The incidence of biliary sludge in first trimester pregnancies with hyperemesis gravidarum and its effect on the course of hyperemesis gravidarum.

Pregnancy is one of the risk factors for biliary sludge (BS) formation. In this cross-sectional study, a total of 959 pregnant women were included. Serum aspartate aminotransferase, alanine aminotransferase, sodium, potassium, triglycerides, cholesterol levels and the presence of ketones in urine were determined. The presence of BS was investigated using maternal abdominal ultrasound. The incidence of BS in pregnancies complicated by hyperemesis gravidarum (HG) was 14%. The degree of ketonuria and low birth weight were statistically higher in pregnancies with maternal BS than women without sludge. Total weight gain during pregnancies with BS was statistically lower than controls. The incidence of BS in pregnancies with HG does not appear to increase due to HG-related complications, such as dehydration, starvation and weight loss. However, the severity of HG may be worse when HG is associated with sludge.Impact StatementWhat is already known on this subject? The incidence of biliary sludge (BS) in pregnant women ranges between 10.9% and 36%. Some clinical conditions, such as pregnancy, prolonged fasting, total parenteral nutrition, rapid weight loss and ceftriaxone treatment can play a role in the formation of gallbladder sludge.What do the results of this study add? This is the first study to investigate the incidence of BS in hyperemesis gravidarum (HG) pregnancies. Results show that HG may transiently be associated with BS. HG is more likely to cause a transient increase in new sludge formation. The symptoms and complications related to HG may be more severe when HG is associated with BS.What are the implications of these findings for clinical practice and/or further research? Our study showed that BS can be found in HG patients, and HG can be a predisposing factor for new sludge formation, although this association is generally driven by advanced maternal age and increased baseline serum lipid and alanine aminotransferase levels. BS may also be independently associated with an increased risk of subsequent preterm delivery in women with HG.

Foetal cardiac function in third trimester pregnancies with reduced fetal movements.

The objective of our study was to investigate the possible relationship between poor perinatal outcome and foetal cardiac functions in pregnant women with reduced foetal movements (RFM). This cross-sectional study included 126 pregnant women with normal foetal movements (Group 1, Controls) and 42 pregnant women over 32 weeks gestation with RFM (Group 2). Group 2 was further divided into two subgroups according to their perinatal outcome: normal perinatal outcome (Group 2a) and poor perinatal outcome (Group 2b). Cardiotocography, the E/A ratio in both atrioventricular valves, myocardial performance index (MPI) and foetal tricuspid annular plane systolic excursion (f-TAPSE) were evaluated. Foetuses with poor perinatal outcome had a higher MPI (p = .003), higher tricuspid and mitral E/A (p < .001), and lower f-TAPSE values (p < .001). In regression analysis, f-TAPSE was the only parameter (p = .04) independently associated with poor perinatal outcome. In conclusion, examining f-TAPSE may predict adverse perinatal outcome in pregnancies with RFM.IMPACT STATEMENTWhat is already known on this subject? Reduced foetal movement (RFM) is associated with adverse pregnancy outcome. Cardiotocography, amniotic fluid assessment, estimated birthweight, foetal Doppler and formal foetal movement count (kick chart) are generally used in the clinical assessment of pregnancies with reduced foetal movements. These tests, we currently use to assess foetal wellbeing in women with reduced foetal movements, have limited sensitivity in predicting foetal compromise.What do the results of this study add? Foetal cardiac Doppler may potentially be used as an important adjunct to the conventional management of women with a perception of reduced foetal movements.What are the implications of these findings for clinical practice and/or further research? Foetal echocardiographic evaluation, such as f-TAPSE, may influence clinical practice by enabling improved risk stratification for poor perinatal outcome, thus allowing more timely definitive intervention. This could help to decrease the rate of stillbirth related to reduced foetal movements. The few established echocardiographically derived parameters, which can asses global right ventricle function, are not always easy to obtain, however, f-TAPSE is easily obtainable using ultrasound and it appears to be a clinically useful echocardiographic measurement of right ventricular function.

Postnatal outcome of prenatally-detected "simple" renal cysts: Are they really simple?

BACKGROUND: The majority of simple renal cysts diagnosed postnatally are asymptomatic and rarely require treatment unless they become symptomatic or complex. We hypothesised that prenatally-detected simple renal cysts would have a similar harmless outcome. AIMS: To establish the natural history and postnatal outcome of prenatally-diagnosed simple renal cysts. STUDY DESIGN: Single-centre retrospective case-series review (12-year period). SUBJECTS: All patients with prenatally-diagnosed simple renal cysts (defined as a solitary, non-septated, non-communicating cyst in an otherwise normal kidney). OUTCOME MEASURES: Prenatal and postnatal changes to cyst size, persistence, resolution or modification of diagnosis. Data is presented as the proportion of patients or median (range). RESULTS: 30 cysts were detected (2 bilateral, 26 unilateral) in 28 fetuses (median gestational age of 23 [20-36] weeks). Median maximum diameter was 15 (4-35) mm at initial diagnosis and 17.5 (4-100) mm across all prenatal scans. On follow-up scans diagnosis was modified in 16 (53%) to: multicystic dysplastic kidney (MCDK), dilated duplex kidney, hydronephrosis, urinoma, renal agenesis and adrenal mass. 12 (40%) cysts resolved. 2 (7%) asymptomatic cysts persisted at one year postnatally. Cyst maximum diameter in the modified diagnosis group (21.5 [10-100] mm) was significantly larger than the simple cyst group (12 [4-20] mm) (P = 0.03). CONCLUSIONS: Our study revealed the challenges of prenatal ultrasound imaging, with modified diagnoses in over half the cases. Kidneys with solitary cysts could evolve into multicystic kidneys or involute completely, which suggests a true alteration in morphology rather than sonographic error. Persistent simple cysts in an otherwise normal kidney, however, resolved spontaneously or remained asymptomatic. Prenatally-detected simple cysts should be monitored with serial imaging.

Factors preventing materno-fetal transmission of SARS-CoV-2.

Although many pregnant women have been infected by coronavirus, the presence of intrauterine vertical transmission has not been conclusively reported yet. What prevents this highly contagious virus from reaching the fetus? Is it only the presence of a strong placental barrier, or is it the natural absence of the some receptor that the viruses use for transmission? We, therefore, need to comprehensively understand the mechanism of action of the mammalian epithelial barriers located in two different organs with functional similarity. The barriers selected as potential targets by SARS-CoV-2 are the alveolo-capillary barrier (ACB), and the syncytio-capillary barrier (SCB). Caveolae are omega-shaped structures located on the cell membrane. They consist of caveolin-1 protein (Cav-1) and are involved in the internalisation of some viruses. By activating leukocytes and nuclear factor-κB, Cav-1 initiates inflammatory reactions. The presence of more than one Cav-1 binding sites on coronavirus is an important finding supporting the possible relationship between SARS-CoV-2-mediated lung injury. While the ACB cells express Cav-1 there is no caveolin expression in syncytiotrophoblasts. In this short review, we will try to explain our hypothesis that the lack of caveolin expression in the SCB is one of the most important physiological mechanisms that prevents vertical transmission of SARS-CoV-2. Since the physiological Cav-1 deficiency appears to prevent acute cell damage treatment algorithms could potentially be developed to block this pathway in the non-pregnant population affected by SARS-CoV-2.

Fetal abdominal cysts: antenatal course and postnatal outcomes.

Background There is little information on which to base the prognostic counselling as to whether an antenatally diagnosed fetal abdominal cyst will grow or shrink, or need surgery. This study aims to provide contemporary data on prenatally diagnosed fetal abdominal cysts in relation to their course and postnatal outcomes. Methods Fetal abdominal cysts diagnosed over 11 years in a single centre were identified. The gestational age at diagnosis and cyst characteristics at each examination were recorded (size, location, echogenity, septation and vascularity) and follow-up data from postnatal visits were collected. Results Eighty abdominal cysts were identified antenatally at 28+4 weeks (range 11+0-38+3). Most (87%) were isolated and the majority were pelvic (52%), simple (87.5%) and avascular (100%). Antenatally, 29% resolved spontaneously; 29% reduced in size; 9% were stable and 33% increased in size. Forty-one percent of cysts under 20 mm diameter increased in size, while only 20% of cysts with a diameter of over 40 mm increased in size. The majority of cysts were ovarian in origin (n=45, 56%), followed by intestinal (n=15, 18%), choledochal (n=3, 4%), liver (n=2, 3%) and renal/adrenal origins (n=2, 3%), respectively. In 16% (n=13), the antenatal diagnosis was not obvious. Seventy-five percent of the cysts that persisted postnatally required surgical intervention. Conclusion Most antenatally diagnosed fetal abdominal cysts were ovarian in origin. Though most disappeared antenatally, nearly three quarters required surgical intervention when present after birth. Cysts of intestinal origin are more difficult to diagnose antenatally and often require surgery.

The role of apoptosis in preterm premature rupture of the human fetal membranes.

PURPOSE: The present study was designed to examine apoptotic cell death via the caspase-dependent pathway in human fetal membranes. METHODS: Amniotic membrane samples were collected from three groups of women: group 1, women with preterm premature rupture of fetal membranes (PPROM) after cesarean delivery (n = 10), group 2, women with preterm labor (PTL) with intact membranes after cesarean delivery (n = 9) and group 3, women with term labor and vaginal delivery after an uncomplicated pregnancy (controls) (n = 11). RESULTS: Active caspase-3 immunopositivity (ACPI) of the PPROM group was significantly higher than that of the control group (p < 0.05). ACPI was higher in the PTL with intact membranes group as compared to the control group; however, it did not reach statistical significance (p > 0.05). CONCLUSION: Active caspase-3 positivity is increased in the fetal membranes of those women with PPROM.

Association of placental volume measured by MRI and birth weight percentile.

PURPOSE: To investigate if placental volume in the second trimester of pregnancy is related to uterine artery blood flow and neonatal birth weight. MATERIALS AND METHODS: In 83 singleton pregnancies at 24-29 weeks' gestation, uterine artery pulsatility index (PI) was measured by Doppler ultrasound and placental volume was calculated from images obtained by magnetic resonance imaging (MRI) at 1.5T. The significance of the association between placental volume, uterine artery PI, and birth weight was examined. RESULTS: In 37 normal pregnancies resulting in delivery of neonates with birth weight at or above the 10th percentile, the median placental volume increased with gestational age from 363 cm(3) at 24 weeks to 515 cm(3) at 29 weeks. In 46 pregnancies that resulted in delivery of small for gestational age (SGA) neonates with birth weight below the 10th percentile the median placental volume, corrected for gestational age, was significantly decreased by 120 cm(3) (P < 0.0001) and median uterine artery PI was increased (1.87 vs. 1.59, P < 0.0001). There were significant associations between placental volume and both uterine artery PI (r = -0.677, P < 0.0001) and birth weight percentile (r = 0.658, P < 0.0001). CONCLUSION: Placental volume during the second trimester is smaller in pregnancies that subsequently deliver SGA neonates and the measurement is related to placental perfusion.

The enigmatic uterine junctional zone: the missing link between reproductive disorders and major obstetrical disorders?

While there is a growing realization that the origins of major obstetrical complications associated with defective deep placentation, such as pre-term labour, fetal growth restriction and pre-eclampsia, may lie in the very early pregnancy events, the underlying mechanisms are not understood. Impaired deep placentation is foremost a vascular pathology, characterized by a lack of endovascular trophoblast invasion and remodelling of a segment of the spiral arteries embedded within the inner myometrium of the uterus. Outside pregnancy, the inner myometrium represents a highly specialized, hormone-dependent structure, termed the junctional zone (JZ), which plays an integral part in the implantation process. The JZ changes with age and is disrupted in several reproductive disorders, such as endometriosis and adenomyosis, which in turn may account for the increased risk of adverse pregnancy outcome. Unlike the endometrium, the myometrial JZ is not readily accessible to biochemical or molecular studies, yet its structure and function can be assessed using imaging techniques, such as high-resolution ultrasound and magnetic resonance imaging. Thus, non-invasive assessment of the JZ prior to conception may turn out to be useful in identifying those women at risk of major obstetrical complications.

Posterior reversible leukoencephalopathy in a case of postpartum eclampsia.

This case report describes an atypical presentation of eclampsia. A 26-year-old lady presented 5 days' postpartum with a series of grand mal seizures after an uneventful pregnancy and delivery. An MRI scan of the brain showed areas of low signal involving cerebral white matter and right cerebellum. Within 2 weeks, all symptoms and radiologic abnormalities had resolved.