OBJECTIVES To evaluate the diagnostic performance of third trimester ultrasound for the diagnosis... more OBJECTIVES To evaluate the diagnostic performance of third trimester ultrasound for the diagnosis of clinically significant Placenta accreta spectrum disorder (PAS) in women with a low-lying placenta (less than 20 mm from the internal cervical os) or placenta praevia (covering the os) METHODS: Pregnant women with a low-lying placenta or placenta praevia, age ≥ 18 years and gestational age at ultrasound ≥ 26+0/7 weeks of gestation were prospectively included in the study. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs: (1) obliteration of the hypoechoic space between the uterus and the placenta; (2) interruption of the hyperechoic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. In order to assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprehensive of both active management at delivery and histopathological confirmation of PAS was considered as the reference standard. PAS was considered of clinical significance if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation, uterine artery embolization. RESULTS A total of 568 women underwent transabdominal and transvaginal ultrasound examinations. Of them, 95 delivered in local hospitals and placental pathology according to the study protocol was therefore not available. Among the 473 for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%). A normal hypoechoic space between the uterus and the placenta reduces post-test probability of PAS from 21% to 5% in women with a low-lying placenta or placenta previa in the third trimester of pregnancy, and from 62% to 9% in the subgroup of women with previous cesarean section and anterior placenta. The absence of lacunae reduces post-test probability of PAS from 21% to 9% in women with low-lying placenta or placenta previa in the third trimester of pregnancy, and from 62% to 36% in the subgroup with previous cesarean section and anterior placenta. On the other side, when lacunae are seen the post-test probability increases from 21% to 59% in the whole study population and from 62% to 78% in women with placenta previa, previous cesarean section and anterior placenta. CONCLUSIONS Grey-scale ultrasound is a good test to identify pregnancies at low risk of PAS in this high risk population. Ultrasound can be safely used to guide management decisions, concentrating greater resources in patients with the higher risk of clinically significant PAS This article is protected by copyright. All rights reserved.
Risk of needlestick injuries (NSIs) is high in surgical staff. Medical students and trainees have... more Risk of needlestick injuries (NSIs) is high in surgical staff. Medical students and trainees have reported the highest rate of NSIs, and Obstetrics and Gynecology is considered a high-risk specialty. The risk associated to NSIs is further increased by the high prevalence of blood borne pathogens in the population. Nevertheless, the degree of concern about contraction of these serious infections has been reported significantly lower over time, showing diminishing attitudes toward prevention of exposure and lack of consideration as a major problem, in fact most of NSIs resulted unreported. Therefore, education is fundamental to change individual attitudes and behaviors, to improve awareness and increase the use of standard protections, in order to reduce the injury rate and implement reporting to hospital surveillance systems. The proposed study aims to assess NSIs in trainees currently attending residency programs in Obstetrics and Gynecology in all academic hospitals of Italy, with a standardized, pre-piloted, national-based survey. At this purpose, we developed the Obstetrics Needlestick Injury Questionnaire (ONSI-Q), a 40-items survey that will be completed via a web-based platform. The ONSI-Q investigates real incidence of NSIs, adopted protection practices, presence of associated risk factors, and attitudes and rate of the reported accidents among trainees during obstetric procedures (suture of perineal tear/episiotomy and cesarean section). These results will provide the opportunity to investigate an underestimated priority, in order to encourage educational practices with the aim to improve prevention and reporting strategies, and therefore increase occupational safety in this high-risk surgical specialty
Abnormally invasive placenta (AIP) includes placenta accreta, increta, and percreta and represent... more Abnormally invasive placenta (AIP) includes placenta accreta, increta, and percreta and represents major complications of pregnancy. This study was designed to assess the role of ultrasonography in the identification of AIP among pregnant women with antepartum diagnosis of placenta previa. A cross-sectional study was performed between May 2015 and April 2016 in 11 centers, including 242 women with antepartum diagnosis of placenta previa. Ninety-eight out of 242 (40.49%) women had a histological diagnosis of placenta accreta. A higher number of caesarean deliveries (p = 0.001) and curettages (p = 0.027) and older age of the woman at the delivery (p = 0.031) were identified as risk factors for placenta accreta. The presence of irregularly shaped placental lacunae (vascular spaces) within the placenta (p = 0.008), protrusion of the placenta into the bladder (p < 0.0001), and turbulent blood flow through the lacunae on Doppler ultrasonography (p = 0.008) were predictors of placenta accreta. Women with a prior delivery by caesarean section have a high incidence of placenta accreta among women with antepartum diagnosis of placenta previa.
The Journal of Maternal-Fetal & Neonatal Medicine, 2015
Abstract Objective: To evaluate whether prenatal diagnosis of intestinal midgut volvulus (a rare ... more Abstract Objective: To evaluate whether prenatal diagnosis of intestinal midgut volvulus (a rare condition due to the small bowel loops twisting) can improve the prognosis of the newborns. Methods: In our Prenatal Diagnosis Center, eight cases of intestinal volvulus observed between 2007 and 2014 were retrospectively considered. Ultrasonographic signs can be direct and specific (whirlpool sign, coffee bean sign) or indirect and non-specific (abdominal mass, dilated bowel loops, pseudocysts, ascites, polyhydramnios). Results: Prenatal diagnosis was performed at 20–34 weeks of gestation. All newborns were exposed to an emergency surgery: the major complication was due to cystic fibrosis. Conclusions: An early suspicion of intestinal volvulus allows the clinician to refer the patient to a tertiary center so to confirm the diagnosis and perform an appropriate follow-up in order to identify the proper time of delivery. The prognosis of the babies with prenatal intestinal volvulus depends on the length of the segment involved, on the level of intestinal obstruction, on the presence of meconium peritonitis and on the gestational age at birth. Our experience, according with the literature, suggests that ascites and absence of abdominal peristalsis are ultrasonographic signs that, in the third trimester of pregnancy, correctly lead to an immediate delivery intervention.
Prevalence of congenital heart disease increases with nuchal translucency (NT) thickness. First-t... more Prevalence of congenital heart disease increases with nuchal translucency (NT) thickness. First-trimester fetal bradycardia may result from heart block associated with complex congenital heart disease. We report two cases detected in the first trimester of pregnancy, in which both fetuses showed an increased nuchal translucency and bradycardia. Fetal karyotype was normal in both fetuses. First-trimester fetal echocardiography was performed and, in both cases, complex congenital heart disease was diagnosed. We discuss the added role of fetal heart rate in first-trimester ultrasound screening, in fetuses with increased nuchal translucency and normal karyotype. We stress, as well, the importance of echocardiography performed in the first trimester as a potential tool for early diagnosis in selected cases.
Abstract: There are few 3D well-documented studies about thoraco-abdominal malformations, except ... more Abstract: There are few 3D well-documented studies about thoraco-abdominal malformations, except for the evaluation of fetal lung volume. Three-dimensional ultrasound provides additional diagnostic information for the evaluation of fetal thorax both for the diagnosis of skeletal anomalies and the biometric measurements of lungs. 3D adds few information about the diagnosis of gastrointestinal malformations, but 3D images are an effective tool to make a careful advice with parents and pediatric surgeons, especially in fetuses with anterior wall defects. Until now its use must be reserved in a research setting and offered to high-risk patients in order to understand which role 3D may play in the study of thoraco-abdominal malformations as a screening or diagnostic tool.
Transvaginal ultrasonography (TVS) and serum biomarkers are widely used in clinical practice to t... more Transvaginal ultrasonography (TVS) and serum biomarkers are widely used in clinical practice to triage adnexal masses, but the effectiveness of current biomarkers is quite weak. To determine the best way to diagnose the patients with adnexal masses, in terms of diagnostic accuracy and economic costs, among four triage strategies: International Ovarian Tumor Analysis group's simple rules (SR) for the interpretation of TVS with the addition of subjective assessment (SA) by an experienced ultrasound operator only when TVS results are inconclusive (hereafter defined as SR±SA), SR±SA+CA125, SR±SA+HE4, and SR±SA+ROMA. Our main hypothesis was that the addition of the biomarkers (CA125, HE4 or ROMA algorithm) to SR±SA could improve the triage of these patients in terms of diagnostic accuracy (i.e., malignant versus benign). As secondary analyses we estimated the cost-effectiveness of the four strategies and the diagnostic accuracy of SR±SA at the study hospitals. From February 2013 to January 2015, 447 consecutive patients who were scheduled for surgery for an adnexal mass at the S.Anna and Mauriziano Hospitals in Turin were enrolled in this multi-center prospective cohort study. Preoperative TVS was performed and preoperative CA125 and HE4 levels were measured. Pathology reports were used to assess the diagnostic accuracy of the four triage strategies, and the costs of each strategy were also calculated. 391 patients were included in the analysis: 57% (221) were premenopausal and 43% (170) were postmenopausal. The overall prevalence of malignancy was 21%. SR were conclusive in 89% of patients; the overall performance of SR±SA was: sensitivity 82%, specificity 92%, and positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio: 74%, 95%, 10.5, and 0.19, respectively. In premenopausal women, mean costs varied from €36.4 for SR±SA, to €70.1 for SR±SA+ROMA. The addition of biomarkers to SR±SA showed no diagnostic advantage compared to SR±SA and was also more costly. Among postmenopausal women, mean costs varied from €39.5 for SR±SA, to €73.2 for SR±SA+ROMA. SR±SA+CA125 and SR±SA+ROMA had a higher sensitivity (92%, 95% confidence interval [CI] 85-99% for both) than SR±SA (81%, 95% CI 71-91%), but SR±SA had a higher specificity (84%, 95% CI 77-91%). SR±SA+CA125 and SR±SA+ROMA improved diagnostic accuracy, each diagnosing 33.3% more malignant adnexal masses. Compared to SR±SA alone, SR±SA+CA125 showed a net reclassification improvement (NRI) of 28.8% at an extra cost of €13, while the extra cost for SR±SA+ROMA was €33, being the gain in terms of NRI superimposable with SR±SA+CA125. In our study sample SR±SA seems to be the best strategy to triage adnexal masses. Among postmenopausal women, SR±SA+CA125 increased the NRI at a reasonable extra cost. Our data does not justify the use of HE4 and ROMA in the initial triage of adnexal masses.
OBJECTIVES To evaluate the diagnostic performance of third trimester ultrasound for the diagnosis... more OBJECTIVES To evaluate the diagnostic performance of third trimester ultrasound for the diagnosis of clinically significant Placenta accreta spectrum disorder (PAS) in women with a low-lying placenta (less than 20 mm from the internal cervical os) or placenta praevia (covering the os) METHODS: Pregnant women with a low-lying placenta or placenta praevia, age ≥ 18 years and gestational age at ultrasound ≥ 26+0/7 weeks of gestation were prospectively included in the study. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs: (1) obliteration of the hypoechoic space between the uterus and the placenta; (2) interruption of the hyperechoic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. In order to assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprehensive of both active management at delivery and histopathological confirmation of PAS was considered as the reference standard. PAS was considered of clinical significance if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation, uterine artery embolization. RESULTS A total of 568 women underwent transabdominal and transvaginal ultrasound examinations. Of them, 95 delivered in local hospitals and placental pathology according to the study protocol was therefore not available. Among the 473 for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%). A normal hypoechoic space between the uterus and the placenta reduces post-test probability of PAS from 21% to 5% in women with a low-lying placenta or placenta previa in the third trimester of pregnancy, and from 62% to 9% in the subgroup of women with previous cesarean section and anterior placenta. The absence of lacunae reduces post-test probability of PAS from 21% to 9% in women with low-lying placenta or placenta previa in the third trimester of pregnancy, and from 62% to 36% in the subgroup with previous cesarean section and anterior placenta. On the other side, when lacunae are seen the post-test probability increases from 21% to 59% in the whole study population and from 62% to 78% in women with placenta previa, previous cesarean section and anterior placenta. CONCLUSIONS Grey-scale ultrasound is a good test to identify pregnancies at low risk of PAS in this high risk population. Ultrasound can be safely used to guide management decisions, concentrating greater resources in patients with the higher risk of clinically significant PAS This article is protected by copyright. All rights reserved.
Risk of needlestick injuries (NSIs) is high in surgical staff. Medical students and trainees have... more Risk of needlestick injuries (NSIs) is high in surgical staff. Medical students and trainees have reported the highest rate of NSIs, and Obstetrics and Gynecology is considered a high-risk specialty. The risk associated to NSIs is further increased by the high prevalence of blood borne pathogens in the population. Nevertheless, the degree of concern about contraction of these serious infections has been reported significantly lower over time, showing diminishing attitudes toward prevention of exposure and lack of consideration as a major problem, in fact most of NSIs resulted unreported. Therefore, education is fundamental to change individual attitudes and behaviors, to improve awareness and increase the use of standard protections, in order to reduce the injury rate and implement reporting to hospital surveillance systems. The proposed study aims to assess NSIs in trainees currently attending residency programs in Obstetrics and Gynecology in all academic hospitals of Italy, with a standardized, pre-piloted, national-based survey. At this purpose, we developed the Obstetrics Needlestick Injury Questionnaire (ONSI-Q), a 40-items survey that will be completed via a web-based platform. The ONSI-Q investigates real incidence of NSIs, adopted protection practices, presence of associated risk factors, and attitudes and rate of the reported accidents among trainees during obstetric procedures (suture of perineal tear/episiotomy and cesarean section). These results will provide the opportunity to investigate an underestimated priority, in order to encourage educational practices with the aim to improve prevention and reporting strategies, and therefore increase occupational safety in this high-risk surgical specialty
Abnormally invasive placenta (AIP) includes placenta accreta, increta, and percreta and represent... more Abnormally invasive placenta (AIP) includes placenta accreta, increta, and percreta and represents major complications of pregnancy. This study was designed to assess the role of ultrasonography in the identification of AIP among pregnant women with antepartum diagnosis of placenta previa. A cross-sectional study was performed between May 2015 and April 2016 in 11 centers, including 242 women with antepartum diagnosis of placenta previa. Ninety-eight out of 242 (40.49%) women had a histological diagnosis of placenta accreta. A higher number of caesarean deliveries (p = 0.001) and curettages (p = 0.027) and older age of the woman at the delivery (p = 0.031) were identified as risk factors for placenta accreta. The presence of irregularly shaped placental lacunae (vascular spaces) within the placenta (p = 0.008), protrusion of the placenta into the bladder (p < 0.0001), and turbulent blood flow through the lacunae on Doppler ultrasonography (p = 0.008) were predictors of placenta accreta. Women with a prior delivery by caesarean section have a high incidence of placenta accreta among women with antepartum diagnosis of placenta previa.
The Journal of Maternal-Fetal & Neonatal Medicine, 2015
Abstract Objective: To evaluate whether prenatal diagnosis of intestinal midgut volvulus (a rare ... more Abstract Objective: To evaluate whether prenatal diagnosis of intestinal midgut volvulus (a rare condition due to the small bowel loops twisting) can improve the prognosis of the newborns. Methods: In our Prenatal Diagnosis Center, eight cases of intestinal volvulus observed between 2007 and 2014 were retrospectively considered. Ultrasonographic signs can be direct and specific (whirlpool sign, coffee bean sign) or indirect and non-specific (abdominal mass, dilated bowel loops, pseudocysts, ascites, polyhydramnios). Results: Prenatal diagnosis was performed at 20–34 weeks of gestation. All newborns were exposed to an emergency surgery: the major complication was due to cystic fibrosis. Conclusions: An early suspicion of intestinal volvulus allows the clinician to refer the patient to a tertiary center so to confirm the diagnosis and perform an appropriate follow-up in order to identify the proper time of delivery. The prognosis of the babies with prenatal intestinal volvulus depends on the length of the segment involved, on the level of intestinal obstruction, on the presence of meconium peritonitis and on the gestational age at birth. Our experience, according with the literature, suggests that ascites and absence of abdominal peristalsis are ultrasonographic signs that, in the third trimester of pregnancy, correctly lead to an immediate delivery intervention.
Prevalence of congenital heart disease increases with nuchal translucency (NT) thickness. First-t... more Prevalence of congenital heart disease increases with nuchal translucency (NT) thickness. First-trimester fetal bradycardia may result from heart block associated with complex congenital heart disease. We report two cases detected in the first trimester of pregnancy, in which both fetuses showed an increased nuchal translucency and bradycardia. Fetal karyotype was normal in both fetuses. First-trimester fetal echocardiography was performed and, in both cases, complex congenital heart disease was diagnosed. We discuss the added role of fetal heart rate in first-trimester ultrasound screening, in fetuses with increased nuchal translucency and normal karyotype. We stress, as well, the importance of echocardiography performed in the first trimester as a potential tool for early diagnosis in selected cases.
Abstract: There are few 3D well-documented studies about thoraco-abdominal malformations, except ... more Abstract: There are few 3D well-documented studies about thoraco-abdominal malformations, except for the evaluation of fetal lung volume. Three-dimensional ultrasound provides additional diagnostic information for the evaluation of fetal thorax both for the diagnosis of skeletal anomalies and the biometric measurements of lungs. 3D adds few information about the diagnosis of gastrointestinal malformations, but 3D images are an effective tool to make a careful advice with parents and pediatric surgeons, especially in fetuses with anterior wall defects. Until now its use must be reserved in a research setting and offered to high-risk patients in order to understand which role 3D may play in the study of thoraco-abdominal malformations as a screening or diagnostic tool.
Transvaginal ultrasonography (TVS) and serum biomarkers are widely used in clinical practice to t... more Transvaginal ultrasonography (TVS) and serum biomarkers are widely used in clinical practice to triage adnexal masses, but the effectiveness of current biomarkers is quite weak. To determine the best way to diagnose the patients with adnexal masses, in terms of diagnostic accuracy and economic costs, among four triage strategies: International Ovarian Tumor Analysis group's simple rules (SR) for the interpretation of TVS with the addition of subjective assessment (SA) by an experienced ultrasound operator only when TVS results are inconclusive (hereafter defined as SR±SA), SR±SA+CA125, SR±SA+HE4, and SR±SA+ROMA. Our main hypothesis was that the addition of the biomarkers (CA125, HE4 or ROMA algorithm) to SR±SA could improve the triage of these patients in terms of diagnostic accuracy (i.e., malignant versus benign). As secondary analyses we estimated the cost-effectiveness of the four strategies and the diagnostic accuracy of SR±SA at the study hospitals. From February 2013 to January 2015, 447 consecutive patients who were scheduled for surgery for an adnexal mass at the S.Anna and Mauriziano Hospitals in Turin were enrolled in this multi-center prospective cohort study. Preoperative TVS was performed and preoperative CA125 and HE4 levels were measured. Pathology reports were used to assess the diagnostic accuracy of the four triage strategies, and the costs of each strategy were also calculated. 391 patients were included in the analysis: 57% (221) were premenopausal and 43% (170) were postmenopausal. The overall prevalence of malignancy was 21%. SR were conclusive in 89% of patients; the overall performance of SR±SA was: sensitivity 82%, specificity 92%, and positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio: 74%, 95%, 10.5, and 0.19, respectively. In premenopausal women, mean costs varied from €36.4 for SR±SA, to €70.1 for SR±SA+ROMA. The addition of biomarkers to SR±SA showed no diagnostic advantage compared to SR±SA and was also more costly. Among postmenopausal women, mean costs varied from €39.5 for SR±SA, to €73.2 for SR±SA+ROMA. SR±SA+CA125 and SR±SA+ROMA had a higher sensitivity (92%, 95% confidence interval [CI] 85-99% for both) than SR±SA (81%, 95% CI 71-91%), but SR±SA had a higher specificity (84%, 95% CI 77-91%). SR±SA+CA125 and SR±SA+ROMA improved diagnostic accuracy, each diagnosing 33.3% more malignant adnexal masses. Compared to SR±SA alone, SR±SA+CA125 showed a net reclassification improvement (NRI) of 28.8% at an extra cost of €13, while the extra cost for SR±SA+ROMA was €33, being the gain in terms of NRI superimposable with SR±SA+CA125. In our study sample SR±SA seems to be the best strategy to triage adnexal masses. Among postmenopausal women, SR±SA+CA125 increased the NRI at a reasonable extra cost. Our data does not justify the use of HE4 and ROMA in the initial triage of adnexal masses.
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