, as we proved transmission from father to son. According to our results, it is recommended to revise guidelines on markers selected for testing of AZFa region deletion, to be more selective against DDX3Y gene and exclude probably benign microdeletions involving only USP9Y gene.

The application of PGT-A for carriers of balanced structural chromosomal rearrangements.

The aim of this study was to analyze differences in chromosomal aberrations and euploidy in embryos of each translocation type and gender of carrier in the case series of 10 couples with balanced translocations who underwent IVF with embryos trophectoderm (TE) biopsy and PGT-A to detect chromosomal aberrations. This is a Case Series (Retrospective study). In each case, controlled ovarian hyperstimulation, oocyte insemination with intracytoplasmic sperm injection (ICSI) and cultivation gave multiple blastocysts, that underwent trophectoderm (TE) biopsy with PGT-A analysis using aCGH and NGS. Number of total unbalanced translocations compared to the number of sporadic aneuploid embryos was 39.6% to 39.6% (50% to 50% of all 37 aneuploid embryos). The highest euploidy rate was in male carrier group - 26.7% and the lowest in the Robertsonian translocation carrier group - 18.2%. Sporadic aneuploidy - 68.2% was highest in Robertsonian translocation carrier group and lowest in female group - 11.1%. Chromosomal aberrations related to translocation were highest in female carrier group - 77.8% and lowest in Robertsonian translocation carrier group - 13.6%. Our study showed that expectancy of total embryo aneuploidy rates will be higher in carriers, than in people with normal karyotype. The prevalence of chromosomal aberrations related to translocation was 4.5 times higher in Reciprocal carrier group than in Robertsonian translocation carrier group. Among maternal and paternal carrier groups, the embryos from female carriers had the lowest euploidy rate, unbalanced translocation rate 4.7 times higher than in the male carrier group and higher total aneuploidy rates.

Latvian experience in conservative management of abnormally invasive placenta: two case reports.

BACKGROUND: Abnormally invasive placentation (AIP) is a clinical term that describes situation when placenta does not separate spontaneously after delivery and its manual removal causes excessive bleeding (1). Historically, the treatment of choice for this condition is hysterectomy. Lately, the new treatment option, conservative management of the AIP, has proven itself an effective alternative to hysterectomy in carefully selected patients (2). However, the use of conservative AIP management is limited in many countries, the reasoning being the lack of doctors' experience in this procedure and concerns regarding a high postpartum infection rate. CASE REPORTS: We present the first two cases of conservative management of AIP in Latvia.Most of prenatally diagnosed AIP cases country-wide are referred to the Paul Stradins University Hospital, which is a tertiary referral hospital. The annual rate of AIP in the hospital varies from five to ten cases.Two pregnant women were diagnosed with AIP prenatally, both of them refused hysterectomy and therefore went for the conservative management of AIP. During Caesarean section operation, placentas were left in situ after delivery of the baby. During the follow-up period of 12 and 14 weeks, both women developed infection complications, but complete placental tissue resolution was diagnosed in the end. CONCLUSION: These two cases demonstrate that conservative management of AIP can be safely applied in small countries/areas with small AIP rate and management experience.

Impact of vaginal ascorbic acid on abnormal vaginal microflora.

PURPOSE: To evaluate the impact of vaginal ascorbic acid (vitamin C) as a treatment/maintenance regimen on increased vaginal pH and abnormal microflora on wet mounts in premenopausal women. METHODS: A randomized study of 140 asymptomatic, low-risk pregnant and non-pregnant premenopausal women with vaginal pH ≥ 4.5 and a variety of partly/completely disrupted Lactobacillus microflora patterns on wet mounts in five outpatient clinics was carried out. Participants were randomized to the intervention group [250 mg vitamin C tablets vaginally at bedtime once a day for 6 days (treatment phase), followed by a one tablet per week, for 12 weeks (maintenance phase)] or the control group (no treatment). Outcomes were evaluated 4 months after randomizing, i.e., 2-3 weeks after the last vitamin C tablet insertion. RESULTS: Normalization to normal flora was observed in 51.4 % of all ascorbic acid and in 24.3 % of control group patients (difference 27.1 %, 95 % CI 11.7-42.6, p < 0.05, ITT population). In the per protocol population, normalization was confirmed in 53.5 % of the intervention and 22.4 % of the control group (difference 31 %, 95 % CI 14.3-47.8, p < 0.05). Results of pregnant subgroup analysis showed better outcomes for the subgroup: difference of normalization rate between ascorbic acid and control group was 41.2 % (95 % CI 21.8-60.1, p < 0.05). Itching occurred in 19 %; 23 % of women reported irritation and 10 % stopped the treatment because of side effects. CONCLUSIONS: Vaginal ascorbic acid improves abnormal vaginal pH and microflora, especially in pregnant women, but is not well tolerated by all women.

Adaptive changes in the splenic artery and left portal vein in fetal growth restriction.

OBJECTIVES: The purpose of this study was to determine whether a low splenic artery pulsatility index (PI) and reduced flow through the left portal vein are involved in redistribution of fetal growth restriction. METHODS: Forty-two women with prenatally diagnosed intrauterine growth restriction of singleton fetuses were included. The next pregnant woman with an appropriately growing fetus, matched for gestational age, was selected as a control. Blood flow velocities were measured in the splenic artery and left portal vein. Obstetric and perinatal information was obtained from standardized medical records. RESULTS: The blood flow through the left portal vein was significantly reduced compared with the controls (P < .0001). Placental impairment in fetal growth restriction was clearly linked to a decreased splenic artery PI (P = .0004). In growth-restricted fetuses with reduced left portal vein flow and a splenic artery PI below the 5th percentile, perinatal mortality, a low 5-minute Apgar score, and neonatal metabolic acidosis were observed significantly more often (P = .04, .01, and .004; P = .03, .03, and .006, respectively). CONCLUSIONS: Reduced blood flow through the left portal vein and low resistance in the splenic artery can be found in growth-restricted fetuses with adverse neonatal outcomes.

Factors related to elevated vaginal pH in the first trimester of pregnancy.

OBJECTIVE: To assess different bacterial and epidemiological factors associations with increased vaginal pH in the pregnant women population during the first trimester. DESIGN: A cross-sectional, observational study. SETTING: Three outpatient clinics in Riga. POPULATION: From July 2009 until January 2010, 139 unselected consecutive pregnant women at the first prenatal visit. METHODS: Pregnant women were submitted to an interview, vaginal examination and vaginal specimen collection for pH measurement and native microscopy. MAIN OUTCOME MEASURES: Vaginal pH ≥4.5 was considered as elevated. Abnormal bacterial microflora was classified according to Donders. RESULTS: Elevated vaginal pH was significantly associated with bacterial vaginosis (p < 0.001), aerobic vaginitis (p < 0.001) and mixed aerobic vaginitis and bacterial vaginosis flora (p < 0.001) and presence of sperm cells in the smears (p= 0.024). Most cases with sperm were associated with abnormal vaginal flora. Normal lactobacillary morphotypes were more often found in the pH ≤4.4 group (p < 0.001), while leptosomic and short types were found more frequently with increased pH. CONCLUSIONS: Elevated vaginal pH is associated with different types of abnormal vaginal flora and the presence of sperm cells.

Microscopic lesions of placenta and Doppler velocimetry related to fetal growth restriction.

PURPOSE: The purpose of the study was to find an association between the uterine and umbilical arteries blood flow patterns in growth-restricted (FGR) and normal fetuses and placental microscopic lesions. METHODS: Fifty women with prenatally suspected and post-delivery confirmed FGR of singleton fetuses were enrolled in a case-controlled follow-up study from May 2007 to December 2008. Unselected patients with appropriately growing fetuses, matched for gestational age, served as controls. Uterine and umbilical Doppler waveforms were recorded before delivery. RESULTS: Compared with control group with normal Doppler, FGR women with abnormal Doppler velocimetry of uterine and umbilical arteries had more intervillous thrombi (p = 0.01 and p < 0.0001, respectively) and villous infarctions (p = 0.02 and p = 0.0003, respectively). Thickening of the basal membrane and villitis was clearly linked to the FGR (p = 0.006 and p = 0.01). Vasculitis, on the other hand, is linked to normal growth, without affecting Doppler velocities. CONCLUSIONS: Abnormal Doppler may predict hemorrhagic and ischemic placental lesions in FGR pregnancies and may lead to future improvement of the management of current and subsequent pregnancies.

Placental pathology in fetal growth restriction.

OBJECTIVES: One of the causes of intrauterine fetal growth restriction (FGR) can be pathology of the placenta. The aim of this study was to compare macroscopic and microscopic changes of the placentas from intrauterine growth restricted fetuses with those from normally developed fetuses, in order to test the hypothesis that vascular damage due to decreased maternal vascular perfusion may be responsible for FGR. STUDY DESIGN: Between May 2007 and December 2008 we performed detailed macroscopic and histological examination of singleton placentas of 50 consecutive neonates with fetal growth restriction (FGR group) and compared them to 50 normal fetuses, born next to an FGR case, as a control group. RESULTS: Gestational age, birth weight, spontaneous delivery rate, mean weight of the placenta and the fetal-placental weight ratio were all lower in the FGR group than in the control group (p<0.05). Thickening of the villous trophoblastic basal membrane, incidence of villous infarction, presence of thrombi or haematomas and the incidence of villitis were more common in the FGR group than in the controls (p<0.05). There were, however, no significant differences in perivillous fibrin deposition, stromal fibrosis and cytotrophoblast proliferation between the groups. In FGR women who smoked, intervillous haematomas and villous infarction were more common (p<0.05) than in controls. CONCLUSIONS: All macroscopic and microscopic pathological changes associated with FGR were directly linked to reduction of placental blood flow. As smoking is a main risk factor for these placental abnormalities these results emphasize the need to persuade women to quit smoking not only during pregnancy, but even better long before pregnancy.

Preventable maternal risk factors and association of genital infection with fetal growth restriction.

INTRODUCTION: Maternal risk factors may interfere with mechanisms regulating fetal growth. The aim of the present study was to determine which sociodemographic and reproductive risk factors may be related to fetal growth restriction (FGR), with a special focus on determinants possible for preventive intervention. MATERIALS AND METHODS: The study period is from May 2007 until December 2009. Data about lifestyle habits were collected by use of a detailed questionnaire in 65 women who attended Riga Maternity Hospital with the confirmed diagnosis of intrauterine FGR of a singleton fetus, and in 65 matched controls with normal pregnancies. RESULTS: Being unmarried (p = 0.04), having pregnancy-related blood pressure rise (p = 0.02), current (p = 0.01) and pre-pregnancy smoking (p = 0.01) and history of more than 3 pregnancy failures (p = 0.04) were more frequent in women with FGR than controls. Surprisingly, the finding of genital infection (STI) during pregnancy (p = 0.006) was also strongly associated with FGR. CONCLUSIONS: Obviously, several maternal risk factors play an important role in FGR. Besides refraining from smoking, screening and treating for STI may not only prevent preterm birth, but also FGR. Identifying such anticipating factors would likely have the potential impact if detected before conception, or as early as possible in gestation.