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Folic acid (FA) supplementation prevents neural tube defects (NTDs), but the effects on other reproductive outcomes are unclear. While common recommendation is 0.4 mg/day in addition to regular nutrition, the most appropriate dose of FA is still under debate. We investigated the effects of a higher dose of periconception FA on reducing adverse reproductive outcomes. In this multicenter double-blind randomized controlled trial (RCT), 1060 women (aged 18–44 years and planning a pregnancy) were randomly assigned to receive 4.0 mg or 0.4 mg of FA daily. The primary outcome was the occurrence of congenital malformations (CMs). A composite outcome including one or more adverse pregnancy outcomes was also evaluated. A total of 431 women had a natural conception within 1 year. The primary outcome occurred in 8/227 (3.5%) women receiving 4.0 mg FA and 9/204 (4.4%) women receiving 0.4 mg FA (RR 0.80; 95%CI 0.31 to 2.03). The composite outcome occurred in 43/227 (18.9%) women receiving 4.0 mg FA and 75/204 (36.8%) women receiving 0.4 mg FA (RR 0.51; 95%CI 0.40 to 0.68). FA 4.0 mg supplementation was not associated with different occurrence of CMs, compared to FA 0.4 mg supplementation. However, FA 4.0 mg supplementation was associated with lower occurrence of other adverse pregnancy outcomes.

Current data show that maternal mental conditions affect about 10% of pregnant women worldwide. Assessing timing and patterns of mental health illness, therefore, is critical to ensure the wellbeing of the mother, the new-born and the whole family. The aim of this review is to summarize the latest evidence linking maternal mental disorders and adverse reproductive outcomes. Following the PRISMA guidelines for systematic reviews, a literature search was conducted to ascertain the possible impact of mental health conditions on reproductive outcomes before and during pregnancy. The comprehensive strategy included cohort studies, randomised controlled trials and literature reviews on women with Primary Maternal Mental Illness (PMMI) and Secondary Maternal Mental Illness (SMMI) considering periconceptional, obstetric and foetal-neonatal outcomes. PubMed, WoS, CINAHL and Google scholar were used for the search. Cross-referencing in bibliographies of the selected papers ensured wider study capture. Evidence linking depressive disorders and infertility among PMMI is weak. Given this, women with prior mental conditions experience additional distress when undergoing fertility treatments. Primary mental disorders may also increase the risk of miscarriage and other pregnancy complications (e.g., gestational diabetes). For SMMI, there is more robust evidence correlating Preterm Birth (PTB) and Low Birth Weight (LBW) with common mental disorders which develop during pregnancy. Prevention and management of maternal mental health diseases and minor mental conditions within the first 1000 days’ timeframe, should have a place in the holistic approach to women going through reproductive decisions, infertility treatment and pregnancy.

No Abstract.Keywords: Cesarean section, peritoneal closure, parietal hematoma, hemoperitoneum

Objective(s) To assess incidence, risk factors, management, and short and long-term outcomes of unintentional transvesical caesarean section (UTV-CS) defined as any extraction of the fetus through a double full thickness bladder wall cystotomy. Study design Data about all UTV-CS between January 2013 and December 2017 were retrieved searching the diagnosis of bladder injury and bladder repair during caesarean section (CS) in our comprehensive computerized labor and delivery database and register. CS with bladder wall injury not classified as UTV-CS were excluded. Data analysis included maternal history, demographics and obstetric parameters, details regarding CSs, bladder injury location and extension, and short- and long-term maternal outcomes. Results Among 28,822 deliveries, 7,616 (26.42%) were CSs. Three cases of UTV-CS were identified with comprehensive incidence of 0.039%. We provided details of the reported cases and described bladder repair procedure. Conclusion(s) This is the first study that assessed the incidence of UTV-CS. UTV-CS risk factors are consistent with factors related to milder bladder injuries. The risk of bladder injury during CS should be always considered, despite the low incidence of this complication. Prompt diagnosis and surgical repair seem to allow avoiding severe complications and recovery of a normal urological function even in UTV-CS.

The desire for pregnancy in sickle cell disease (SCD) women has become a true challenge for hematologists, requiring a multidisciplinary approach. Erythrocytapheresis (ECP) is an important therapeutic tool in SCD, but only limited data on starting time and the effects of ECP during pregnancy are available.This is a double-center retrospective cross-sectional study on a total of 46 single pregnancies in SCD women from January 2008 to June 2017. ECP was started at 10.7 ± 5.2 weeks of gestation, and prophylactic enoxaparin (4,000 U daily) was introduced due to the reported high prevalence of thromboembolic events in pregnant SCD women.The alloimmunization ratio was 2.1 per 1,000 and the alloimmunization rate was 5.6%. In early ECP-treated SCD women, no severe vaso-occlusive crisis, sepsis or severe infection, or preeclampsia or eclampsia were observed. We found normal umbilical arterial impedance during pregnancy, suggesting an optimal uteroplacental function in early ECP-treated SCD women. This was also supported by the improvement in newborn birthweights compared to previous studies. In our cohort, three SCD women were started later on ECP (20-25 weeks), and gestation ended with late fetal loss. Placenta pathology documented SCD-related damage and erythroblasts in placental vessels, indicating fetal hypoxia.Collectively, our data generate a rationale to support a larger clinical trial of early ECP program in SCD pregnancy.

Intramural hematoma of the esophagus is a rare injury causing esophageal mucosal dissection. Forceful vomiting and coagulopathy are common underlying causes in the elderly population taking antiplatelets or anticoagulation agents. Acute retrosternal pain followed by hematemesis and dysphagia differentiates the hematoma from other cardiac or thoracic emergencies, including acute myocardial infarction or aortic dissection. Direct inspection by endoscopy is useful, but chest computed tomography best assesses the degree of obliteration of the lumen and excludes other differential diagnoses. Intramural hematoma of the esophagus is generally benign and most patients recover fully with conservative treatment. Bleeding can be managed medically unless in hemodynamically unstable patients, for whom surgical or angiographic treatment may be attempted; only rarely esophageal obstruction requires endoscopic decompression. We report an unusual case of esophageal hematoma, presenting in a young preeclamptic woman after surgical delivery of a preterm twin pregnancy, with a favorable outcome following medical management.

BACKGROUND Epoxyeicosatrienoic acids (EETs) derived from cytochrome P450 (CYP)-dependent metabolism of arachidonic acid are increased in the plasma of women with preeclampsia as compared with normal pregnancy and are significantly higher in fetal than in maternal plasma and erythrocytes. We hypothesized that differences in EET synthesis or metabolism in the feto-placental unit contributed to the observed differences in circulating EETs. METHOD To evaluate EETs, formation as well as the expression of relevant CYP isoforms and the metabolizing enzyme, soluble epoxide hydrolase (sEH), biopsies of placenta were collected from 19 normal pregnancy and 10 preeclampsia at the time of cesarean section delivery. EETs were extracted from tissue homogenates and analyzed by liquid chromatography coupled with tandem mass spectrometry. RESULTS Both cis-EETs and trans-EETs were detected in the placenta. Concentration of total EETs was higher in the placenta from preeclampsia compared with normal pregnancy (2.37 ± 1.42 ng/mg vs. 1.20 ± 0.72 ng/mg, mean ± SD, P

We tested the hypothesis that maternal peripheral blood leukocytes contribute to elevated levels of soluble TNF receptors (sTNFR) in preeclampsia (PE) with concomitant intrauterine growth restriction (IUGR). TNFR1 and TNFR2 were evaluated in a cross-sectional study comparing preeclamptic (n = 15) with or without IUGR versus normotensive pregnant women (PREG, n = 30), and non-pregnant controls (Con; n = 20). Plasma levels of sTNFR1 were higher in PE (1675.0 ± 227.1 pg/mL) compared with PREG (1035.0 ± 101.1 pg/mL) and Con (589.3 ± 82.67 pg/mL), with the highest values observed in PE with IUGR (2624.0 ± 421.4 pg/mL; n = 6). Plasma sTNFR2 was higher during pregnancy (PE: 1836.0 ± 198.7 pg/mL; PREG: 1697.0 ± 95.0 pg/mL) compared with Con (598.3 ± 82.7 pg/mL). Urinary levels of sTNFR1 and sTNFR2 were higher in PE and PREG compared with the Con group. Abundance of TNFR1 mRNA in peripheral blood leukocytes was strongly correlated with plasma levels of sTNFR1 in PE. However, TNFR2 mRNA accumulation in leukocytes did not correlate with sTNFR2 plasma levels. The level of sTNFR1 in plasma was correlated with body weight of the newborn (r = -0.56). The data suggest that maternal leukocytes contribute to sTNFR1 levels in plasma in association with decreasing newborn weight and PE with concomitant IUGR.

To assess prevalence and causes of severe acute maternal morbidity cases and evaluate their impact on feto-maternal wellbeing and on facility resources.Observational retrospective study adopting management-based criteria in a tertiary care public hospital during a 5-year period. Criteria adopted were: intensive care unit admission, blood transfusion ≥ 4 units, emergency peripartum hysterectomy and arterial embolization at any time during pregnancy.A total of 80 cases were identified, most of them (97.5%) through a combination of two criteria, ICU admission and blood transfusion. Commonest severe obstetric morbidities were major obstetric haemorrhage (48.8%) and hypertensive disorders (27.5%). Immigrant status (OR 1.68, 95% CI 1.03-2.7), pre-term birth (OR 4.15, 95% CI 2.5-6.8), Caesarean section (OR 7.74,95% CI 4.2-14.3) were factors significantly associated with SAMM cases. Major abdominal surgery was necessary in 26 women (32.5%), with emergency peripartum hysterectomy in 11 (13.5%). These events led to an average blood consumption per woman of 6.5 ± 12.8 units and a mean hospital stay of 8.9 ± 5.0 days, significantly longer (p0.001) than the average duration of post-delivery care. Maternal mortality to morbidity ratio was 1:80.An integrated intervention-based approach proved to be effective in finding severe acute maternal morbidity cases. Information on underlying causes and associated risk factors may improve prevention and treatment of obstetric morbidities, thus reducing feto-maternal adverse effects and hospital expenditures.

Objective To present a rare case of endometrial stromal sarcoma arising in endometriosis of the rectovaginal septum. Design Case report. Setting Academic tertiary referral center for endometriosis treatment. Patient(s) A 50-year-old woman with a history of endometriosis presented with catamenial rectal pain and deep dyspareunia. Imaging findings suggested new endometriotic lesions in the rectovaginal space. Intervention(s) Total hysterectomy, salpingo-oophorectomy, and excision of the lesion in the rectovaginal septum were performed. Although extemporary pathology confirmed endometriosis, the final histologic diagnosis was extrauterine adenosarcoma in the rectovaginal septum. Two years later, recurrence of the malignancy occurred and was treated by resecting the new perirectal mass. Subsequent radiotherapy and chemotherapy were administered. Main outcome measure(s) Imaging findings at follow-up evaluation. Result(s) The patient was in good health for 2 years after the initial surgery, when she developed a new lesion at the site of the previous resection. The histologic appearance of the lesion was consistent with recurrence of the tumor. After postoperative therapy, the patient is now without evidence of disease. Conclusion(s) Malignant transformation of endometriosis should be considered in the differential diagnosis of a new pelvic lesion in a patient with a history of endometriosis.

The study evaluates the mode of delivery and quality of care given to 1014 pregnant women not belonging to the European Union (EU) during the 10-year period, 1992-2001. The non-EU patients were delivered significantly more often by caesarean section than Italian controls, 35.0% vs. 29.3% (P

Our objectives were to compare the prevalence of sexually transmitted infections (STIs) in 103 women undergoing induced legal abortion (LA) and in 101 women with confirmed, recent illegal abortion (IA), in Maputo, Mozambique. For the purpose of this study, LA was considered the abortion provided in the Maputo Central Hospital with the approval of the Ministry of Health, and IA the one not provided through the approved facility, mentioned above. Women with IA were recruited in the outpatient gynaecology ward and women with LA in the emergency gynaecology ward in the Maputo Central Hospital, during the same time period. Serological tests for syphilis (rapid plasma reagin, ELISA-IgG and fluorescent treponemal antibody absorption), gonorrhoea (indirect haemagglutination) and chlamydia (microimmunofluorescence) were carried out. Direct immunofluorescence for detection of Chlamydia trachomatis antigen was done on endocervical smears from all the women. The prevalence of syphilis seropositivity in IA women is twice that of LA women (odds ratio [OR] 2.13; 95% confidence interval [CI] 0.55-9.95), with 10.9% and 4.9%, respectively. Exposure to gonorrhoea in these 2 groups is similar (OR 1.18; 95% CI 0.63-2.20), with seroprevalence of 31.1% in the LA and 34.7% in the IA group. The high titres are also similar in both groups. Serology findings for C. trachomatis indicate prevalence of seropositivity of 40.6% in the LA and 44.4% in the IA group with no significant difference (OR 1.17; 95% CI 0.64-2.13). In conclusion, STIs are highly prevalent in both IA and LA groups in Maputo. Urgent interventions are needed to reduce their prevalence and consequently their adverse consequences.

The objective of this study was to evaluate the efficacy of the local use of oxytocin as adjuvant treatment in conservative surgery for tubal pregnancy. The patients were 25 women with laparoscopic diagnosis of tubal pregnancy who were candidates for salpingotomy. Before salpingotomy, each patient was randomly allocated to intramesosalpingeal injection of 20 IU oxytocin diluted to 20 ml with saline solution or 20 ml saline solution. The surgeon then proceeded with salpingotomy and removal of the pregnancy according to the usual technique. The main outcome measures were bleeding during salpingotomy, ease of removal of the pregnancy, bleeding at the site of the pregnancy, and need for recourse to salpingectomy. Twelve women were randomized to the oxytocin group and 13 to the control group. Examination of the surgeons' assessments of the difficulties encountered at the different stages of surgery revealed statistically significant differences between the oxytocin group and controls in each variable. In particular, the amount of endosalpingeal bleeding after removal of the pregnancy was less in the oxytocin group. In one control patient, persistent bleeding due to incomplete trophoblast removal forced the surgeon to perform salpingectomy. Our results indicate that intramesosalpingeal injection of oxytocin facilitates the performance of conservative laparoscopic treatment for tubal pregnancy.

In the Maputo Central Hospital 103 women undergoing induced legal abortion (LA), 103 women with confirmed, recent illegal abortion (IA), and 100 randomly recruited antenatal clinic (AC) attenders were compared in order to find characteristic features regarding obstetric history, reproductive performance and contraceptive knowledge, attitude and practice. Women with IA were younger, had almost never undergone LA, had more often their first sexual intercourse and their first pregnancy below 20 years of age, had less knowledge of contraceptives and more often had never used contraceptives, had fewer previous spontaneous abortions and fewer previous stillbirths than LA women. There were three maternal deaths, all in the IA group. The most frequent illegal abortionist was a health worker (38%). It is concluded that, in this first comparative African study on IA and LA regarding reproductive profile and post-abortion health consequences, the former are at a disadvantage regarding early unprotected sexual intercourse with first pregnancy at a young age and with almost no experience of safe, legal abortion.

To elucidate whether recent syphilis infection is significantly more prevalent among women with mid-trimester miscarriage than among antenatal care attenders in midtrimester pregnancy.Two categories of pregnant women were compared regarding serological signs of syphilis. Rapid Plasma Reagin (RPR) analyses were done in Mozambique and Veneral Disease Research Laboratory (VDRL) tests in Sweden. In case of RPR and/or VDRL positivity, Treponema pallidum haemagglutination (TPHA) and Captia Syphilis-M were performed.A suburban antenatal care clinic and the emergency ward at the Department of Obstetrics and Gynecology at the Central Hospital in Maputo, Mozambique, were studied June-August 1991.Randomly selected women seeking antenatal care in midtrimester pregnancy (N = 202) were compared with 114 women consecutively entering with clinical signs of midtrimester miscarriage.Among antenatal care attenders, 37/202 (18.3%), and among women with midtrimester miscarriage, 37/114 (32.5%), had syphilis confirmed with the Treponema pallidum haemagglutination test (p0.01). Significant titres of IgM antibodies tended to be more prevalent among women with miscarriage (7.0%) than among women attending antenatal care (4.5%), though the difference only approached statistical significance.The findings suggest a potential association between syphilis seropositivity and midtrimester miscarriage. Present findings justify more extensive studies to establish whether or not recent syphilis infection is a risk factor for midtrimester miscarriage.During June-August 1991 in Mozambique, obstetricians and bacteriologists compared the results of laboratory tests for Treponema pallidum of 114 women entering Maputo Central Hospital with clinical signs of second trimester spontaneous abortion with those of 202 pregnant women in the second trimester who sought prenatal care at a suburban prenatal clinic (Primeiro de Maio). They wanted to learn whether a recent syphilis infection was much more common among women with second trimester miscarriage than among pregnant women in the second trimester who seek prenatal case. 4.5% of the prenatal care group and 7% of the miscarriage group had immunoglobulin M (IgM) antibodies, indicating a recent syphilis infection. The difference between the 2 groups was not significant. The Treponema pallidum hemagglutination test detected a higher prevalence of syphilis in the miscarriage group than in the prenatal care group (32.5% vs. 18.3%; p 0.01), however. All but 1 of the seronegative women had normal pregnancy outcomes. 27% of the women with locally diagnosed seroreactive syphilis did not receive treatment. The findings indicate a possible link between syphilis seropositivity and midtrimester spontaneous abortion.