Uterocervical angle as a predictor of spontaneous preterm birth in twin pregnancies.

OBJECTIVE: To assess the ability of uterocervical angle (UCA) compared with cervical length (CL) to predict the risk of spontaneous preterm birth (sPTB) in twin pregnancies and its performance when it was included in a combined predictive model of clinical and ultrasonographic parameters. METHODS: We conducted a retrospective cohort study of twin pregnancies undergoing transvaginal ultrasound between 19+0-21+6 weeks to measure CL during routine second trimester scan from January 2015 through December 2016. Recorded ultrasound images of CL were reassessed to evaluate UCA. Medical and obstetric data were also collected for statistical analysis. A logistic regression model was created for predicting sPTB including UCA and other variables. RESULTS: A total of 177 women were included. The rates of sPTB rate below 28, 32 and 34 weeks of gestation were 4.5%, 6.8% and 12.4%, respectively. ROC curves showed a better area under the curve (AUC) for UCA at all gestational ages compared with CL (AUC for sPTB <28 weeks 0.840 (p = .005) vs 0.627 (p = .388); AUC for sPTB <32 weeks 0.706 (p = .022) vs 0.619 (p = .255); AUC for sPTB <34 weeks 0.674 (p = .008) vs 0.568 (p = .344). UCA >117 degrees was significantly associated with sPTB <28 weeks (p = .002; OR 15.3; CI 1.66-142.37; NPV, 99.2%), <32 weeks (OR 3.84; p = .031) and <34 weeks of gestation (OR 3.10; p = .016). Based on multivariate analyses, the best predictive model included uterocervical angle (p = .032), cervical length (p = .002) and maternal height (p = .001) (Nagelkerke R2 0.944). CONCLUSION: In our study, an UCA > 117 degrees allowed to identify those women with twin pregnancies at risk of sPTB and performed better than CL measurement. Our combined prediction model was able to adequately predict the risk of sPTB in the twin pregnancies of our research.

Uterocervical angle at 20 weeks: A promising predictor of spontaneous preterm birth in twin pregnancies.

OBJECTIVE: To compare the performance of uterocervical angle (UCA) and cervical length (CL) measurement at 20 weeks of pregnancy for prediction of spontaneous preterm birth (sPTB) in twin pregnancies. STUDY DESIGN: We conducted a retrospective cohort study of 424 twin pregnancies who delivered in our center from October 2014 to December 2018 and who underwent transvaginal ultrasound between 19+0-22+0 weeks to measure CL during routine second trimester scan. Recorded ultrasound images of CL were reassessed to evaluate UCA. Medical and obstetric data were also collected for statistical analysis. RESULTS: A total of 424 women were included. The rates of sPTB rate below 28, 32 and 34 weeks of gestation were 2.8 %, 5.4 % and 10.4 %, respectively. ROC curves showed a better area under the curve (AUC) for UCA at all gestational ages compared with CL (AUC for sPTB <28 weeks 0.902 (p < 0.001) vs 0.620 (p 0.175); AUC for sPTB <32 weeks 0.740 (p 0.001) vs 0.620 (p 0.058); AUC for sPTB <34 weeks 0.676 (p 0.001) vs 0.632 (p 0.047). UCA > 120 degrees was significantly associated with sPTB <28 weeks (p < 0.001; OR 39.17; CI 4.81-319.23; NPV, 99.65 %), <32 weeks (OR 4.23; p 0.002) and <34 weeks of gestation (OR 2.66; p 0.01). CONCLUSION: In our study, an UCA > 120 degrees allowed to identify those women with twin pregnancies at risk of sPTB and performed better than CL measurement.

Ultrasound-guided intrasacular injection of methotrexate in the management of ectopic pregnancies with embryo. A 12 year experience report in a tertiary hospital.

OBJECTIVE: To evaluate the efficacy and safety of combined-therapy with ultrasound guided intrasacular injection of 50 mg of methotrexate (MTX) and a 50 mg/m2 dose of systemic MTX in uncomplicated ectopic pregnancies with ultrasonographic evidence of embryonic structures in the gestational sac. STUDY DESIGN: We designed a retrospective study including 60 patients to assess the efficacy of combined MTX treatment and to determine which clinical or ultrasonographic variables could be associated with successful medical treatment. Failed medical treatment was defined when surgery was needed. For statistical analysis, we developed a descriptive analysis and a univariate logistic regression study. RESULTS: Medical approach was effective in 73.3 % of patients. MTX treatment was successful in 32 (68.1 %) out of 47 tubal pregnancies None of the 4 cervical or 2 abdominal pregnancies required surgery. Six (85.7 %) out of 7 cornual pregnancies were successfully treated. No statistically significant differences were found in the success rates according to clinical data, ultrasound or analytic characteristics of women. CONCLUSION: Combined MTX therapy could be an effective and safe alternative in ectopic pregnancies with embryo in hemodynamically stable women. Clinical, ultrasound or analytic characteristics of patients should not entail a contraindication. In locations where surgery implies a technical difficulty, this option may decrease morbimortality rates frequently associated to a more invasive alternative.

HE4 tumor marker as a predictive factor for lymphatic metastasis in endometrial cancer.

Endometrial cancer is the most common genital cancer in high-resource countries. Treatment is essentially surgical, but the role of lymphadenectomy in the treatment of low-stage and low-grade tumors has not been defined. Although no tumor factors have been validated for use as preoperative prognostic markers of endometrial cancer at yet, human epididymis protein 4 (HE4) has received much interest as a potential diagnostic and prognostic tumor marker. Since 2008, several studies have explored its utility in the management of endometrial cancer: HE4 may be a useful preoperative prognostic marker because it is associated with lymphatic metastasis and other unfavorable factors in endometrial cancer. In addition, some studies have explored a HE4 cutoff value to classify patients according to lymph node involvement. HE4 might be beneficial as a serum marker that helps clinicians in the decision-making algorithm for treatment of endometrial cancer, enabling them to perform individualized operations and decrease the adverse effects of unnecessary surgery.

Low-dose vaginal misoprostol vs vaginal dinoprostone insert for induction of labor beyond 41st week: A randomized trial.

INTRODUCTION: The aim of this study was to compare the efficacy and safety of a low-dose protocol of vaginal misoprostol and vaginal dinoprostone insert for induction of labor in women with post-term pregnancies. MATERIAL AND METHODS: We designed a prospective, randomized, open-labeled trial with evaluators blinded to the end-point, including women of at least 41 weeks of gestational age with uncomplicated singleton pregnancies and a Bishop score <6. They were randomized into dinoprostone or misoprostol groups in a 1:1 ratio. Baseline maternal data and perinatal outcomes were recorded for statistical analysis. Successful vaginal delivery within 24 hours was the primary outcome variable. A P value <0.05 was considered statistically significant. This study was registered in ClinicalTrials.gov (number NTC03744364). RESULTS: We included 198 women for analysis (99 women in each group). Vaginal birth rate within 24 hours did not differ between groups (49.5% vs 42.4%; P = 0.412). When the Bishop score was <4, dinoprostone insert showed a higher probability of vaginal delivery within 12 hours (17.8% vs 4%; P = 0.012). In the dinoprostone group, removal of the insert was more likely to be due to an adverse event (5.1% vs 14.1%; P = 0.051) and an abnormal fetal heart rate pattern during active labor (44.4% vs 58.6%; P = 0.047). Both groups were similar in neonatal outcomes including Apgar score, umbilical cord pH and neonatal intensive care unit admission. CONCLUSIONS: Low-dose vaginal misoprostol and vaginal dinoprostone insert seem to be equally effective and safe for induction of labor in pregnant women with a gestational age beyond 41 weeks.

Delayed-interval delivery in twin pregnancies: report of three cases and literature review.

INTRODUCTION: Delayed delivery is sometimes performed in selected multifetal pregnancies when the first twin birth occurs inevitably. The aim of this procedure is to improve the prognosis and decrease the morbidity and mortality of the second twin. We report three cases of delayed-interval delivery of dichorionic-diamniotic twin pregnancies assisted in our center between 2015 and 2017. After the first twin delivery, the second twin was left in utero and the patient received tocolytic therapy and antibiotics. Cervical cerclage was not performed. RESULTS: Our patients were admitted between 21 + 3 and 23 + 6 weeks of gestation. We achieved an average interval delivery of 6.33 d. Four out of six twins did not survive the delayed interval procedure. The average stay of the first and second twins that were admitted to the neonatal intensive care unit (NICU) was of 72 d (28-116) and 39.5 d (12-67), respectively. The first twin birth was vaginal in all cases, while the second twin delivery was performed by cesarean section in two out of our three patients. Our neonatal results are not favorable, probably due to the extreme prematurity. CONCLUSIONS: Delayed delivery of the second twin before 28 weeks of gestation can be an alternative for the obstetrician since it could prolong the pregnancy until a gestational age which confers a better prognosis and a better perinatal outcome for the second twin.

Double-balloon catheter for induction of labour in women with a previous cesarean section, could it be the best choice?

INTRODUCTION: We analysed the efficacy and safety of double-balloon catheter for cervical ripening in women with a previous cesarean section and which were the most important variables associated with an increased risk of repeated cesarean delivery. MATERIALS AND METHODS: We designed an observational retrospective study of 418 women with unfavourable cervices (Bishop Score <5), a prior cesarean delivery, and induction of labour with a double-balloon catheter. Baseline maternal data and perinatal outcomes were recorded for a descriptive, bivariate, and multivariate analysis. A p value <0.05 was considered statistically significant. RESULTS: Most women improved their initial Bishop Score (89.5%) although only a 20.8% of them went into spontaneous active labour. Finally, 51.4% of the women achieved a vaginal delivery. Five cases of intrapartum uterine rupture (1.2%) occurred. After multivariate analysis, main risk factors for repeated cesarean section were dystocia in the previous pregnancy (OR 1.744; CI 95% 1.066-2.846), the absence of previous vaginal delivery (OR 2.590; CI 95% 1.066-6.290), suspected fetal macrosomia (OR 2.410; CI 95% 0.959-6.054), and duration of oxytocin induction period (OR 1.005; CI 95% 1.004-1.006). The area under the curve was 0.789 (p < 0.001). CONCLUSIONS: Double-balloon catheter seems to be safe and effective for cervical ripening in women with a previous cesarean delivery and unfavourable cervix. In our study, most women could have a vaginal delivery in spite of their risk factors for cesarean delivery. A multivariate model based on some clinical variables has moderate predictive value for intrapartum cesarean section.

Atypical decelerations: do they matter?

OBJECTIVE: To estimate the association between atypical variable decelerations and neonatal acidemia. METHOD: We conducted a one-year case-control study comparing the last thirty minutes before delivery of fetal heart rate tracings of 102 acidemic neonates (umbilical arterial cord gas pH ≤ 7.10) with 100 non-acidemic controls (umbilical arterial cord gas pH > 7.10). Incidence of atypical features and total number of decelerations, number of atypical decelerations, number of slow return decelerations and number of decelerations with loss of moderate variability during deceleration were extracted. We estimated the association between atypical features, neonatal acidemia and neonatal morbidity. RESULTS: Acidemic neonates showed a larger number of atypical decelerations (4 [0-12] vs. 3 [0-10]), "slow return" decelerations (4 [0-11] vs. 1 [0-10]) and decelerations with non-moderate variability (0[0-12] vs. 0 [0-6]) compared to non-acidemic controls. "Slow return" was significantly associated with an increased risk of acidemia at birth (OR 4.46; CI 95%: 2.18 - 9.15) "Slow return" was the most discriminating feature between groups with an AUC: 0.745. CONCLUSION: Certain atypical features, as "slow return" and loss of moderate variability within decelerations are associated with neonatal acidemia. "Slow return" could help in the gradation of acidemia risk levels, as an indicator of gravity.