Threatened miscarriage and recurrent miscarriage: Expert opinions on progesterone therapy and treatment challenges.

It is crucial to gain a better understanding of threatened and recurrent miscarriages, including the existing knowledge and unknowns, as well as to discuss medical approaches and assess the situation. These issues are outstanding problems, causing significant physical and emotional burdens on women and their families, not only in Turkey but also worldwide. This article aims to explore the topic of miscarriages, including the implications, challenges, and potential therapeutic approaches in Turkey. Nineteen statements were presented to 6 Turkish perinatologists and obstetricians and gynecologists to evaluate the management of threatened and recurrent miscarriage and to compare the results with literature recommendations in an expert opinion meeting. Turkish perinatologists and obstetricians & gynecologists provided their responses using a 5-point Likert scale and discussed every statement. Progesterone use, particularly oral dydrogesterone, was supported by most of the experts. Opinions varied on the preference for dydrogesterone in recurrent miscarriage treatment. Experts unanimously agreed on the efficacy and safety of dydrogesterone and its recommendation in guidelines for threatened and recurrent miscarriage. Regarding progesterone therapy, vaginal progesterone was not associated with an increased rate of live births. Side effects of vaginal and oral micronized progesterone were acknowledged, and compliance with oral progesterone treatment was generally agreed upon. Dydrogesterone activity and effectiveness in threatened miscarriage received positive responses, while opinions on its effectiveness in recurrent miscarriage were divided. The loading dose of dydrogesterone and the practice of checking blood progesterone levels had different opinions among experts.This manuscript provides valuable insights in the management of threatened and recurrent miscarriages, highlighting the role of progesterone therapy, specifically dydrogesterone, and the need for adherence to relevant guidelines. Further research and a national Turkish guideline are warranted to address areas of uncertainty and optimize the management of these conditions.

Effects of spontaneous first breath on placental transfusion in term neonates born by cesarean section: A randomized controlled trial.

Background: The role of umbilical cord management in placental transfusion in cesarean section (CS) requires clarification. The spontaneous first breath may be more important than the timing of cord clamping for placental transfusion in neonates born by CS. Objective: This study aimed to evaluate the impact of cord clamping after the first spontaneous breath on placental transfusion in neonates born by CS. Methods: We recruited women with a live singleton pregnancy at ≥37.0 weeks of gestation admitted for CS. The interventions performed, such as physiologic-based cord clamping (PBCC), intact-umbilical cord milking (I-UCM), 30-s delay in cord clamping (30-s DCC), and 60-s delay in cord clamping (60-s DCC), were noted and placed in a sealed envelope. The sealed envelope was opened immediately before delivery to perform randomization. Results: A total of 123 infants were eligible for evaluation. Of these, 31, 30, 32, and 30 were assigned to the PBCC, I-UCM, 30-s DCC, and 60-s DCC groups, respectively. The mean hemoglobin (Hb) and mean hematocrit (Hct) were significantly higher in the 60-s DCC group than in the PBCC group (p = 0.028 and 0.019, respectively), but no difference was noted among the I-UCM, 30-s DCC, and PBCC groups at 36 h of age. Further, no significant differences were observed in the mean Hb and mean Hct among the I-UCM, 60-s DCC, and 30-s DCC groups. Peak total serum bilirubin (TSB) levels were higher in the 60-s DCC group than in the I-UCM and PBCC groups (p = 0.017), but there was no difference between the 60-s DCC and 30-s DCC groups during the first week of life. The phototherapy requirement was higher in 60-s DCC than in IUCM and 30-sDCC (p = 0.001). Conclusions: Our findings demonstrated that PBCC, 30-s DCC, and I-UCM in neonates born by CS had no significant differences from each other on placental transfusion. The Hb and Hct in the neonates were higher after 60-s DCC than after PBCC.

Prenatal diagnosis of a rare isolated thoracic-type ectopia cordis with complete form: a case report.

Ectopia cordis (EC) is a rare malformation that occurs as an isolated lesion or as part of the pentalogy of Cantrell which is characterized by midline closure defects. This was first described by Haller et al. in 1706. EC is seen with a frequency of 5.5-7.9 per 1 million births. It has five types that are: cervical, cervico-thoracic, thoracic, thoraco-abdominal, and abdominal. Its differentiation from the pentalogy of Cantrell, first described by Cantrell in 1958, must be done well. Thoracic type has the worst prognosis and due to this poor prognosis in the postnatal period, termination may be offered to these patients as an option. In this paper, a case of an isolated thoracic-type complete EC detected in the prenatal ultrasonography of a pregnant woman referred to our clinic at the 18 weeks and 3 days of gestation is presented.

Perinatal outcomes and survival predictors of severe red-cell alloimmunization treated by intrauterine transfusion.

OBJECTIVE: To evaluate perinatal survival rates and predictors in severely anemic fetuses that underwent intrauterine transfusion (IUT). METHOD: This was a retrospective study of both Turkish and Syrian patients who underwent IUT for fetal anemia due to Rh alloimmunization between 2015 and 2019. The association between pretransfusion factors and perinatal survival was evaluated by multivariate logistic regression. Receiver operating characteristics (ROC) curves were used to identify the level of fetal hemoglobin deficits that predict perinatal survival. RESULTS: Eighty-seven IUTs were performed in 42 pregnancies. Approximately 75% of fetuses were severely anemic and the overall perinatal survival rate was 50%. The survival rate was better in Syrian refugees compared to Turkish patients (71.4% vs. 39.3%, p < 0.05). In univariate analysis, hydrops presence (odds ratio [OR] = 0.2; 95% confidence interval [CI] = 0.05-0.7; p < 0.05), first IUT week (OR = 1.4; 95% CI = 1.1-1.8; p < 0.05), pretransfusion hemoglobin level (OR = 1.99; 95% CI = 1.22-3.27; p < 0.05), hemoglobin deficit (OR = 0.5; 95% CI = 0.3-0.8; p < 0.05), and birth week (OR = 2.3; 95% CI = 1.3-3.9; p < 0.05) were associated with survival. However in a multivariate analysis, only hemoglobin deficit (OR = 0.47; 95% CI = 0.22-0.99; p < 0.05) and birth week (OR = 3.3; 95% CI = 1.1-10.3; p < 0.05) were found to be associated with survival. On ROC analysis, a hemoglobin deficit of ≤6.25 g/dl showed a sensitivity of 0.95 and specificity of 0.62 for predicting perinatal survival. CONCLUSION: Despite the improvement in the treatment of fetal anemia, perinatal survival rate remains extremely low in severely anemic cases. Among pretransfusion factors, hemoglobin deficit seemed to be most important in predicting survival during fetal anemia.

The relationship between isolated pes equinovarus and aneuploidies and perinatal outcomes: Results of a tertiary center.

OBJECTIVE: Congenital pes equinovarus (PEV) is the most common congenital deformity of the foot, characterized by plantar flexion with a frequency of 0.2-0.3%. It can be diagnosed from the 12th week of pregnancy. Non-isolated cases tend to be syndromic and complex. We aimed to evaluate the results of perinatally diagnosed isolated PEV. MATERIALS AND METHODS: This was a retrospective cohort study conducted between March 2015-March 2020. Women who presented for fetal anomaly screening or were referred due to any suspected fetal anomaly were subjected to detailed fetal anomaly scans and checked for the presence of PEV. Karyotype analysis was discussed for patients with PEV. Pregnancy termination was recommended for those with chromosomal/life-threatening anomalies. The diagnosis was confirmed by postnatal examination/autopsy. Postnatal diagnosis was accepted as false-positive in those with no PEV. RESULTS: One-hundred thirty-eight patients were found to have PEV, 41 (29.7%) of which were isolated. In the isolated group, the false-positive rate in the first trimester was significantly higher compared with the second trimester, 50%/15.3%, respectively (p<0.05). Chromosomal anomalies were detected in 2 (4.8%) patients in the isolated group. Termination was performed to 1 (2.4%) patients due to trisomy 21. In the non-isolated group, chromosomal anomalies were detected in 13 (13.4%) patients, and termination was recommended. Termination was also recommended to 18 (18.5%) patients due to anomalies incompatible with life. In the postnatal evaluation, the surgical treatment rate in the isolated/non-isolated groups was 6%/39.7% (p<0.05). CONCLUSION: When PEV is diagnosed, detailed fetal anomaly screening must be performed, patients should be informed about the chromosomal anomaly risk. High false-positive rates in the first trimester should be kept in mind for diagnosis. Karyotype analysis should be recommended also to isolated cases. It should be remembered that some neuromuscular/skeletal system anomalies may occur for the first time in the postnatal period in isolated cases.

Evaluation of prenatally diagnosed fetal sacrococcygeal teratomas: A case series of seventeen pregnancies from South-central Turkey.

OBJECTIVE: To evaluate sacrococcygeal teratoma (SCT) cases according to associated cardiac, extracardiac, and chromosomal anomalies in the prenatal period, and to review their outcomes. MATERIALS AND METHODS: Data of pregnancies with a prenatal diagnosis of SCT between 2009 and 2019 were retrospectively reviewed. RESULTS: One ongoing pregnancy was excluded. There were five medically terminated cases, three due to severe heart failure and the remaining two due to additional congenital defects. Two infants who had heart failure due to hyperdynamic flow died in the neonatal period. Nine infants are well and alive at the time of writing. CONCLUSION: When a lesion is detected in the sacrococcygeal region during fetal sonography, the differential diagnosis should be made with an appropriate evaluation with emphasis on a possible diagnosis of fetal SCT. Tumor growth and heart failure should be monitored with serial scans when SCT has been diagnosed prenatally.

Prenatal diagnosis of persistent left superior vena cava: a retrospective study of associated congenital anomalies.

OBJECTIVE: To evaluate persistent left superior vena cava (PLSVC) cases according to associated cardiac, extracardiac, and chromosomal anomalies in the prenatal period and to review their outcomes. MATERIALS AND METHODS: The data of patients with a prenatal diagnosis of PLSVC between January 2013 and December 2017 were reviewed retrospectively. RESULTS: Data of 32 cases were reviewed. Nineteen (60%) cases were associated with cardiac defects, 5 (15%) were associated with both cardiac and extracardiac defects, and 8 (25%) had no associated anomalies. Two fetuses had karyotype anomalies. All patients with isolated PLSVC survived. Among the cases associated with extracardiac anomalies, cardiac anomalies, and with both extracardiac and cardiac anomalies, the survival rate was 40%, 40%, and 25%, respectively. Outcome was more favorable in cases with isolated PLSVC (100% vs. 40%). CONCLUSION: Prenatally diagnosed PLSVC is associated with cardiac and extracardiac anomalies in the majority of cases. The prognosis is good in isolated cases, but worsens when accompanied by cardiac or extracardiac anomalies.

Fetal Oropharyngeal and Neck Tumors: Determination of the Need for Ex-Utero Intrapartum Treatment Procedure.

BACKGROUND: The aim of this study was to assess the ex-utero intrapartum therapy (EXIT) applied to 3 of the 7 cases with oropharyngeal or neck masses and review the indicators of the need for an EXIT procedure. CASE REPORT: Prenatal presentation, size and localization of the masses, existence of fetal hydrops and associated findings such as polyhydramnios, intraoperative managements, complications, and maternal and neonatal outcomes were evaluated through a retrospective analysis. Four cases had neck masses and three cases had oropharyngeal masses. Prenatal sonography was used as the main diagnostic tool for all patients. The median gestational age was 34.5 weeks at the time of diagnosis and 36 weeks at delivery. Polyhydramnios was observed in three of the seven cases and they were delivered prematurely. Interventions such as endotracheal intubation or tracheostomy were performed to provide patency of the airway during delivery by the EXIT procedure in three cases. Hemangioma was found in two cases, teratoma in two cases, lymphangioma in two cases and hamartoma in one case following pathological examination of the masses. CONCLUSION: The localization of mass, its characteristics, invasion (if it exists), and relation to the airway are the main factors used to determine the need for EXIT. The presence of polyhydramnios may be an important indicator to predict both the need for EXIT and fetal outcomes.

Comparison of clinical and laboratory findings in early- and late-onset preeclampsia.

OBJECTIVE: To compare clinical and laboratory findings between the early-onset preeclampsia (EOP) and late-onset preeclampsia (LOP). METHODS: This prospective longitudinal study was performed at a tertiary referral university clinic. All patients meeting the inclusion criteria were divided into two groups, the EOP group and the LOP group, according to gestational age at the onset of disease. The distinction criterion for early versus late onset was set as week 34 of gestation. Clinical and laboratory findings, and maternal-perinatal outcomes were compared between the groups. RESULTS: A total of 157 patients with preeclampsia were included. A significant difference was observed between the groups in terms of diagnosis and severity of the disease (p = 0.007 and <0.001, respectively). The history of previous preeclampsia, diastolic blood pressure and hourly urine output on admission to the hospital were significantly different between the groups (p = 0.016, 0.018 and 0.024, respectively). Latent period for delivery and postpartum hospitalization time were longer in the EOP group than in the LOP group (p = 0.024 and 0.002, respectively). The patients with EOP received betamethazone (p < 0.001) and MgSO4 (p = 0.029) more frequently. Neonatal characteristics such as birth weight, low APGAR score and admission to neonatal intensive care unit were significantly different between the groups (p < 0.001, for all variables). Total proteinuria at 24 h was found significantly higher in the EOP group than in the LOP group (p = 0.012). CONCLUSION: The results confirmed the opinion that EOP is a distinct and more severe clinical entity than LOP. In particular, higher proteinuria is associated with EOP.

Intravenous leiomyomatosis extending into the right ventricle after subtotal hysterectomy.

A case of intravenous leiomyomatosis with extension into the right ventricle is described. A tumor in the inferior vena cava was detected three years after a subtotal hysterectomy had been performed for a myomatous uterus but was misdiagnosed as a thrombus. The tumor enlarged and intruded into the right ventricle for which she underwent surgery. The correct diagnosis was made during the surgery, therefore a two-stage resection was planned. Surgical resection is the best treatment for intracardiac extension of intravenous leiomyoma. We recommend iliac venotomy to remove the ilio-caval portion of the tumor in both stages of operations.