Effects of Recreational Therapy and 3D Ultrasonography for High-Risk Pregnancies on Psychological Well-Being during Hospitalization and in the Puerperal Phase.

Hospitalization during pregnancy often produces psychosocial distress for pregnant women. In this study, 3D ultrasound and recreational therapy were compared to the standard treatment for their influence on depressive symptoms and anxiety. In this prospective one-year intervention study, women who were admitted to the hospital for any pregnancy complication, other than psychiatric, were included. A control group, with standard clinical treatment, and two intervention groups, both additionally receiving either 3D ultrasound or recreational therapy, were established. Psychological well-being was assessed at defined times by the PHQ-health-questionnaire. A total of 169/211 women were included: control group n = 79, 3D ultrasound group n = 43, and crochet group n = 83. A higher than estimated underlying depression was seen for all women on admission. The intervention groups showed less depression (p = 0.02762). No difference was seen between the intervention groups (p = 0.23029). Anxiety decreased throughout intervention, but not significantly. On admission, all women showed similar results of underlying depression, indicating that hospitalization itself already causes mild psychological stress. Both interventions decreased depressive symptoms. Intervention with either recreational therapy or 3D ultrasound can prevent the development of mild and major depression and decrease anxiety disorders, and therefore has a positive effect on well-being during hospitalization. These results emphasize the need to implement forms of interventions to improve the well-being of women, as this might improve pregnancy and neonatal outcome.

Peri- and postoperative management and outcomes of morbidly obese patients (BMI > 40 kg/m2) with gynaecological disease.

INTRODUCTION: For the last two decades, obesity rates have been increasing in both developed and developing countries, with the number of obese women roughly doubling during this period (Stevens et al. in Popul Health Metr 10(1):33, 2012). Obesity represents one of the biggest epidemics of the 21st century. The aim of this retrospective study is to characterise the outcomes of gynaecologic surgeries in cases of extremely obese women with a body mass index (BMI) over 40 kg/m2. METHODS: This study is a retrospective case control study in a single-centre setting. Our clinical database was searched for gynaecological operations performed on morbidly obese patients (BMI > 40 kg/m2) between 2009 and 2014 in the Department of Gynaecology and Obstetrics at Hannover Medical School. We matched these results with random patients of normal body weight who had similar surgical procedures and diseases. RESULTS: We included 97 obese patients in our case group and 99 patients in the control group. We found an association between a strongly elevated BMI and peri- and postoperative morbidity. Both intraoperative and postoperative complications are significantly increased in morbid obesity with a BMI over > 40 kg/m2. We observed intraoperative complications in 55.6% and postoperative complications in 50.5% of patients with extreme obesity. In contrast, the complication rate in the control group with a normal BMI was 11% intraoperatively (p = 0.0001) and 3% postoperatively (p = 0.0001). The data showed that perioperative and postoperative morbidity could be reduced by laparoscopic surgery in many cases, with a significant lower rate of difficulties with closing the wound, a significant shorter duration of surgery and a significant lower rate of infections combined with a significant lower reoperation rate and shorter hospital stay. In gynaecological-oncological diseases, we could demonstrate a reduced radicality during the operative procedure due to extreme obesity. DISCUSSION: Dealing with the growing number of obese patients is essential, because the problems emerging from obesity are manifold for the treating hospitals as well as the general health system. For this high-risk patient group, it is indispensable to obtain a thorough overview of the patient's overall situation preoperatively to ensure good perioperative care and complications management.

Neonatal and Maternal Short-Term Outcome Parameters in Instrument-Assisted Vaginal Delivery Compared to Second Stage Cesarean Section in Labour: A Retrospective 11-Year Analysis.

BACKGROUND: This study is aimed at comparing the neonatal and maternal short-term outcomes after instrumental-assisted vaginal delivery and cesarean section (CS) in labour. METHODS: This retrospective study over a period of 11 years included singleton pregnancies above 34 + 0 gestational weeks, giving birth either by instrumental-assisted delivery or CS in labour. Maternal and neonatal outcome parameters were analysed using t test or linear regression. RESULTS: A total of 1,971/2,571 deliveries were included for analysis: 149 forceps-, 393 vacuum-assisted deliveries and 1,420 CS in labour. Regarding maternal outcome, the rate of severe anaemia and hemorrhage in women who delivered by CS in labour was lower than in instrumental-assisted delivery. Analysis of neonatal outcome parameters showed a lower cord pH <7.20 in CS; however, 5-min Apgar score and the need for intervention did not differ with the mode of delivery. The mode of anaesthesia affected the neonatal recovery rate. Subanalysis within instrumental deliveries showed reduced rates of vaginal tears, but higher rates of episiotomy in forceps-assisted deliveries. Except for higher rates of cephalhaematomas after ventouse, no differences were detected regarding further neonatal outcome measures. CONCLUSION: Assuming that indication and application is correct, vaginal instrumental-assisted delivery can be considered as an alternative delivery mode to second stage CS in labour.

Estimation of neonatal outcome artery pH value according to CTG interpretation of the last 60 min before delivery: a retrospective study. Can the outcome pH value be predicted?

PURPOSE: The aim of this study was to analyze whether the umbilical artery pH value can be estimated throughout CTG assessment 60 min prior to delivery and if the estimated umbilical artery pH value correlates with the actual one. This includes analysis of correlation between CTG trace classification and actual umbilical artery pH value. Intra-and interobserver agreement and the impact of professional experience on visual analysis of fetal heart rate tracing were evaluated. METHODS: This was a retrospective study. 300 CTG records of the last 60 min before delivery were picked randomly from the computer database with the following inclusion criteria; singleton pregnancy >37 weeks, no fetal anomalies, vaginal delivery either spontaneous or instrumental-assisted. Five obstetricians and two midwives of different professional experience classified 300 CTG traces according to the FIGO criteria and estimated the postnatal umbilical artery pH. RESULTS: The results showed a significant difference (p < 0.05) in estimated and actual pH value, independent of professional experience. Analysis and correlation of CTG assessment and actual umbilical artery pH value showed significantly (p < 0.05) diverging results. Intra- and interobserver variability was high. Intraobserver variability was significantly higher for the resident (p = 0.001). No significant differences were detected regarding interobserver variability. CONCLUSION: An estimation of the pH value and consequently of neonatal outcome on the basis of a present CTG seems to be difficult. Therefore, not only CTG training but also clinical experience and the collaboration and consultation within the whole team is important.

Ultrasound versus Clinical Examination to Estimate Fetal Weight at Term.

Introduction At term, fetal weight estimation is an important factor for decisions about the delivery mode and the timing of labor induction. This study aimed to compare the accuracy of abdominal palpation with that of ultrasound performed by different examiners to estimate fetal weight. The study investigated whether differences in the examiners' training affected fetal weight estimates. The accuracy of the weight estimates made for fetuses with extreme birth weights was also evaluated. Finally, the accuracy of Johnson's method and of Insler and Bernstein's formula for estimating fetal weight were compared with the other two methods. Methods This prospective study included singleton pregnancies between 37 weeks of gestation and 12 days post-term planned for vaginal delivery or cesarean section. Ultrasound and abdominal palpation using Leopold's maneuvers were performed by examiners with different levels of professional experience. Fetal weight was additionally estimated using Insler and Bernstein's formula and Johnson's method. Statistical analysis calculated the accuracy of fetal weight estimates for the different examiners and the four methods. Results A total of 204 women were included in the analysis. Trained ultrasound examiners were most accurate when estimating fetal weight compared with all other examiners. The comparison of all four methods showed that fetal weight was assessed most accurately with ultrasound. No learning curve could be established. BMI and advanced gestational age affected the accuracy of the estimated weight. The analysis showed that a greater deviation between estimated weight and actual weight occurred with all four methods for fetuses at either end of the extremes of fetal weight, i.e., with very low or very high birth weights. Conclusion Fetal weight should be estimated using ultrasound. A good ultrasound training is essential.

Maternal anxiety and its correlation with pain experience during chorion villus sampling and amniocentesis.

PURPOSE: Invasive prenatal diagnostic procedures, such as chorion villus sampling (CVS) and amniocentesis (AC), are routinely performed to exclude or diagnose fetal chromosomal abnormalities. The aim of this study was to investigate anxiety-dependent pain experience during CVS and AC and the potential factors that increase anxiety and pain levels. PATIENTS AND METHODS: During a 2-year period, women undergoing invasive procedures in three specialist centers were asked to participate in the study. Anxiety was evaluated before the procedure using the Spielberger State-Trait-Anxiety-Inventory, and pain was evaluated directly after the procedure using a verbal rating scale. RESULTS: Among the women, 348/480 (73%) underwent AC, while 131/480 (27%) underwent CVS. There was a significant correlation between state and trait anxiety (p<0.0001). A positive correlation existed between the degree of anxiety and the level of pain experienced (p=0.01). There was a positive correlation for trait anxiety (p=0.0283) as well as for state anxiety (p=0.0001) and pain perception (p=0.0061) when invasive procedure was performed owing to abnormal ultrasound finding or to a history of fetal aneuploidy. Maternal age was found to be another influencing factor for the experienced pain (p=0.0016). Furthermore, the analysis showed a significant negative correlation between maternal age and anxiety. That applies for trait anxiety (p=0.0001) as well as for state anxiety (p=0.0001). The older the woman, the less anxious the reported feeling was in both groups. The main indication for undergoing CVS was abnormal ultrasound results (45%), and the main reason for undergoing AC was maternal age (58%). CONCLUSION: Procedure-related pain intensity is highly dependent on the degree of anxiety before the invasive procedure. In addition, the indication has a significant impact on the emerging anxiety and consequential pain experiences. These influencing factors should therefore be considered during counseling and performance.

Maternal and pregnancy characteristics affect plasma fibrin monomer complexes and D-dimer reference ranges for venous thromboembolism in pregnancy.

BACKGROUND: D-dimers have a high negative predictive value for excluding venous thromboembolism outside of pregnancy but the use in pregnancy remains controversial. A higher cut-off value has been proposed in pregnancy due to a continuous increase across gestation. Fibrin monomer complexes have been considered as an alternative diagnostic tool for exclusion of venous thromboembolism in pregnancy due to their different behavior. OBJECTIVE: We sought to establish normal values of fibrin monomer complexes and D-dimer as a diagnostic tool for the exclusion of venous thromboembolism in pregnancy and examine the effect of maternal and obstetric factors on these markers. STUDY DESIGN: Plasma D-dimer and fibrin monomer complexes were measured by quantitative immunoturbidimetry in 2870 women with singleton pregnancies attending their routine first-trimester hospital visit in a prospective screening study for adverse obstetric outcome. Multiple regression analysis was used to determine maternal characteristics and obstetric factors affecting the plasma concentrations and converting these into multiple of the median values after adjusting for significant maternal and obstetric characteristics. RESULTS: Plasma fibrin monomer complexes increased with maternal weight and were lower in women with a history of cocaine abuse and chronic hypertension. D-dimers increased with gestational age and maternal weight and were higher in sickle cell carriers and in women of African and South Asian racial origin compared to Caucasians. CONCLUSION: Fibrin monomer complexes and D-dimers are affected by maternal and obstetric characteristics rather than only gestational age. The utility of these fibrin-linked markers as a tool for exclusion of venous thromboembolism in pregnancy might be improved by adjusting for patient-specific characteristics.

Correlation of fetal scalp blood sampling pH with neonatal outcome umbilical artery pH value.

PURPOSE: Fetal scalp blood sampling is considered as a complimentary tool in addition to cardiotocography to assess fetal well-being. This blood sampling is important as the obstetrician has to judge and make decisions regarding the further management of the delivery based on this pH result. The aim of this study was to analyze the correlation between fetal scalp blood pH and the umbilical artery pH after birth. Furthermore, it was investigated whether tocolysis, a performed episiotomy or cord encirclement have an influence on the umbilical artery pH. METHODS: This retrospective study over a period of 11 years included all singleton pregnancies without fetal anomalies, which were monitored by fetal scalp blood sampling during labor. RESULTS: 844 out of 1502 deliveries were included for analysis. The analysis demonstrates a good correlation between fetal scalp pH value and outcome pH value. Subgroup analysis with fetal scalp blood pH <7.20 showed a difference in 40 of 82 cases, with an outcome pH value ≥7.20, but this difference was statistically insignificant. Neither did tocolysis, episiotomy or the presence of cord encirclement show an overall effect, nor did they have an impact on the subgroup. CONCLUSION: Obstetricians must consider that the values of fetal scalp blood are not always reliable and can be false. However, on the basis of CTG and fetal scalp blood pH, decisions are made regarding delivery interventions. Therefore, we would encourage the consideration of taking two samples routinely at every attempt of fetal blood sampling.

The cost efficiency of HPV vaccines is significantly underestimated due to omission of conisation-associated prematurity with neonatal mortality and morbidity.

INTRODUCTION: Cervical intraepithelial neoplasia (CIN) represents the precursor of invasive cervical cancer and is associated with human papillomavirus infection (HPV) against which two vaccines have been approved in the last years. Standard treatments of high-grade CIN are conisation procedures, which are associated with an increased risk of subsequent pregnancy complications like premature delivery and possible subsequent life-long disability. HPV vaccination has therefore the potential to decrease neonatal morbidity and mortality. This has not been taken into account in published cost-effectiveness models. MATERIAL AND METHODS: We calculated the possible reduction rate of conisations for different vaccination strategies for Germany. Using this rate, we computed the reduction of conisation-associated preterm deliveries, life-long disability and neonatal death due to prematurity. The number of life-years saved (LYS) and gain in quality-adjusted life-years (QALYs) was estimated. The incremental costs per LYS / additional QALY were calculated. RESULTS: The reduction of conisation procedures was highest in scenario I (vaccination coverage 90% prior to HPV exposition) with about 50%. The costs per LYS or additional QALY were lowest in scenario I, II and III with 45,101 € or 43,505-47,855 € and rose up to 60,544 € or 58,401-64,240 € in scenario V (50% vaccinated prior to sexual activity + additional 20% catch-up at a mean age of 20 y). CONCLUSION: Regarding the HPV 16 / 18 vaccines as "vaccines against conisation-related neonatal morbidity and mortality" alone, they already have the potential to be cost-effective. This effect adds up to reduction of cervical cancer cases and decreased costs of screening for CIN. Further studies on cost-effectiveness of HPV vaccination should take the significant amount of neonatal morbidity and mortality into account.

The risk of ectopic pregnancy following tubal reconstructive microsurgery and assisted reproductive technology procedures.

PURPOSE: The incidence of ectopic pregnancy (EP) in the general population is 2%, whereas the EP rate following assisted reproductive technologies (ART) is between 2.1 and 11%. EP is also an adverse effect of tubal surgery with incidences up to 40% depending on the type, location, and severity of tubal disease and the surgical procedure. METHODS: This paper looks at the incidence of EP following tubal reconstructive microsurgery, analyzes risk factors for EP following own 1,295 ART cycles and looks on the incidence of EP in 128,314 pregnancies following ART according to the presence or absence of tubal infertility using data from the German IVF Registry (DIR). RESULTS: In our clinic, the EP rate following resterilization was 6.7%. In the presence of acquired tubal disease, the EP rate following adhesiolysis, salpingostomy, salpingoneostomy, fimbrioplasty, and anastomosis was 7.9%. The EP rate following ART in our clinic was 5.6%. Previous abdominal surgeries, microsurgical procedures, hydro-/sactosalpinges, salpingitis, salpingitis isthmica nodosa, and periadnexal adhesions showed a significant positive correlation with EP as outcome. Data of DIR demonstrate a significantly increased incidence of EP in the presence of tubal pathology. The highest EP rate related to all clinical pregnancies was 4.5% (95% CI 3.0-6.0) in smoking women <30 years with tubal pathology following IVF. CONCLUSIONS: In the presence of tubal infertility, the incidence of EP following ART and tubal microsurgery are approximately comparable with each other and higher than in women without tubal infertility. The success of infertility surgery depends on a careful selection of appropriate patients.

Prevalence and outcome of absence of ductus venosus at 11(+0) to 13(+6) weeks.

INTRODUCTION: To examine the prevalence and outcome of absent ductus venosus (DV) diagnosed at 11-13 weeks' gestation. METHOD: Prospective screening study for aneuploidies in 65,840 singleton pregnancies, including measurement of nuchal translucency (NT) thickness and examination of the DV. Prenatal findings and outcome of fetuses with absent DV were examined. RESULTS: Absent DV was diagnosed in 26 cases giving a prevalence of 1 in 2,532. In 15 (57.7%) cases the NT was above the 95th centile for crown-rump length. In 11 (42.3%) cases, there was an aneuploidy, mainly Turner syndrome. The incidence of aneuploidies was 66.7% (10 of 15) for those with NT above the 95th centile and 9.1% (1 of 11) in those with normal NT (p = 0.015). In addition to the aneuploidies, there were 3 cases with other abnormalities, including one case each of Ebstein anomaly, Noonan syndrome and Pierre Robin sequence. In 9 of the 11 (81.8%) fetuses with NT below the 95th centile, absent DV was an isolated finding and the pregnancies resulted in healthy live births. CONCLUSION: The prognosis of fetuses with absent DV depends on the measurement of NT thickness, being poor if the NT is increased and good if the NT is normal.

Screening for trisomies in dichorionic twins by measurement of fetal nuchal translucency thickness according to the mixture model.

OBJECTIVE: To examine the distribution of fetal nuchal translucency (NT) thickness in dichorionic twins and investigate the effect of the correlation between NT measurements in each twin pair on the performance of screening for trisomies. METHODS: The distribution of fetal NT for crown-rump length (CRL) was examined in 5646 dichorionic twin pregnancies, including 103 with fetal trisomies 21, 18 or 13. The correlation in fetal NT in each euploid twin pregnancy was estimated. RESULTS: The distribution of NT in both euploid and trisomic fetuses was consistent with the mixture model in singleton pregnancies. In the euploid pregnancies, there was a correlation in log NT measurements in each twin pair (r = 0.42, 95% CI: 0.39-0.45) and, after removal of the effect of the operator, this correlation was reduced to 0.34. Allowing for this correlation in risk assessment for trisomies had a major impact on the estimated patient-specific risk but had little effect on the overall performance of screening. CONCLUSIONS: In dichorionic twin pregnancies, the mixture model of distributions of NT can be applied as in singletons. In screening for trisomies, the correlation in NT measurements between the fetuses should be taken into account in the estimation of patient-specific risks.

Reference range of birth weight with gestation and first-trimester prediction of small-for-gestation neonates.

OBJECTIVE: Firstly, to establish a reference range of birth weight with gestation at delivery; secondly, to identify maternal characteristics that are significantly associated with birth weight; and thirdly, to determine if combinations of maternal characteristics, fetal nuchal translucency thickness (NT), and serum concentrations of free beta-human chorionic gonadotrophin (ß-hCG) and pregnancy-associated plasma protein-A (PAPP-A) are significant predictors of small-for-gestational-age (SGA) neonates in the absence of preeclampsia. METHOD: Maternal characteristics were recorded; fetal NT, maternal serum free ß-hCG and PAPP-A were measured at 11 weeks to 13 weeks 6 days in 33,602 women with singleton pregnancies. Regression analysis was used to determine the association of birth weight with gestation at delivery and to establish a reference range with gestation. Logistic regression analysis was used to determine if maternal factors, fetal NT, free ß-hCG, and PAPP-A contribute significantly in predicting SGA in the absence of preeclampsia. RESULTS: Birth weight increased with maternal weight and height; it was higher in parous than in nulliparous women and in those with a medical history of pre-pregnancy diabetes mellitus, and it was lower in cigarette smokers, in all racial groups other than in Caucasian women, and in those with a medical history of chronic hypertension and in those who previously delivered SGA neonates. In the SGA group compared with the unaffected group, there were lower median delta NT (0.10 vs 0.12 mm), free ß-hCG [0.9 vs 1.0 MoM (multiples of median)], and PAPP-A (0.8 vs 1.0 MoM). The prediction of SGA provided by maternal factors was significantly improved by the addition of fetal NT and PAPP-A (34.0 vs 37.0% at a false-positive rate of 10%). CONCLUSION: Prediction of the birth of SGA neonates in the absence of preeclampsia can be provided in the first trimester of pregnancy by a combination of maternal characteristics and measurements of parameters used in early screening for aneuploidies.

Quality assured ultrasound simulator training for the detection of fetal malformations.

OBJECTIVE: Sonographic training in obstetrics differs broadly in Germany, although there are clearly defined quality-oriented requirements. In order to improve professional education, a training concept was devised utilizing an ultrasound simulator system. DESIGN: Between October 2004 and May 2006, 100 obstetric ultrasound training courses were held in 12 federal states of Germany. In these daily courses, doctors were trained in the detection of the most common malformations. SAMPLE: One hundred training courses with a total of 1,266 participants. METHODS: As a measure of quality assurance, a standardized questionnaire focusing on testing sonographic proficiency before and after the courses was issued in order to analyze the effect of these simulator-based ultrasound courses. MAIN OUTCOME MEASURES: Effectiveness of the method with reference to its potential role in structured sonographic training. RESULTS: The concept found prevailing approval (90%) at the level of principle, practical implementation, and clinical usefulness. Of the participants, 91% estimated their subjective training effect as good. The questionnaire analysis showed significant improvement. On average, 75.3% of the questions relating to sonographic proficiency were answered correctly at the end of the course as opposed to 48.6% at the beginning. CONCLUSION: Structured ultrasound training courses based on an ultrasound simulator system seem to be useful for defining a basic standardized quality of training and significantly improving examiners' skills. This is a suitable additional instrument to improve the education in obstetric ultrasound.

Outcome of pregnancies with trisomy 2 cells in chorionic villi.

OBJECTIVE: To describe the outcome of pregnancies with trisomy 2 in cultures of first-trimester chorionic villous samples (CVS) and determine whether amniocentesis is necessary in the management of such cases. METHODS: Cultures of chorionic villi were performed at 11-13 weeks in 37 474 pregnancies. In those with trisomy 2 cells, amniocentesis was performed at 16 weeks. Pregnancy outcome was obtained from maternity records. RESULTS: Trisomy 2 cells in CVS cultures were observed in 45 of 37 474 pregnancies (1.2 per 1000). In 43 cases ultrasound examination at 16-20 weeks showed no fetal abnormalities, amniocentesis demonstrated the presence of only normal cells, and all 43 pregnancies ended in normal healthy live births. The birth weight was below the 5th centile in six neonates (13.9%). There was a significant association between the birth weight centile and the percentage of trisomic cells in the CVS culture (r = 0.409, p = 0.010). In one case, there was fetal death at 15 weeks. In a second case, amniocentesis showed one cell with trisomy 2 in a total of 53 cells, and ultrasound examination at 18 weeks showed severe fetal growth restriction and coarctation of the aorta. CONCLUSION: In at least 95% of cases with trisomy 2 in CVS cultures there is confined placental mosaicism (CPM). The prognosis is good, but in about 15% of cases there is fetal growth restriction.

Maternal serum screening marker levels in women with a previous aneuploidy pregnancy.

OBJECTIVE: To re-evaluate in a larger cohort of patients if the maternal serum biochemical markers used in first trimester aneuploidy screening have the same marker distributions in pregnancies with a previous history of aneuploidy compared with those that have no previous history. METHODS: Information related to previous pregnancy history is routinely recorded as part of first trimester screening in three centres King George, Kings College and Fetal Medicine Centre, London. From the database, records were extracted for women who had a previous pregnancy diagnosed with trisomies 13, 18 or 21. For each woman with a previous aneuploidy, five unaffected pregnancies in women of the same maternal age and with no previous aneuploidy pregnancy were selected as controls. A comparison was made between the marker distributions for pregnancy associated plasma protein-A (PAPP-A) and free beta-human chronic gonadotrophin (beta-hCG) amongst the cases and controls using nonparametric statistical tests. RESULTS: A series of 8240 controls were compared against group of 1032 cases with a previous trisomy 21, 293 with a previous trisomy 18 and 158 with a previous trisomy 13. Cases with multiple previous trisomies were excluded. There were no significant differences in the level of free beta-hCG; however, in cases of trisomy 21 and trisomy 13 the levels of PAPP-A were increased by 5 and 16%, respectively. CONCLUSION: Risk calculation algorithms may need to take account of the increased PAPP-A levels in women with a previous trisomy 21 or trisomy 13.

First-trimester uterine artery Doppler and serum pregnancy-associated plasma protein-a in preeclampsia and chromosomal defects.

OBJECTIVE: We examined the potential value of the uterine artery pulsatility index (PI) in pregnancies with fetal aneuploidies and in those that developed preeclampsia (PE) with the aim of distinguishing between these complications in pregnancies with low pregnancy-associated plasma protein-A (PAPP-A). METHODS: Uterine artery PI and serum PAPP-A at 11-13 weeks were measured in 165 cases of PE, including 33 that required delivery before 34 weeks (early PE) and 132 with late PE, and in 301 cases with aneuploidies, including 200 with trisomy 21. Each case of aneuploidy and PE was matched with 4 unaffected controls. RESULTS: Serum PAPP-A was lower in early PE (0.58 multiples of the normal median, MoM) and in trisomy 21 (0.54 MoM), trisomy 18 (0.22 MoM) and Turner syndrome (0.51 MoM) - but not in late PE (0.90 MoM) - than in controls (1.01 MoM). Uterine artery PI was higher in early PE (1.52 MoM), late PE (1.20 MoM), trisomy 18 (1.20 MoM) and Turner syndrome (1.29 MoM) - but not in trisomy 21 (1.02 MoM) - than in controls (1.0 MoM). CONCLUSION: The uterine artery PI at 11-13 weeks may be useful in distinguishing between low PAPP-A due to trisomy 21 and early PE.

Ductus venosus Doppler at 11 to 13 weeks of gestation in the prediction of outcome in twin pregnancies.

OBJECTIVE: To examine the independent contribution of abnormal flow in the ductus venosus at 11 to 13 weeks of gestation in the prediction of adverse pregnancy outcome in relation to chorionicity. METHODS: This was a prospective study in 516 dichorionic and 179 monochorionic twin pregnancies in which the fetal ductus venosus flow was assessed at 11 0/7 to 13 6/7 weeks of gestation. The prevalence of reversed a-wave in the fetal ductus venosus was compared between monochorionic and dichorionic pregnancies and between those with and without pregnancy complications. Comparisons between each of the pregnancy outcomes and the normal outcome group and between monochorionic and dichorionic pregnancies were made using the Mann-Whitney U-test for continuous variables and the chi2 test and Fisher exact test for categorical variables. RESULTS: The prevalence of reversed a-wave in at least one of the fetuses was significantly higher in monochorionic than in dichorionic pregnancies (18.4% compared with 8.3%, P<.001) and in pregnancies complicated by miscarriage (28.6%, P=.005), fetal aneuploidy (70.0%, P<.001), and twin-twin transfusion syndrome (38.5%, P<.001) compared with the pregnancies with two healthy live births (7.7%). Pregnancy outcome was normal in 33 of the 43 (76.7%) dichorionic and in 14 of the 33 (42.4%) monochorionic twins with reversed a-wave in at least one of the fetuses. CONCLUSION: In twins, reversed a-wave in the ductus venosus at 11 to 13 weeks of gestation is associated with increased risk for aneuploidies, miscarriage, and development of severe twin-twin transfusion syndrome. However, in about 75% of dichorionic twins and 40% of monochorionic twins with reversed a-wave, the pregnancy outcome is normal. LEVEL OF EVIDENCE: II.

Photodynamic diagnosis and therapy in gynecology.

Photodynamic diagnosis (PDD) and therapy (PDT) are modern methods that are evaluated in different fields in gynecology. PDD is currently under investigation in gynecologic conditions such as cervical intraepithelial neoplasia (CIN), vulvar intraepithelial neoplasia (VIN), endometriosis, and ovarian cancer. PDT has been successfully evaluated in HPV-related genital dysplasia such as CIN and VIN, in genital warts, in local recurrent breast cancer, and for endometrial ablation. The aim of this review is to give an overview about current applications.