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Background: Placenta accreta spectrum and vasa previa (VP) are congenital disorders of placentation associated with high morbidity and mortality for both mothers and newborns when undiagnosed before delivery. Prenatal diagnosis of these conditions is essential to allow multidisciplinary management and thus improve perinatal outcomes., Objective: The objective of the study was to compare perinatal outcome in women with placenta accreta spectrum or vasa previa before and after implementation of targeted scanning protocols., Study Design: This retrospective study included 2 nonconcurrent cohorts for each condition before and after implementation of the corresponding protocols (2004-1012 vs 2013-2016 for placenta accreta spectrum and 1988-2007 vs 2008-2016 for vasa previa). Clinical reports of women diagnosed with placenta accreta spectrum and vasa previa during the study periods were reviewed and outcomes were compared., Results: In total, there were 97 cases of placenta accreta spectrum and 51 cases with vasa previa, all confirmed at delivery. In both cohorts, the prenatal detection rate increased after implementation of the scanning protocols (28 of 65 cases [43.1%] vs 31 of 32 cases [96.9%], P < .001, for placenta accreta spectrum and 9 of 18 cases [50%] vs 29 of 33 cases [87.9%], 87.9%, P < .01 for vasa previa). The perinatal outcome improved also significantly in both cohorts after implementation of the protocols. In the placenta accreta spectrum cohort, the estimated blood loss and the postoperative hospitalization stay decreased between periods (1520 ± 845 vs 1168 ± 707 mL, P < .01, and 10.9 ± 14.1 vs 5.7 ± 2.2 days, P < .05, respectively). In the vasa previa cohort, the number of 5 minute Apgar score ≤5 and umbilical cord pH <7 decreased between periods (5 of 18 cases [27.8%] vs 1 of 33 cases [3%]; P < .05, and 4 of 18 cases [22.2%] vs 1 of 33 cases [3%], P < .05, respectively)., Conclusion: The implementation of standardized prenatal targeted scanning protocols for pregnant women with risk factors for placenta accreta spectrum and vasa previa was associated with improved maternal and neonatal outcomes. The continuous increases in the rates of caesarean deliveries and use of assisted reproductive technology highlights the need to develop training programs and introduce targeted scanning protocols at the national and international levels., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The purpose of this study was to analyse the association between free beta hCG (fβhCG) increased levels and pregnancy complications (PC), foetal growth restriction (FGR) and preeclampsia (PE). This connection was evaluated in two stages (i) investigating the association between those PC with first trimester fβhCG and second trimester intact hCG (ihCG), and (ii) studying the association between these two analytes in the same pregnancy. This was a retrospective study in two settings: medical centre that provided data on fβhCG and ihCG levels in pregnancies with FGR and PE, and central laboratory that provided fβhCG and ihCG levels that were compared in the same pregnancy. No association was found between those PC and the hCG analytes, except for elevated ihCG levels and FGR. Elevated fβhCG (>3.00 MoM) was found in 570/16,849 (3.4%) women. However, only 14% of whom had elevated second trimester ihCG. A positive correlation was found between the magnitude of first trimester fβhCG levels and the percentage of women who had elevated second trimester ihCG. This association was determined by the magnitude of the elevation of fβhCG levels. Impact statement What is already known on this subject: The two analytes, first trimester fβhCG and second trimester ihCG, are independently produced and parameters of the biochemical screening during pregnancy. What the results of this study add: Referring to 3.00 MoM as cut-off levels, most pregnancies with elevated levels of first trimester fβhCG will have normal ihCG second trimester levels. What the implications are of these findings for clinical practice and/or further research: The risk of developing pregnancy complications, FGR and PE should be associated with second trimester ihCG levels. About 3.5% of women had high fβhCG levels during the first trimester. However, only 14% also had increased ihCG levels, defined as >3.00 MoM; additional studies are needed to explore the association between increased first trimester fβhCG levels and the risk of developing pregnancy complications, independent of ihCG levels in the second trimester.

As technology becomes increasingly integrated with education, research on the relationships between students' computing-related emotions and motivation following technological difficulties is critical to improving learning experiences. Following from Weiner's (2010) attribution theory of achievement motivation, the present research examined relationships between causal attributions and emotions concerning academic computing difficulties in two studies. Study samples consisted of North American university students enrolled in both traditional and online universities (total N = 559) who responded to either hypothetical scenarios or experimental manipulations involving technological challenges experienced in academic settings. Findings from Study 1 showed stable and external attributions to be emotionally maladaptive (more helplessness, boredom, guilt), particularly in response to unexpected computing problems. Additionally, Study 2 found stable attributions for unexpected problems to predict more anxiety for traditional students, with both external and personally controllable attributions for minor problems proving emotionally beneficial for students in online degree programs (more hope, less anxiety). Overall, hypothesized negative effects of stable attributions were observed across both studies, with mixed results for personally controllable attributions and unanticipated emotional benefits of external attributions for academic computing problems warranting further study.

Purpose: The aim of this study was to investigate the association of clinical, laboratory and ultrasound findings with the surgical diagnosis of adnexal torsion in a retrospective cohort of women operated for suspected torsion., Methods: The study included 199 reproductive age women > 16-year-old who underwent urgent laparoscopy for suspected adnexal torsion between January 2008 and December 2014. The association of various parameters with adnexal torsion was analyzed with a multivariate logistic regression analysis and described as odds ratios (OR) ± 95% confidence intervals (CI)., Results: Adnexal torsion was surgically diagnosed in 111/199 (55.8%) cases. On the multivariate logistic regression analysis, complaints of nausea/vomiting (OR 4.5, 95% CI 1.8-11.1), peritoneal irritation signs (OR 100.9, 95% CI 4.2-2421.9), elevated white blood cell count > 11,000 cells/mL (OR 3.7, 95% CI 1.3-10.8), presence of free pelvic fluid on ultrasound (OR 34.4, 95% CI 6.7-177.9), ultrasound findings suggestive of ovarian edema (OR 4.2, 95% CI 1.5-11.6), ultrasound findings suggestive of benign cystic teratoma (OR 7.8. 95% CI 1.2-49.4) and location of the ultrasound pathology on the right side (OR 4.7. 95% CI 1.9-11.9) were positively associated with adnexal torsion, while ultrasound findings suggestive of hemorrhagic corpus luteum cyst (OR 0.04, 95% CI 0.008-0.2) were negatively associated with adnexal torsion. By combining these eight parameters, the ROC curve was calculated, yielding an area under the curve of 0.93, 95% CI 0.90-0.97 (p < 0.0001)., Conclusion: Routine clinical, laboratory and grayscale ultrasound findings may be incorporated into the emergency room workup of women with suspected adnexal torsion. Laparoscopy should be considered in all patients with suspected adnexal torsion.

Objectives: There is no consensus about the optimal surveillance strategy in women with a diagnosis of vasa previa. The aim of this study was to evaluate the role of the rate of change in cervical length measurements in the management of singleton pregnancies with a diagnosis of vasa previa., Methods: We performed a retrospective case-control study of our databases for pregnancies with a prenatal diagnosis of vasa previa that were followed with transvaginal sonography for cervical length and evaluated the impact of the changes in cervical length on the need for emergency cesarean delivery., Results: The cohort included 29 singleton pregnancies with a prenatal diagnosis of vasa previa in the second trimester. There were 14 and 15 pregnancies that underwent elective and emergency cesarean delivery, respectively. The rate of cervical length shortening was significantly slower for women with elective compared to emergency cesarean delivery (median [range], 0.7 [0.1-2.0] versus 1.5 [0.25-3.0] mm/wk; P = .011). For each additional millimeter-per-week decrease in cervical length, the odds of emergency cesarean delivery increased by 6.50 (95% confidence interval, 1.02-41.20). The receiver operating characteristic curve for the rate of cervical length shortening in the prediction of emergency cesarean delivery yielded an area under the curve of 0.85 (95% confidence interval, 0.69-0.99)., Conclusions: Our findings indicate an association between the rate of cervical length shortening and the risk of emergency cesarean delivery in pregnancies with a diagnosis of vasa previa in the second trimester. Further multicentric studies are required to validate our data prospectively and, in particular, the role of serial cervical length measurements in determining the optimal delivery time for individual cases., (© 2017 by the American Institute of Ultrasound in Medicine.)

Objective: To assess fetal abnormalities leading to very late termination of pregnancy (VLTOP) performed after 32 weeks' gestation., Method: The study population included all pregnant women with singleton pregnancy that underwent VLTOP in our institute because of fetal indications between the years 1998 and 2015., Results: Fifty-seven cases (2.0%) were at ≥32 weeks' gestation and are the subjects of the current study. Our VLTOP cases were subdivided into four categories according to the sequence of events that led to the decision for VLTOP: (1) No routine prenatal screening with an incidental fetal finding discovered after 32 weeks' gestation (9 fetuses ∼16%); (2) Routine early prenatal care raised suspicion of abnormalities, and the final diagnosis was established by additional tests (8 fetuses, ∼14%); (3) Developmental findings detected during the third trimester (21 fetuses; ∼37%), and (4) fetal abnormalities that could have been detected earlier during pregnancy (19 fetuses; ∼33%)., Conclusions: The two categories in which the pregnant women did not underwent any fetal evaluation (i.e. group 1) or those that could have been detected earlier (i.e. group 4) consists ∼49% from our cohort in which VLTOP could have been avoided.

Purpose: To construct a calculator for 'bedside' estimation of morbidly adherent placenta (MAP) risk based on ultrasound (US) findings., Materials and Methods: This retrospective study included all pregnant women with at least one previous cesarean delivery attending in our US unit between December 2013 and January 2017. The examination was based on a scoring system which determines the probability for MAP., Results: The study population included 471 pregnant women, and 41 of whom (8.7%) were diagnosed with MAP. Based on ROC curve, the most effective US criteria for detection of MAP were the presence of the placental lacunae, obliteration of the utero-placental demarcation, and placenta previa. On the multivariate logistic regression analysis, US findings of placental lacunae (OR = 3.5; 95% CI, 1.2-9.5; P = 0.01), obliteration of the utero-placental demarcation (OR = 12.4; 95% CI, 3.7-41.6; P < 0.0001), and placenta previa (OR = 10.5; 95% CI, 3.5-31.3; P < 0.0001) were associated with MAP. By combining these three parameters, the receiver operating characteristic curve was calculated, yielding an area under the curve of 0.93 (95% CI, 0.87-0.97). Accordingly, we have constructed a simple calculator for 'bedside' estimation of MAP risk. The calculator is mounted on the hospital's internet website ( http://www.assafh.org/Pages/PPCalc/index.html ). The risk estimation of MAP varies between 1.5 and 87%., Conclusions: The present calculator enables a simple 'bedside' MAP estimation, facilitating accurate and adequate antenatal risk assessment.

Study Objective: To investigate the use of operative hysteroscopy instead of traditional curettage in women with retained products of conception (RPOC) following first trimester medical abortion, with the aim of reducing post-operative intrauterine adhesions., Design: Retrospective study., Setting: Gynecology department in a University affiliated hospital., Patients: All women treated by hysteroscopy for RPOC following first trimester medical abortion using the mifepristone-misoprostol protocol for pregnancy termination or the misoprostol protocol for early missed abortion from January 2013 to August 2016., Intervention: Operative hysteroscopy for removal of RPOC. Post-operative intrauterine adhesions were assessed by diagnostic office hysteroscopy after 6-8 weeks., Measurements and Main Results: 50 cases were identified. The mean time from medication administration to the operative hysteroscopy was 1.7 ± 0.7 months. Operative hysteroscopy with blunt use of the resectoscopic loop was used to remove all specimens, and all procedures were completed without intra-operative complications. Two patients (4.0%) were readmitted for fever. Pathology confirmed the presence of RPOC in 45 (90.0%) cases. On follow-up office hysteroscopy, a normal uterine cavity without evidence of intrauterine adhesions was seen in 29/29 (100%) women., Conclusion: Hysteroscopy for removal of RPOC following medical abortion is associated with low rates of complications and post-operative intrauterine adhesions., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest relevant to this article.

Introduction: A vasa previa (VP) refers to aberrant chorionic vessels which can either connect the chorionic plate to a velamentous cord (type I) or a succenturiate or accessory lobe to the main placental mass (type II)., Methods: We performed retrospective cohort study of 32 singleton pregnancies diagnosed with VP. The levels of maternal serum alpha-fetoprotein (AFP), human chorionic gonadotropin (hCG) and unconjugated estriol (uE3) were measured at 15-18 weeks as part of the triple test screening for Trisomy 21. The data were subdivided according to the type of VP and compared with those of a control group with central cord insertion and no succenturiate or accessory placental lobe., Results: Twenty one (65.6%) parturient women presented with VP type I and 11 (34.4%) with VP type II. The mean birthweight and placental weight was significantly higher in pregnancies with VP type II than in pregnancies with VP with VP type I (3037.3±400.9 gr vs 2493.5±491.6 gr; p=0.004 and 511.0±47.2 gr vs 367.1±64.3 gr; p<0.0001; respectively). The mean hCG level in VP type II was significantly (p<0.001) higher than those with type I (2.38MoM vs 1.17MoM) and compared to controls (2.38MoM vs 0.99MoM)., Conclusions: There is no obvious impact on both placental and fetal growth in VP type II. By contrast, VP type I is associated with slower feto-placental growth secondary to impaired development and biological functions of the placenta during the first half of pregnancy., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose: Since more senior and attending physicians work in labor wards during morning shifts, we expect a better delivery outcome during that time period., Materials and Methods: A retrospective study was conducted between 1/2005 and 12/2014. Records of 56 428 singleton deliveries from a tertiary hospital in which cord blood pH was routinely measured at birth were analyzed. Time of birth was divided into shifts: 7 AM-3 PM (morning shift), 3 PM-11 PM (afternoon shift), and 11 PM-7 AM (night shift). Additional stratification compared weekdays and weekend deliveries., Results: 19 601, 18 429, and 18 398 neonates were born during morning, afternoon, and night shifts, respectively. There was no significant difference in maternal age, neonatal weight, or mean 5-min Apgar score among the three shift periods. Furthermore, there was no correlation between shift time of delivery and newborn acidosis with respect to cord pH less than 7 (0.1% in each time periods, p = 0.67). Despite the above, instrumental deliveries and cesarean sections were more common in the morning shift compared to the afternoon and night shift, respectively (p = 0.001 each)., Conclusions: Although shift time of delivery was found to be related to mode of delivery it was not related to either 5-min Apgar score or newborn acidosis as reflected by cord pH.

This study assessed the correlation between the magnitude of the elevation in maternal serum human chorionic gonadotropin (MShCG) levels and pregnancy complications. Among 80,716 screened pregnancies, 120 with moderately elevated MShCG (3.00-5.99 MoM) were compared to 84 with extremely elevated MShCG >6.00 MoM. A control series of 120 women with normal MShCG (<3.00 MoM) were matched. Rates of intrauterine growth restriction, preterm labour, antepartum foetal death (APFD), pre-eclampsia, and placental abruption were analysed. We found that the study group had more adverse outcomes than the control group (73/204 [36%] vs. 18/120 [15%]; p < .0001). The rate was higher in the extremely elevated group than in the moderately elevated group (43/84 [51%] vs. 30/120 [25%]; p < .0001). All 12 cases of APFD (14%) occurred among the extremely elevated series. In conclusion, adverse pregnancy outcomes are more common in women with extremely elevated MShCG. The patients should receive counselling regarding this trend and undergo close pregnancy monitoring. Impact statement • What is already known on this subject?In addition to its contribution to Down syndrome (DS) screening, maternal serum human chorionic gonadotropin (MShCG) levels are a marker for pregnancy complications such as intrauterine growth restriction (IUGR), preterm labour (PTL), antepartum fatal death (APFD), pre-eclampsia (PE), placental abruption (PA) and fetal malformations with or without chromosomal aberrations. • What the results of this study add? We found that in the presence of elevated MShCG levels, the incidence of IUGR and PTL increased. PE increased clinically, but statistical significance was seen only when MShCG was extremely elevated (≥ 6.00 MoM). APFD and PA were associated with very high MShCG levels only. • What the implications are of these findings for clinical practice and/or further research? Women with high MShCG levels should be counselled. In case of very high levels (≥ 6.00 MoM), the risk of APFD and PA should be discussed. The pregnancy should be monitored for IUGR, PTL and PE. In view of the limited number of enrolled patients with very high levels of MShCG, the experience of other institutions is needed to corroborate these findings.

Background: Twin pregnancies are at higher risks of velamentous cord insertion and vasa previa. In vitro fertilization is an additional risk factor of abnormal cord insertion and thus the incidence of vasa previa is likely to increase over the next decades., Objective: We sought to evaluate the role of ultrasound imaging in optimizing the management of twins diagnosed with vasa previa antenatally., Study Design: We searched our database for twin pregnancies diagnosed with vasa previa and managed antenatally using measurements of cervical length and performed a systematic review of articles that correlated prenatal diagnosis of vasa previa in twins and pregnancy outcome. PubMed and MEDLINE were searched for studies published from 1987 through October 20, 2016, using specific medical subject heading terms, key words, and their combination. The primary eligibility criteria were articles that correlated prenatal ultrasound imaging of vasa previa and pregnancy outcome in twins. The secondary eligibility criteria was the use of cervical length in the management of twin pregnancies diagnosed antenatally with vasa previa. Two authors independently assessed inclusion criteria, data extraction, and analysis. The final selection included 3 case report series, 9 retrospective cohort studies, and 1 retrospective case-control study of vasa previa diagnosed prenatally and confirmed at birth in twin pregnancies., Results: The search of our databases identified 6 cases of dichorionic-diamniotic twins and 1 case of monochorionic-diamniotic twins diagnosed prenatally with vasa previa between 22-29 weeks and managed using cervical length. Two cases were delivered by emergency because of rapid changes in cervical length in one and bleeding on placenta previa in the other at 33 and 30 weeks, respectively. The systematic review identified data on 56 cases. The incidence of twin pregnancies diagnosed antenatally with vasa previa in the cohort and case-control studies was 11.0%. Data on chorionicity were available in only 34 cases and cervical length measurements were used by only the authors of 2 case reports and 4 cohort studies. Velamentous cord insertion was the most common additional ultrasound findings in twins presenting with vasa previa in both our series and the systematic review., Conclusion: Vasa previa is associated with specific prenatal and obstetric complications with different outcomes in singletons compared to twins. Data on the diagnosis and management of vasa previa in twin pregnancies are limited but there is enough evidence to warrant guidelines for targeted screening. To enable the development of efficient management protocols tailored to the need of individual cases, future studies of the screening, diagnosis, and management of vasa previa should be prospective and multicentric with detailed data on twins including chorionicity and use of cervical length., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Growing evidence suggests that cesarean scar pregnancy (CSP) and morbidly adherent placenta (MAP) may represent a continuum of the same disease., Objectives: To investigate and compare the prior risk factors in women with either CSP or MAP., Methods: The study included 33 women diagnosed with CSP in our department between 2006 and 2014. For each CSP case, two pregnant patients with MAP were matched for hospitalization date from delivery ward records, constituting the control group., Results: In both groups, maternal age, parity, and previous early and late abortions were similar. The rate of conception by assisted reproductive technologies was 9% in both groups. Although the number of previous cesarean sections was statistically different between CSP versus MAP (2.0 ± 1.0 vs. 1.0 ± 1.0, respectively, P = 0.006), the leading indication of previous cesarean section was breech presentation in both groups (28.1% and 27.8%, respectively, P > 0.05)., Conclusions: CSP and MAP share similar prior risk factors. Due to high morbidity in both diseases, further research is needed toward reducing the known etiological factors contributing to the growing number of both complications.

Objective: The article aimed to assess the spectrum of fetal renal tract abnormalities as a major finding leading to termination of pregnancy (TOP)., Method: The study population included all pregnant women with singleton pregnancy who underwent TOP in our institute because of fetal renal tract indications between 1998 and 2015. We specifically excluded TOPs performed because of multiple pregnancies, multisystem defects, abnormal karyotype and chromosomal or genetic defect not related to renal tract abnormalities. The patients were stratified into late TOP (≥24 weeks' gestation) and early TOP (<24 weeks' gestation)., Results: There were 97 (3.5%) cases of TOP because of fetal renal abnormalities and are the subjects of this study. Of these cases, 19 (19.6%) were at ≥24 weeks' gestation. Renal cystic disease was the leading indication for late TOP compared with early TOP group (31.8% vs 21.8%, respectively, p = 0.001). Routine prenatal care raised suspicion of abnormalities in 11 (50.9%) cases, and diagnosis was established by additional tests. Abnormal findings were either missed in one (5.3%) case or developed later in two (10.5%) cases. No routine prenatal screening was performed in the remaining five (26.3%) cases., Conclusions: We found a different distribution for fetal renal tract abnormalities leading to late versus early TOP. As many of renal tract malformations could have been diagnosed earlier (~32%), timely scanning may reduce the need for late TOPs in some cases. © 2016 John Wiley & Sons, Ltd., (© 2016 John Wiley & Sons, Ltd.)

Objective: To assess fetal abnormalities leading to termination of pregnancy (TOP) performed in twin pregnancies., Method: The current study consisted of all women with dichorionic twin pregnancies (study group) who underwent TOP due to fetal abnormalities in our institute from 1999 to 2015. The data were compared to our registry of all parturient women with a singleton pregnancy (control group) that underwent TOP due to fetal anomalies at the same period., Results: There were 2495 cases of TOP because of fetal indications during the study period. Of them, 86 (3.4%) and 2409 (96.6%) were from the study and control group, respectively. Structural anomalies were the leading indication for TOP in twins compared with singleton pregnancies (81.4% versus 50.9%, respectively, p < 0.0001). For twins, the leading indication for TOP was central nervous system (CNS) abnormalities and it was more common compared with singleton pregnancies (26.1% versus 12.2%, respectively, p < 0.0001). This was followed by chromosomal/genetic abnormalities (16.3% versus 40.4%, respectively, p < 0.0001)., Conclusions: We found a different distribution for fetal anomalies leading to TOP in twins versus singleton pregnancies. The main indication for TOP in the study group was structural malformations, with a predominance of CNS abnormalities.

Objective: We studied a series of patients with fetal akinesia deformation sequence (FADS)/arthrogryposis multiplex congenita (AMC), with nemaline bodies on muscle specimens, which revealed mutations in the NEB gene., Method: We pathologically assessed seven cases from three families, who presented with AMC/FADS. Targeted genetic analysis for Ashkenazi Jewish mutation (in relevant patients) was followed by next-generation sequencing and multiplex ligation-dependent probe amplification., Results: All cases were detected on prenatal ultrasound. Characteristic nemaline bodies on muscle specimens were demonstrated in at least one case in each of the nuclear families. In the Ashkenazi Jewish family, the known founder mutation was compounded by one recurrent novel splice site. The other two families were of Chinese and Korean origins, and only one pathogenic heterozygous mutation was detected in each., Conclusions: Nemaline myopathy due to NEB mutation(s) leads to FADS/AMC. Currently, mutated NEB is under-recognized as a cause for AMC/FADS. Our study attempts to raise recognition of this gene as a cause, suggesting the NEB gene should be included in genetic panels used for FADS/AMC cases and be fully covered when EXOME sequencing is utilized. A heterozygous mutation may suggest either compounding undetected one or digenic interaction that requires further genetic analyses. © 2016 John Wiley & Sons, Ltd., (© 2016 John Wiley & Sons, Ltd.)

Objective: The present study aims to compare the presence and localization of collagen type IV in the prenasal tissue of fetuses with and without Down syndrome (DS)., Methods: Products of conception were obtained from mid-gestation uterine evacuations of 14 DS fetuses and 15 unaffected controls. Microdissection of the prenasal area and an analysis of the prenasal tissue specimens were performed by a single pathologist, blinded to the karyotype results. Immunohistological presence and localization of type IV collagen were analyzed in the basement membrane (BM), blood vessels, and stroma of the tissues., Results: There were no statistically significant differences in the presence and localization of antibodies for collagen IV in the blood vessels and stroma between the two groups. However, the presence and localization of type IV collagen in the BM of the prenasal skin were significantly higher in DS specimens compared to the control group (P=0.023). When combining both groups altogether, a significant correlation was found between the increased prenasal thickness (PT) and the high presence and location of collagen type IV, irrespective of the karyotype results (Spearman's correlation; R=0.459; P=0.012)., Conclusion: Using the immunohistochemistry technique, we were able to confirm the overexpression of collagen type IV in the BM of the prenasal area. This may explain the sonographic finding of increased PT seen mainly in DS fetuses.

Objectives: Construct a new preeclampsia predicting algorithm in twins., Methods: Twins sampled at 10-13 and 16-20 gestational weeks and their marker values were log transformed into multiples of the gestation-specific medians (MoMs) for singletons and entered into a new logistic regression model with/without prior risk factors., Results: The cohort included 9 PE (18 samples) and 96 unaffected cases (175 samples) twin pregnant women. The algorithm constructed of PlGF, PAPP-A, PP13, Doppler UTPI, and MAP with prior risk factors generated an area under the curve of 0.918, 75% detection rate for 10% false-positive rate., Conclusions: The algorithm effectively forecasted twin risk to develop PE.

Introduction: During their professional careers, physicians and other health care providers are repeatedly exposed to emotional stress. This is usually secondary to coping with the results of a medical error or complicated medical event. Generally, in the above cases, the patient and his/her family are in the center of the medical system, being "the first victim" of such an event, while the involved caregiver, who provided the medical service, is categorized as the "second victim". "Second victims" may feel anxiety, fear, guilt or anger and experience social withdrawal, which may lead to troubling memories, depression and insomnia. Over the years, this situation may lead to deterioration in his/her work and personal life and, in rare circumstances, may lead to pharmaceutical and even alcohol consumption. In the literature there are even some rare case reports of "second victims" who have committed suicide. To meet these challenges, several leading institutions in western countries have developed formal support programmes that allow health care providers to cope with their emotional distress by obtaining timely support in an emphatic, confidential, non-judgmental environment. The above scheme of support is not meant to disrupt any correct medical investigation or to stand between the "second victim" and his superiors, but rather to allow them to cope with these events. We believe that the time has come to develop national support programs appropriate to our culture and behavioural circumstances. Local health care organizations should build a supporting scheme for the "second victims", helping them to cope with these events, thereby assisting them to return to their daily work and former routine.

Objective: To investigate maternal serum inhibin as a marker of pre-eclampsia (PE) in twins., Methods: One hundred forty-three twins and 109 unaffected singleton pregnancies were recruited in the first trimester from the same institution. Blood samples were stored at recruitment and in the second trimester, retrospectively tested for inhibin and values expressed in multiples of the gestation-specific median (MoMs) in singletons, adjusted for maternal weight, as appropriate., Results: The median inhibin level in unaffected twins was 2.04 MoM compared with 1.00 MoM in singletons (P < 0.0001, Wilcoxon Rank Sum Test, one-tailed). Excluding early fetal losses the median in 22 samples from 12 twins with PE was 2.65 MoM compared with 1.99 MoM in 201 samples from 120 unaffected twins (P < 0.02, Wilcoxon Rank Sum Test). This effect was restricted to second trimester samples with medians in cases and controls of 2.86 and 1.91 MoM respectively. Logistic regression of inhibin A together with established PE marker placental growth factor and placental associated plasma protein showed that in the second trimester, it improved screening performance although not reaching statistical significance (P = 0.08)., Conclusions: Inhibin A is a potential second trimester marker of PE in twins. It may improve on existing twin screening protocols but more data are required. © 2016 John Wiley & Sons, Ltd., (© 2016 John Wiley & Sons, Ltd.)

Objective: To evaluate the accuracy of an ultrasound-based scoring system for diagnosing morbidly adherent placenta (MAP)., Methods: This study included pregnant women referred to our ultrasound unit during 2013-2015 because of suspected MAP on a previous ultrasound examination or because they had at least one previous Cesarean delivery. All women were assessed using a scoring system based on the following: number and size of placental lacunae; obliteration of the demarcation between the uterus and placenta; placental location; color Doppler signals within placental lacunae; hypervascularity of the placenta-bladder and/or uteroplacental interface zone; and number of previous Cesarean deliveries. Each criterion was assigned 0, 1 or 2 points and the sum of points yielded the final score. Patients were classified into low, moderate or high probability for MAP based on the final score. The presence of MAP was determined by the surgeon at delivery and clinical descriptions were documented in the electronic patient file. Pathological diagnoses were available only in cases that underwent hysterectomy., Results: In total, 258 pregnant women were included in the study, of whom 23 (8.9%) were diagnosed with MAP. There was a statistically significant difference in the prevalence of MAP when women were grouped according to the scoring system, with 0.9%, 29.4% and 84.2% in the low, moderate and high probability groups, respectively (P < 0.0001). All sonographic criteria of the scoring system were significantly associated with MAP (P < 0.0001). Receiver-operating characteristics (ROC) curves for prediction of MAP using the number of placental lacunae and obliteration of the uteroplacental demarcation yielded an area under the ROC curve of 0.94 (95% CI, 0.86-1.00)., Conclusions: Our proposed scoring system is highly predictive of MAP in patients at risk. This allows an adequate multidisciplinary team approach for the planning and timing of delivery in such cases. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: To compare adnexal torsion characteristics and torsion recurrence rates in a pre- and postmenarchal pediatric and adolescent population., Design: Retrospective cohort study., Setting: University-affiliated medical center., Patient(s): Females <18 years old with surgically diagnosed adnexal torsion., Intervention(s): Adnexal detorsion, cystectomy, salpingectomy, or salpingo-oophorectomy by laparoscopy or laparotomy. Oophoropexy using the utero-ovarian ligament plication technique was performed in cases of recurrent torsion of normal adnexa., Main Outcome Measure(s): The clinical presentation, laboratory and ultrasound characteristics, surgical findings, surgical procedures, pathologic diagnosis, and torsion recurrence rates were analyzed and compared between pre- and postmenarchal patients., Result(s): Twenty premenarchal and 24 postmenarchal patients were identified. The clinical presentation, laboratory findings, and ultrasound characteristics were similar between the two groups, except for a higher prevalence of paraovarian cysts on preoperative ultrasound in the postmenarchal compared with in the premenarchal group (20.8% vs. 0%). For the whole cohort, torsion of normal adnexa constituted 25.0% (11/44) of cases, while torsion of "pathologic" adnexa constituted 75.0% (33/44) of torsion cases. Torsion recurrence was significantly more common among girls whose first torsion episode occurred in the premenarchal period compared with in postmenarche (35% vs. 4.2%). On multivariate logistic regression analysis, torsion recurrence was significantly associated with premenarchal status (odds ratio [OR] = 12.7; 95% confidence interval [CI], 1.1-152.0) and with torsion involving normal adnexa (OR = 19.1; 95% CI, 2.3-154.5)., Conclusion(s): Recurrent torsion is common in patients whose first torsion episode occurred in the premenarchal period and involved otherwise normal adnexa. Ovarian fixation procedures may be considered in patients at risk for torsion recurrence., (Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to compare the accuracy of multiple sonographic fetal weight estimation models in assessing small-for-gestational-age (SGA) fetuses., Materials and Methods: The cohort included all singleton pregnancies recorded at a single medical center from January 2004 to September 2011, with a minimum of 24 weeks of gestation. SGA was defined as a fetal weight of less than the 10th percentile. We used birth weight (BW) distribution curves for our population, matched according to fetal gender and gestational age. Predicted birth weights were calculated using 26 sonographic fetal weight estimation models, including targeted formulas for SGA fetuses., Results: 1218 cases of SGA fetuses that underwent sonographic fetal weight estimation within one week prior to delivery were found. Prediction of fetal weight was significantly less accurate in SGA fetuses than in the general population. The random error for SGA fetuses ranged from 7.2 % to 13.9 % in different models, while the systematic error ranged from -12.8 % to 26 %. Most non-targeted formulas showed a specificity of over 90 % but a sensitivity of only 20 - 35 % in the detection of SGA fetuses, while most targeted formulas had a low specificity but a high sensitivity. The model by Scott et al. was found to be the most accurate in assessing SGA fetuses in our population., Conclusion: Estimation of fetal weight in SGA fetuses is less accurate than in the general population. Some formulas which are designed for SGA are more accurate than others and their use might increase the sensitivity in identifying SGA fetuses, with only a small decline in specificity., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To evaluate the distribution of first- and second-trimester maternal serum markers in twin pregnancy with and without pre-eclampsia., Methods: One-hundred and forty-four twin and 109 unaffected singleton pregnancies were recruited from the same institution. First- and second-trimester maternal blood samples were stored and measured retrospectively for serum placental growth factor (PlGF), pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG) and α-fetoprotein (AFP). All had measurement of first-trimester serum markers, and 167 (66%) had second-trimester tests. Values were expressed in multiples of the gestation-specific median (MoMs) in singletons, adjusted for maternal weight, as appropriate., Results: Pre-eclampsia was diagnosed in 12 (9.0%) twin pregnancies of 133 continuing beyond 22 weeks. In unaffected twin pregnancies, all serum markers were statistically significantly increased (P < 0.0001), consistent with a doubling of concentration. Among twin pregnancies, those with pre-eclampsia had a significantly reduced median PlGF compared with surviving unaffected twin pregnancies (0.96 MoM vs 1.46 MoM; P < 0.0002, two-tailed), whilst median PAPP-A, which is known to be reduced in affected singleton pregnancies, was increased (3.91 MoM vs 2.43 MoM; P < 0.0005, two-tailed). The levels of free β-hCG (P < 0.02) and AFP (P < 0.05) were also significantly raised, but to a lesser extent than was the level of PAPP-A. Using a logistic regression algorithm based on first- and second-trimester PlGF and PAPP-A, together with previously published uterine artery Doppler and mean arterial pressure measurements in the same series, the predicted pre-eclampsia detection rate was 65% for a 10% false-positive rate., Conclusions: In twin pregnancy, the predicted detection rate of pre-eclampsia using first- and second-trimester maternal serum and biophysical markers is good. In contrast to singleton pregnancy, PAPP-A levels are raised in the first trimester of twin pregnancies destined to develop pre-eclampsia and therefore a different prediction algorithm is needed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.)

Background: We sought to investigate and compare the clinical presentation, ultrasound findings, surgical characteristics, and causes of adnexal torsion among three groups: pediatric and adolescent population, reproductive-age women, and pregnant women., Material and Methods: Two hundred twenty-seven surgically confirmed episodes of adnexal torsion in 199 patients treated in our department from January 2008 to December 2014 were retrospectively analyzed., Results: Abdominal pain duration of >24 hours before emergency room presentation was more common in pediatric and adolescent patients compared with reproductive-age and pregnant women (42.3% vs. 28.4% and 15.5%, respectively, p = 0.04). However, there was no difference between the groups in the time interval from their emergency room admission to surgery. Torsion of "normal adnexa" occurred in 11/44 (25.0%) of pediatric and adolescent patients, 30/99 (30.3%) of reproductive-age patients, and 12/56 (21.4%) of pregnant patients, while torsion involving multicystic ovaries occurred in 0%, 4%, and 32.1%, respectively, torsion involving paraovarian cysts occurred in 20.5%, 14.1%, and 1.8%, respectively, and torsion involving benign dermoid cysts occurred in 4.5%, 15.2%, and 5.4%, respectively (p < 0.001). Torsion involving supposedly functional ovarian cysts occurred in 45.5%, 34.3%, and 69.6%, respectively (p < 0.001). The torsion recurrence rates were 18.2% in the pediatric subjects, 19.2% in reproductive-age women, and 10.7% in pregnant women (p = 0.3)., Conclusions: The presentation of adnexal torsion is similar in pediatric and reproductive-age and pregnant women, although the underlying adnexal pathology may be different. Functional ovarian cysts cause the majority of torsion cases in pregnant women. Recurrence of torsion may occur in any age group.

Purpose: The use of maternal serum alpha fetoprotein (MSAFP) levels as a predictor of pregnancy complications (PC) is well established. We hypothesized that the ratio between the MSAFP/AFAFP levels (RATIO) will more accurately predict PC than MSAFP levels alone., Methods: Women who had a MSAFP test followed by amniocentesis were divided into two groups: those who had PC comprised the study group and those who had an uneventful pregnancy served as the control group. Data regarding pregnancy and delivery course were collected. The RATIO between the study and the control groups was compared., Results: 166 women were included in the study, of which 24 had PC. A significant correlation was found between the RATIO and intrauterine growth restriction (IUGR) and week of delivery. Six pregnancies had elevated MSAFP levels; two with RATIO below 2 had uneventful pregnancies. Among the other four pregnancies with RATIO above two, one had IUGR and the other, placental abruption., Conclusion: Our data suggest that the RATIO might serve as a predictor of IUGR and week of delivery. Although the number of patients in the current study was relatively small, the novelty of the proposed simple marker implies that a larger scale study is warranted. Such studies may confirm this finding and a possible advantage of using this RATIO instead of or in addition to MSAFP values for better prediction of pregnancies at risk for PC.

Objective: To compare the incidence of twin-to-twin transfusion syndrome (TTTS) in spontaneous versus IVF-conceived twin pregnancies., Design: Retrospective multicenter study., Setting: University-affiliated tertiary medical centers., Patient(s): Women admitted for 11-14 week's scan between January 1997 and July 2013 who were diagnosed with monochorionic (MC) diamniotic twin pregnancies., Intervention(s): None., Main Outcome Measure(s): Mode of conception, TTTS., Result(s): The study cohort included 327 pregnant women with live MC diamniotic twins. Of them, 284 (86.9%) and 43 (13.1%) were spontaneous and IVF conceived, respectively. The mean maternal age was significantly higher in IVF compared with in spontaneously conceived pregnancies (33.8 ± 5.5 vs. 31.6 ± 5.4, respectively). Thirty-seven twins (11.3%) had TTTS, of whom 36/284 (12.7%) versus 1/43 (2.3%) were spontaneously and IVF conceived, respectively. The mean week of delivery was significantly lower in MC twins diagnosed with TTTS compared with those without TTTS (32.7 ± 3.3 vs. 35.5 ± 2.5, respectively). Furthermore, there was a significantly higher birthweight discordancy in twins diagnosed with TTTS compared with those without (20.6% vs. 11%, respectively)., Conclusion(s): The significantly lower proportion of TTTS found in IVF-conceived twins may suggest a different embryological process that lies at the core of IVF conception of monozygotic twinning., (Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

The first prenatal screening test to be introduced was based on a single maternal serum marker of neural tube defects. Since then various prenatal screening concepts have been developed, the most successful being Down syndrome risk estimation using multiple serum and ultrasound markers. Today a completely new approach to aneuploidy screening is available based on maternal plasma cell-free DNA testing. This has the potential to markedly improve screening performance but routine testing is currently too expensive in a public health setting. However, it can be cost-effective when used in combination with existing multi-maker tests. Some are beginning to broaden prenatal screening to include pregnancy complications such as pre-eclampsia that can be prevented using soluble low-dose aspirin treatment started before 16 weeks of gestation. Prenatal screening for cardiac abnormalities, fragile X syndrome and recessive genetic disorders is underutilized and public health planners should considered a more widespread application of available methods., (Copyright © 2016. Published by Elsevier Inc.)

Objective: To investigate the clinical presentation of women with primary ovarian pregnancy diagnosed in recent years and to compare it to tubal pregnancy., Study Design: Seven women treated for primary ovarian pregnancy from 2002-2013 were retrospectively identified and compared to 42 women with tubal pregnancies (involving either tubal rupture or tubal abortion) operated on during the same period. In the ovarian pregnancy group the pathology examination confirmed primary ovarian pregnancy according to the Spiegelberg criteria., Results: Seven women underwent surgery for primary ovarian pregnancy during the study period. Five women presented with hemodynamic shock. A ruptured ovarian pregnancy was identified in all cases. Wedge resection was performed by laparotomy in 1 case and by laparoscopy in 6 cases. The mean estimated blood loss was significantly higher in those women with ovarian versus tubal pregnancy (1057.1 ± 472.1 mL vs. 250.2 ± 241.5 mL, respectively, p<0.001). Moreover, a statistically significant difference was found when we compared postoperative hospitalization days (2 ± 0.6 vs. 1.3 ± 0.7, respectively; p=0.01) in the ovarian pregnancy group as compared with the tubal pregnancy group., Conclusion: Primary ovarian ectopic pregnancy is still a major challenge for early diagnosis and treatment; it is associated with rupture and massive intraabdominal bleeding.

Campylobacter is a gram-negative, microaerophilic, curved rod and a normal resident of the gastrointestinal flora and may be the cause of disease in animals. Transmission to humans occurs by ingestion of contaminated food or by direct contact with infected animals. In the past few decades, an increasing number of reports have implicated the presence of this organism in human abortions as well. An infectious mechanism due to primary placental inflammatory damage followed by secondary damage to the fetus following placental insufficiency and ischemia was suggested. The most common species of Campylobacter are Campylobacter jejuni and Campylobacter coli, which are classically associated with enteritis in humans. We present a rare case of mid-gestation intrauterine growth restriction (IUGR) associated with maternal bacteremia caused by C. coli infection. Our literature review focuses on Campylobacter infections occurring in the second and third trimesters of pregnancy. In all cases, mild maternal symptoms consisting of fever and weakness were presented. However, associated adverse fetal outcome, including abortions, IUGR or preterm labor may occur more frequently than anticipated. Our report strengthens the importance of awareness to this finding and focuses the need to consume properly cooked meat during pregnancy., (© 2015 John Wiley & Sons, Ltd.)

Background: Despite awareness regarding tubal pregnancy, ovarian pregnancy still remains a diagnostic challenge. The correct diagnosis is most frequently made intraoperatively and requires histopathologic confirmation. Therefore, additional diagnostic measurements are needed for earlier and more accurate detection of ovarian pregnancies which will allow more rapid and efficient treatment., Objectives: To assess the time trends, clinical manifestations, surgical management and post-procedure outcome of 46 primary ovarian pregnancies in a single institution during three time periods., Methods: In this retrospective study we compared 20 patients with primary ovarian pregnancy during the years 1971- 1989 (first period), 19 patients in 1990-2001 (second period) and 7 patients in 2002-2013 (third period). In all cases the pathology examination confirmed primary ovarian pregnancy., Results: The number of tubal ectopic pregnancies almost doubled, from 637 in the first period to 1279 in the third period (P < 0.001). However, there was a significant fall in the number of ovarian ectopic pregnancies, from 20 cases in the first period to 7 cases in the third (P = 0.009). A significant difference was noted when we compared the postoperative hospitalization time (4.06 ± 1.4 vs. 2.0 ± 0.6 days respectively, P = 0.001) in the second versus the third time period., Conclusions: Ovarian pregnancy continues to be a diagnostic challenge, associated with a high rate of circulatory collapse, hemoperitoneum and requirements for blood transfusions, all leading to longer hospitalization.

Objective: The objective of this study was to compare the associations of crown-rump length (CRL) discrepancy with birthweight discordance in spontaneous versus in vitro fertilization (IVF) monochorionic (MC) twin pregnancies., Method: This is a multicenter retrospective study on women with twin pregnancies assessed for nuchal translucency between January 1997 and July 2013. The study group was subdivided into MC twins conceived spontaneously and after IVF. Pregnancies with later fetal death or twin transfusion syndrome were excluded. A large-weight discordance was defined as a difference of birthweights of >15%., Results: The study group included 171 pregnancies; of them, 142 (83%) were spontaneous and 29 (17%) were IVF conceived. In the entire cohort, we found a significant correlation between birthweight discordance and CRL discrepancy (r = 0.173, P < 0.05). While a significant correlation was found between CRL discrepancy and birthweight discordance in spontaneous-conceived pregnancies (n = 142, r = 0.24, P = 0.005), such correlation was not present in IVF pregnancies (n = 29, r = -0.7, P = 0.724). A logistic regression analysis found significant odds of larger-weight discordance for each increase of 1% in CRL discrepancy among spontaneously conceived pregnancies (odds ratio = 1.1, confidence interval = 1.03-1.2, P = 0.005). A receiver operating characteristic (ROC) for large-weight discordance in the spontaneously conceived pregnancies demonstrated an area under the ROC curve of 0.613 (P = 0.039)., Conclusion: The significant correlation between CRL discrepancy and birthweight discordance in spontaneous versus IVF MC twin pregnancies might suggest differential monozygotic twinning process., (© 2015 John Wiley & Sons, Ltd.)

Although engaging in pleasant experiences following successful performance may be hedonically rewarding, in the present research we proposed that individuals might forego pleasant experiences when they have not yet completed a task. In Study 1 (N = 100), participants reported the extent to which they would like to engage in pleasant experiences in a hypothetical situation where their performance outcome on a task (successful vs. average) and task completion (task in progress vs. completed) were manipulated. In Study 2 (N = 115), participants were in a real situation in which they achieved either a successful or average performance outcome. Task completion was manipulated (task in progress vs. completed) and motivation to engage in a pleasant experience was assessed by a behavioral measure. Results of both studies provided support for our prediction by showing individuals to have a lower desire to engage in pleasant experiences following successful, but not average, performance when the task was in progress than when it was complete. These findings are discussed in light of the underlying mechanisms and consequences of the tendency to forego pleasant experiences.

Objective: To construct prenatal age-specific reference intervals using ultrasound measurement of total axial length (TAL) in normal fetuses for assessing microphthalmia., Method: Prospective cross-sectional study of fetuses assessed at a prenatal ultrasound unit between 2011 and 2014. The study cohort comprised 309 pregnant women attending for routine fetal biometry, viability, or anomaly scan between 14 and 41 weeks of gestation. Only singleton viable fetus with normal anatomy, adequate amniotic fluid, accurate gestational age, and no maternal medical complications of pregnancy were enrolled. Biometric measurements were obtained in the axial plane in all the fetuses. Those measurements and the relevant gestational age were registered in a computerized database., Results: A linear growth function was observed between gestational age and bi-orbital diameter (r(2)  = 0.95; p < 0.001), ln (TAL) (r2  = 0.89; p < 0.001), OD (r(2)  = 0.86; p < 0.001), and IOD (r2  = 0.79; p < 0.001). Tables showing the 5th, 50th, and 95th centiles of orbital parameters were created based on the reference interval charts., Conclusions: Ultrasound measurement of the fetal TAL ocular distance is feasible. This may assist the multidisciplinary team in the evaluation of fetal eye abnormalities that might be expressed by deviation in TAL., (© 2015 John Wiley & Sons, Ltd.)

Objectives: The objectives of this study are to present our collective experience with the prenatal diagnosis of testicular torsion and to propose a possible prenatal management scheme., Methods: We retrospectively collected and reviewed all medical records of cases that were diagnosed with perinatal testicular torsion in our medical center between the years 2002 and 2013. Prenatal torsion was categorized as torsion diagnosed in utero or on immediate newborn examination., Results: A total of five unilateral prenatal torsions were diagnosed. Two fetuses were diagnosed in the third trimester of pregnancy. In both cases, cesarean section was performed immediately upon diagnosis. One newborn underwent immediate orchiectomy with contralateral orchiopexy. Torsion was confirmed by pathological examination. The other was managed conservatively, just as the three newborns who were diagnosed immediately after birth. On follow-up scan, the affected testicle was found atrophied with lack of blood flow on color Doppler examination. The unaffected contralateral testicle remained within the normal size with good blood flow., Conclusions: Prenatal diagnosis of unilateral testicular torsion is a coincidental rare finding. Because the twisted testicle cannot be salvaged, induced delivery and prompt surgery are not recommended., (© 2014 John Wiley & Sons, Ltd.)

Objective: The aim of this study was to assess the effect of fetal sex on the accuracy of multiple formulas for sonographic estimation fetal weight (SEFW)., Methods: The cohort included all singleton live births recorded at a single medical center from January 2004 to September 2011. The accuracy of SEFW was compared between male and female fetuses using 6575 SEFW performed within 3 days prior to delivery. Fetal weight was estimated using 27 models., Results: The accuracy of different formulas in predicting birth weight of male and female fetuses was found to be significantly different in almost every accuracy index that was compared (P < 0.05). The model by Sabbagha et al. was found to be the most accurate in assessing female fetuses. The most accurate model for male fetuses was a sex-specific formula by Melamed et al. We also found that a combination of the most accurate formula for each sex to one combined sex-specific model increased SEFW accuracy significantly., Conclusion: The accuracy of SEFW is significantly related to fetal sex. The combination of the formulas by Melamed et al. and Sabbagha et al. for male and female fetuses accordingly allowed more accurate SEFW in our research population., (© 2014 John Wiley & Sons, Ltd.)

Objective: This study aims to evaluate the distribution of mean arterial pressure (MAP) and uterine artery Doppler pulsatility index (PI) in first trimester twins with and without preeclampsia., Method: A total of 147 twins were recruited from a specialist clinic and 110 unaffected singleton pregnancies attending the same institution served as controls. MAP and Doppler PI values were expressed in multiples of the gestation-specific median using published equations., Results: Among the twins, 12 had preeclampsia and two had pregnancy-induced hypertension. Among unaffected pregnancies, there was no significant difference in MAP levels between twins and singletons (P = 0.17, Wilcoxon rank sum test, two-tail). However, the Doppler PI levels were highly statistically significantly lower than in singletons (P < 0.0005). MAP was unrelated to chorionicity (P = 0.46), but there was a statistically significant increase in Doppler PI among monochorionic compared with dichorionic twins (P < 0.01). In twins with preeclampsia, MAP was significantly higher than in unaffected twins (P < 0.02, one-tail), whereas Doppler PI levels were significantly reduced (P < 0.01, two-tail)., Conclusion: If first trimester screening for preeclampsia is extended to twins, a different normal median Doppler PI equation will be needed. Contrary to expectations, Doppler PI levels may not be raised in affected twins, although this needs confirmation in a larger study., (© 2014 John Wiley & Sons, Ltd.)

Pelvic ultrasound is commonly used as part of the routine gynecologic exams, resulting in diagnosis of adnexal masses, the majority of which are functional or benign. However, due to the possible complications involving benign adnexal cysts (ie, adnexal torsion, pelvic pain) and the utmost importance of early diagnosis and treatment of ovarian cancer, the correct ultrasound diagnosis of adnexal masses is essential in clinical practice. This review will describe the typical ultrasound appearance of the common physiologic, benign, and malignant adnexal masses with the aim of aiding the clinician to reach the correct diagnosis.

Introduction: Triploidy (69 chromosomes) is the most common chromosomal anomaly encountered in human gestation, occurring in 1% of all conceptions. Most triploidies abort spontaneously during the 1st trimester. In cases that last, it is usually associated with fetal distress that can Lead to many obstetric complications., Objective: To assess the indications for prenatal karyotyping of triploidy during pregnancy in our medical center., Methods: This retrospective cohort study involved all singleton pregnancies diagnosed or referred to our institute because of triploidy, during the years 1998-2011., Results: There were 1879 cases of termination of pregnancies (TOPs). During this period 8 cases of triploidy were aborted. The main indications for prenatal karyotyping in our study group were abnormal sonographic findings during anomaly scans. In addition, in all of the triploidy cases, the NT test was normal. Also, the 1st or 2nd trimester serum markers tests for early diagnosis of trisomy 18 predicted all of the triploidy cases that performed the tests., Discussion: Our findings corresponded with other studies and show that the 1st or 2nd trimester serum markers tests for early diagnosis of trisomy 18, can lead to identification of triploidy pregnancies., Conclusions: The routine screening tests applied in Israel INT, serum markers tests and 2nd trimester anomaly scans) were highly effective in the identification of triploidy pregnancies.

Introduction: Trisomy 18 and 13 are the most common autosomal trisomies, after trisomy 21, and their frequency is rising due to the increased maternal age of pregnant women. The fetuses suffer from multi-organ damage that may lead to many gestational complications as well as short life expectancy., Objective: To assess the indications for prenatal karyotyping of trisomy 13 (T-13, Patau syndrome) and trisomy 18 (T-18, Edwards syndrome) during pregnancy in our medical center., Methods: This retrospective cohort study involved all singleton pregnancies locally diagnosed or referred to our Institute because of T-13 and T-18, during the years 1998-2011., Results: There were 1879 cases of termination of pregnancies (TOPs) because of fetal indications, of them 53 cases of T-18 and 10 cases of T-13. The main indications for prenatal karyotyping in our study group were abnormal sonographic findings during anomaLy scans. In addition, 7 newborns with T-18 and 3 infants with T-13 were born in our hospital during the same period of time. We examined all cases that led to the Live birth of newborns with chromosomal anomalies, stemming from the Lack of extraction of the tests mentioned above and/or ignoring findings that raise suspicion that requires performing prenatal karyotyping during pregnancy., Discussion: Our findings corresponded with other studies and showed that prenatal diagnosis of T-13/T-18 due to abnormal sonographic finding is rising., Conclusions: Our study shows that it was possible to identify the vast majority of T-13/T-18 among the pregnant women who had an increased risk based on a combination of the routine screening tests applied in Israel.

Objective: This study aimed to compare the associations of crown-rump length (CRL) discrepancy with birthweight discordance in spontaneous versus vitro fertilization (IVF) conceived dichorionic twin pregnancies., Method: A computerized retrospective study of women referred to our ultrasonographic unit for nuchal translucency examination between January 1997 and December 2011. The study group was subdivided into twins conceived after IVF, non-IVF fertility treatment and spontaneously conceived twins. Birthweight discordance was defined as a difference of birthweights of >20%., Results: A total of 688 dichorionic twin pregnancies were included, all of them ending in live birth of both twins. IVF-conceived pregnancies were associated with a significant increased risk of extreme birthweight discordance compared with spontaneous-conceived twin pregnancies (OR = 2.3; CI = 1.4-3.8, P < 0.001). A significant correlation was found between CRL discrepancy and birthweight discordance in spontaneous-conceived pregnancies (r = 0.15, P < 0.05). In contrast, there was no significant correlation between CRL discrepancy and birthweight discordance in both IVF and fertility treatment-conceived pregnancies., Conclusion: Because birthweight discordance in IVF-conceived twins did not correlate with CRL discrepancy, we assume that it emerges later in pregnancy, maybe related to maternal underplaying complications, for which IVF was indicated in the first place., (© 2014 John Wiley & Sons, Ltd.)

Objectives: The impact of nuchal translucency (NT) screening in twins conceived after use of assisted reproduction technology (ART) has not been addressed properly in the literature. The aim of the current study was to assess, in a large cohort from a single center, NT in twins following various modes of ART as compared with NT in spontaneously-conceived twins and to differentiate results with regard to chorionicity., Methods: Retrospective data from 825 twin pregnancies were available for this study. All pregnant women underwent NT screening and chorionicity determination between 11 + 0 and 13 + 6 weeks' gestation in our center. Information about mode of conception and pregnancy outcome was obtained from hospital records and by telephone interviews. Twins were classified as having been conceived after in-vitro fertilization (IVF) with the woman's own or a donated embryo, after non-IVF ART or spontaneously. NT distribution in subgroups of fetuses was compared on the basis of the multiple of the normal median (MoM), SD of log10 MoM estimated by the 90(th) -10(th) centile range divided by 2.563 and the proportion of NT values exceeding the normal 95(th) centile which was 1.641 MoM in the singletons., Results: NT values were statistically significantly higher in ART pregnancies as compared with spontaneously-conceived pregnancies (Wilcoxon rank-sum test, P < 0.05) with medians of 1.073 and 1.038 MoM, respectively, but the proportion with values above the normal 95(th) percentile did not differ (chi-square test, P = 0.89). Among the ART twins, NT values were significantly higher for those conceived using IVF methods (P < 0.005), with a median of 1.082 MoM, compared with a median of 1.022 MoM using other methods. However, although a greater proportion exceeded the 95(th) centile (7.3% compared with 4.8%) this difference did not reach statistical significance (P = 0.17). There were no differences in NT values according to chorionicity (Wilcoxon rank-sum test, P = 0.75). The standard deviation of log10 NT was similar for all subgroups of twins. The correlation coefficient between fetuses in ART pregnancies was statistically significantly lower than that in spontaneously-conceived pregnancies (P < 0.05) but no significant differences were found between types of ART or according to chorionicity., Conclusions: There was a small but significant increase in NT levels among ART pregnancies, which appeared to be confined to those conceived using IVF, and a small reduction in the correlation between fetuses. These effects probably have little impact on the estimated risk based on algorithms in use today., (Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester., Methods: The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined., Results: Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93)., Conclusions: EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester., (Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd.)

Background: Arabin cervical pessary is a silicone ring pessary for the prevention of preterm birth (PTB] for pregnant women at risk with second trimester short uterine cervix. Progesterone supplementation has been found to prevent PTB., Objective: To review our first year of experience using Arabin cervical pessary with intravaginal micronized progesterone in the prevention PTB., Methods: The study included patients (pt) with singleton and twin pregnancies at 16-30 weeks with uterine cervical length < or = 25 mm treated with Arabin cervical pessary and intravaginal progesterone over one year from September 2011 to September 2012. Progesterone treatment was continued until 34 weeks and pessary was extracted at 36 weeks or in cases of preterm labor, bleeding or other medical indications., Results: The study group included 43 patients, 31 (72.1%) singleton and 12 (27.9%) twins. The average week at admission was 25+2 weeks [w] [SD +/- 3.05], and the average cervical length at admission was 13.5 mm (SD +/- 5.0). A total of 11 patients had previous PTB; in 2 patients the pessary was placed after cerclage failure. The average week of delivery was 35 + 5 weeks SD +/- 3.2 (singleton 36 + w SD +/- 2.6, twins 33 + 4 SD +/- 4.1, p = 0.05); the average time between pessary insertion to delivery 72.1 days SD +/- 26.2 (singleton 76.3 SD +/- 22.9 twins 60.2 SD +/- 28.9 p = 0.02), in 23 patients (53.5%) the pessary was extracted at > or = 36 + 6w, 5 patients 111.6%) delivered < or = 32w (2 singleton, 3 twins, p = 0.08) and 18 patients (41.8%) reported increased vaginal discharge., Conclusion: The use of cervical pessary in conjunction with intravaginal progesterone is safe and feasible. Patients with twin pregnancies had a significantly higher rate of preterm birth compared to singleton pregnancies. Further research is needed to assess device efficacy.

Objectives: The primary aim of this study was to evaluate the effects of different maternal, fetal, and examiner related factors on the accuracy of sonographic fetal weight estimation (SFWE)., Methods: A retrospective cohort study analyzing 9064 SFWEs performed within 1 week prior to delivery, including singleton pregnancies with a gestational age of 37 to 42 weeks, was recorded at one medical center from January 2004 to September 2011. Predicted birth weights were calculated according to models by Sabbagha et al., Hadlock et al., and Combs et al. and were compared with the actual birth weight. Effects of different factors on SFWE accuracy were assessed. The systematic error, random error, and mean absolute percentage error were used as measures of accuracy., Results: High maternal weight, height, body mass index, multiparity, older maternal age, diabetes, and fetal male sex were associated with underestimation of SFWE (P < 0.05). Fetal presentation and the sonographer's experience influenced SFWE differently using various models. The amniotic fluid index did have a significant effect on SFWE. Overall, more than 90% of the systematic errors were unaccounted for in the factors we assessed., Conclusions: Many maternal and fetal factors significantly influence the SFWE; nevertheless, most errors are probably due to inherent problems in SFWE formulas., (© 2013 John Wiley & Sons, Ltd.)

Objective: The objective of this study was to provide a critical analysis of the impact of assisted conception on prenatal screening for Down syndrome (DS) in twin pregnancies and the value of various screening modalities for early detection of anomalies., Methods: The literature was searched using PubMed and the Cochrane Library focusing on prenatal screening and antenatal care of assisted-conception twin pregnancies., Results: Serum screening alone is of limited value in detecting aneuploid twins, because the unaffected cotwin can "mask" the abnormal serum results of an affected one. In addition, this test can designate the pregnancy as at high risk but not identify the affected fetus. Nuchal translucency (NT) screening is the best available modality and a highly effective screening method for twin pregnancies. Among twins, NT alone has a 69% DS detection rate, first-trimester combined NT and serum biochemistry has a 72% DS detection rate, and an integrated screen will have an 80% DS detection rate at a 5% FPR. The data in the literature concerning the effect of assisted conception on maternal serum screening markers in twin pregnancies are scarce., Conclusions: Down syndrome screening in assisted-conception twins presents clinical and technical challenges. Therefore, assisted-conception twins need close monitoring from conception to delivery, by a practitioner familiar with the available screening modalities and their relative accuracy.