Unique Severe COVID-19 Placental Signature Independent of Severity of Clinical Maternal Symptoms.

BACKGROUND: Although the risk for transplacental transmission of SARS-CoV-2 is rare, placental infections with adverse functional consequences have been reported. This study aims to analyse histological placental findings in pregnancies complicated by SARS-CoV-2 infection and investigate its correlation with clinical symptoms and perinatal outcomes. We want to determine which pregnancies are at-risk to prevent adverse pregnancy outcomes related to COVID-19 in the future. METHODS: A prospective, longitudinal, multicentre, cohort study. All pregnant women presenting between April 2020 and March 2021 with a nasopharyngeal RT-PCR-confirmed SARS-CoV-2 infection were included. Around delivery, maternal, foetal and placental PCR samples were collected. Placental pathology was correlated with clinical maternal characteristics of COVID-19. RESULTS: Thirty-six patients were included, 33 singleton pregnancies (n = 33, 92%) and three twin pregnancies (n = 3, 8%). Twenty-four (62%) placentas showed at least one abnormality. Four placentas (4/39, 10%) showed placental staining positive for the presence of SARS-CoV-2 accompanied by a unique combination of diffuse, severe inflammatory placental changes with massive perivillous fibrin depositions, necrosis of syncytiotrophoblast, diffuse chronic intervillositis, and a specific, unprecedented CD20+ B-cell infiltration. This SARS-CoV-2 placental signature seems to correlate with foetal distress (75% vs. 15.6%, p = 0.007) but not with the severity of maternal COVID-19 disease. CONCLUSION: We describe a unique placental signature in pregnant patients with COVID-19, which has not been reported in a historical cohort. We show that the foetal environment can be seriously compromised by disruption of placental function due to local, devastating SARS-CoV-2 infection. Maternal clinical symptoms did not predict the severity of the SARS-CoV-2-related placental signature, resulting in a lack of adequate identification of maternal criteria for pregnancies at risk. Close foetal monitoring and pregnancy termination in case of foetal distress can prevent adverse pregnancy outcomes due to COVID-19 related placental disease.

Endometriosis of the Bartholin gland: a case report and review of the literature.

BACKGROUND: In this case report we present a case of endometriosis in the Bartholin gland without surgery in the perineal area. So far, only five cases concerning endometriosis in the Bartholin gland, which may or may not be an isolated finding, have been reported in the literature. CASE PRESENTATION: A 31-year-old Indo-surinamese woman with primary infertility presented at our out-patient clinic with cyclical vulvar pain. On gynecological examination, a cyst of 1 × 2 cm was found in the right gland of Bartholin. A transvaginal ultrasound revealed normal gynecological anatomy and did not reveal any contributing information. Due to the recurring pain of the cyst, surgery was scheduled. During surgery, the marsupialization of the cyst resulted in drainage of a chocolate-colored fluid. Pathological examination revealed stroma lined with non-typical columnar epithelium with hemosiderin pigments, which confirmed a diagnosis of endometriosis in the Bartholin gland. CONCLUSION: Our findings revealed a case of endometriosis outside the pelvis, without any deep intraperitoneal involvement. So far, only five cases concerning endometriosis in the Bartholin gland, which may or may not be an isolated finding, have been reported in literature.

Evaluation of First-Trimester Physiological Midgut Herniation Using Three-Dimensional Ultrasound.

INTRODUCTION: The aim of this study was to investigate the development of midgut herniation in vivo using three-dimensional (3D) ultrasonographic volume and distance measurements and to create reference data for physiological midgut herniation in ongoing pregnancies in a tertiary hospital population. MATERIALS AND METHODS: The transvaginal 3D ultrasound volumes of 112 women, seen weekly during the first trimester of pregnancy, were obtained and subsequently analysed in a virtual reality environment. The width of the umbilical cord insertion, the maximum diameter of the umbilical cord, and the volume of midgut herniation were measured from 6 until 13 weeks gestational age (GA). RESULTS: All parameters had a positive relation with GA, crown-rump length, and abdominal circumference. In approximately 1 of 10 volumes no midgut herniation could be observed at 9 and 10 weeks GA. In 5.0% of the fetuses the presence of midgut herniation could still be visualised at 12 weeks GA. CONCLUSION: Reference charts for several dimensions of physiological midgut herniation were created. In the future, our data might be used as a reference in the first trimester for comparison in case of a suspected pathological omphalocele.

First trimester physiological development of the fetal foot position using three-dimensional ultrasound in virtual reality.

AIM: In anatomic studies of the embryo, it has been established that during the development of the lower limb, several changes in foot position can be observed defined as a temporary 'physiological clubfoot'. The aim of this study was to develop and test a measurement tool for objective documentation of the first trimester foot position in vivo and made an attempt to create a chart for first trimester foot position. METHODS: We developed a virtual orthopedic protractor for measuring foot positioning using three-dimensional virtual reality visualization. Three-dimensional ultrasound volumes of 112 pregnancies of women examined during the first trimester were studied in a BARCO I-Space. The frontal angle (plantar flexion) and the lateral angle (adduction) between the leg and foot were measured from 8 until 13 weeks gestational age. RESULTS: We observed that the frontal angle steadily decreases, whereas the lateral angle first increases, resulting in transient physiological clubfeet position at 10- to 11-week gestation, followed by a decrease to a normal foot position. CONCLUSION: A transient clubfoot position is present during the normal development of the lower limbs, and it has been measured in vivo for the first time. This study emphasizes that a diagnosis of congenital clubfoot should not be made in the first trimester of pregnancy.

Human embryonic curvature studied with 3D ultrasound in ongoing pregnancies and miscarriages.

Embryonic growth is often impaired in miscarriages. It is postulated that derangements in embryonic growth result in abnormalities of the embryonic curvature. This study aims to create first trimester reference charts of the human embryonic curvature and investigate differences between ongoing pregnancies and miscarriages. Weekly ultrasonographic scans from ongoing pregnancies and miscarriages were used from the Rotterdam periconceptional cohort and a cohort of recurrent miscarriages. In 202 ongoing pregnancies and 33 miscarriages, first trimester crown rump length and total arch length were measured to assess the embryonic curvature. The results show that the total arch length increases and shows more variation with advanced gestation. The crown rump length/total arch length ratio shows a strong increase from 8+0 to 10+0 weeks and flattening thereafter. No significant difference was observed between the curvature of embryos of ongoing pregnancies and miscarriages. The majority of miscarried embryos could not be measured. Therefore, this technique is too limited to recommend the measurement of the embryonic curvature in clinical practice.

A viable caesarean scar pregnancy in a woman using a levonorgestrel-releasing intrauterine device: a case report.

BACKGROUND: Although the levonorgestrel-releasing intrauterine device (LNG-IUD) is one of the most reliable methods of contraception, it is associated with an increased risk of ectopic pregnancy in case of unintended pregnancy. A rare form of ectopic pregnancy is the caesarean scar pregnancy (CSP), with a high risk of serious maternal morbidity, such as uterine rupture, massive haemorrhage and resulting infertility. This report describes the first case of a viable CSP at 13 weeks of gestation in association with the use of a LNG-IUD. Case-presentation: A 36-year-old Caucasian woman was referred to our outpatient clinic because of suspicion of a CSP. The pregnancy was unintended and was diagnosed during replacement of the LNG-IUD after five years. The patient had undergone two caesarean sections in the past. Ultrasound investigation showed an intact pregnancy of approximately 13 weeks of gestation located in the uterine scar. Because of the size of the gestational sac, a laparotomy was performed under general anaesthesia using a Joel-Cohen incision. The procedure was complicated by a total blood loss of 1500 mL, mostly caused by diffuse bleeding from the placental bed. CONCLUSION: Unintended pregnancies in women using a LNG-IUD are frequently ectopic pregnancies with a preponderance to nidate outside the fallopian tube. Therefore, early diagnosis and location of the pregnancy in women using a LNG-IUD is essential.

Accuracy of fetal sex determination in the first trimester of pregnancy using 3D virtual reality ultrasound.

PURPOSE: Early detection of fetal sex is becoming more popular. The aim of this study was to evaluate the accuracy of fetal sex determination in the first trimester, using 3D virtual reality. METHODS: Three-dimensional (3D) US volumes were obtained in 112 pregnancies between 9 and 13 weeks of gestational age. They were offline projected as a hologram in the BARCO I-Space and subsequently the genital tubercle angle was measured. Separately, the 3D US aspect of the genitalia was examined for having a male or female appearance. RESULTS: Although a significant difference in genital tubercle angles was found between male and female fetuses, it did not result in a reliable prediction of fetal gender. Correct sex prediction based on first trimester genital appearance was at best 56%. CONCLUSION: Our results indicate that accurate determination of the fetal sex in the first trimester of pregnancy is not possible, even using an advanced 3D US technique.

Renal pelvis rupture during pregnancy: diagnosing a confusing source of despair.

We present an impressive case of a pregnant woman presenting with severe right flank pains. A rare rupture of the right renal pelvis turned out to be the cause of her problems. Renal pelvis rupture in pregnancy is difficult to diagnose. It is easily confused with other more prevalent diagnoses, like hydronephrosis, ureteral distension, renal calculus and pyelonephritis. Ultrasonography is not always conclusive. Pyelography seems to be a good diagnostic tool, this case shows that MRI is another option. Renal pelvis rupture can be effectively treated with the insertion of a JJ-stent.

Postpandemic Influenza A/H1N1pdm09 is still Causing Severe Perinatal Complications.

Although influenza A/H1N1pdm09 is not causing a pandemic anymore, we recently observed two critically ill pregnant women infected by this virus. We present these cases to illustrate the possible severe complications of an - at that moment - seasonal influenza in pregnancy. We discuss the epidemiological differences between the pandemic and post pandemic phase and try to explain the high virulence of influenza A/H1N1pdm09 -infections in pregnancy by discussing insights in immunology during pregnancy. We conclude that although influenza A/H1N1pdm09 is in the post pandemic phase, infection by this influenza virus still needs to be considered in pregnant women with progressive respiratory dysfunction.

Complications of the 2009 influenza A/H1N1 pandemic in pregnant women in The Netherlands: a national cohort study.

The 2009 influenza A/H1N1 pandemic caused an increase in complications in pregnant women. To be well prepared for a next pandemic, we investigated the obstetric and maternal complications of this pandemic. In our national cohort of 59 pregnant women who were admitted to the hospital, no major complications apart from preterm birth and admission to the neonatal intensive care unit were observed. Although the small size of this study precludes us drawing any definitive conclusions, comparing our results with those in other countries suggests that the influenza A/H1N1 pandemic had a relatively benign course in pregnant women in The Netherlands.

No apparent impact of increased post-operative blood glucose levels on clinical outcome in kidney transplant recipients.

BACKGROUND: Our objective is to evaluate whether hyperglycemia in the first 48 h after renal transplantation is independently associated with rejection, post-operative infection and post-transplant diabetes mellitus (PTDM) in a retrospective cohort study. METHODS: Patients who received a renal transplant in our hospital in 2003 or 2004 were included. Glucose values until 48 h after surgery were retrieved from laboratory reports. Biopsy proven acute rejection, culture proven infections and PTDM were scored until four months after transplantation. Data were analyzed using univariate analysis and logistic multivariate analysis. RESULTS: At least one post-operative glucose value could be retrieved for 150/151 patients. Rejection occurred in 46/150 (30.5%), infection in 47/150 (31.1%) and PTDM in 19/150 (12.6%) patients. When corrected for other risk factors, no relation was found between post-operative glucose levels and rejection (weak inverse relation, OR = 0.82; 95% CI = 0.65-1.03; p = 0.09), post-operative glucose and infections (OR = 0.98; 95% CI = 0.80-1.21; p = 0.84) and post-operative glucose and PTDM (OR = 0.93; 95% CI = 0.70-1.23; p = 0.63). CONCLUSION: Increased post-operative blood glucose levels after renal transplantation were not found to be a risk factor for graft rejection. Also, post-operative glucose levels were not found to be associated with PTDM and post-operative infections.