Clinical Management of Pregnancy-Related Complications

The purpose of this prospective cohort study is to identify the predictive factors for vaginal delivery among women (n = 146) who underwent cervical ripening using a dinoprostone insert (PG) alone (13.7%), cervical ripening balloon (CRB) alone (52.7%), oral misoprostol (M) alone (4.1%), or repeated methods (R, 29.5%) for gestational diabetes mellitus (GDM) at term, and to analyze maternal and neonatal morbidity outcomes according to the method for cervical ripening. After cervical ripening, vaginal delivery occurred in 84.2% (n = 123) and was similar among groups (90.0% after PG, 83.1% after CRB, 83.3% after M, and 83.7% after R; p = 0.89). After a multivariable logistic regression analysis adjusted for potential confounders, the internal cervical os being open before cervical ripening was a predictor of vaginal delivery (adjusted odds ratio (OR) of 4.38, 95% confidence index (CI) of 1.62–13.3, p = 0.03), and previous cesarean delivery was a predictor of cesarean delivery (aOR of 7.67, 95% CI of 2.49–24.00, p < 0.01). Birthweight was also significantly associated with cesarean delivery (aOR of 1.15, 95% CI of 1.03–1.31, p = 0.02). The rates of maternal and neonatal morbidity outcomes were 10.9% (n = 16) and 19.9% (n = 29), respectively, and did not differ according to the mode of delivery and to the method used for cervical ripening. Identifying these specific high-risk women (previous cesarean delivery and internal cervical os being closed before cervical ripening) for cesarean delivery among women who underwent cervical ripening for GDM at term is important and practical for all physicians to make a decision in partnership with women. Full article

Background: The incidence of pregnant women with uterine fibroids is increasing. As they are reactive to hormonal stimuli, in some cases, uterine fibroids tend to grow during pregnancy and potentially generate symptoms with different levels of severity, causing maternal–fetal complications. In very select cases, when other treatment strategies fail to manage symptoms and there is a substantial risk of adverse pregnancy outcomes, a surgical approach during pregnancy may be considered. Methods: From 2016 to 2021, the data from 28 pregnant women with symptomatic uterine fibroids who underwent laparotomic myomectomy during pregnancy were prospectively collected, and operative and maternal–fetal outcomes were analyzed (ClinicalTrial ID: NCT06009562). Results: The procedure was carried out between 14 and 16 weeks of pregnancy. Four (14.3%) patients had intraoperative complications (miscarriages) and nine (32.1%) had postoperative complications (threatened preterm birth). Overall, 24 (85.7%) women delivered at full term (mean: 38.2 gestational weeks), more than half (n = 13; 54.2%) by vaginal delivery, with normal fetal weights and 1 and 5 min Apgar scores. Conclusions: Laparotomic myomectomy during pregnancy can be considered in selected cases for uterine fibroids with severe symptoms when other treatment options have failed and there is high risk of adverse maternal–fetal outcomes. Full article

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

Background: Pregnancy is a physiological state in which the female body undergoes a series of changes and adaptations to provide the best possible conditions for the growth and development of the forming baby. The internal adaptations that take place lead to the production of inflammation, which is necessary for the initial and final stages of pregnancy (embryo implantation and induction of labor). Gestational diabetes mellitus is considered to be the most common pathology during this period. However, many more serious health complications can arise, which include pre-eclampsia, fetal stunting, and preterm labor. The purpose of this study was to analyze the impact of the levels of individual eicosanoids on the course of normal pregnancy and the possibility of pathologies including gestational diabetes and pre-eclampsia. Methods: Sixty-nine pregnant women who were overweight or obese before and during pregnancy were studied. Eicosanoids were extracted as appropriate and then determined using liquid chromatography. The levels of eicosanoids studied in pregnant women differed not only according to the week of pregnancy but also in relation to individual anthropometric and biochemical parameters. Results: There was a significant correlation between being overweight and having a high BMI before pregnancy—as well as biochemical parameters of lipid and carbohydrate profiles—and the occurrence of pathological conditions in pregnancy. Conclusions: Eicosanoids are involved in the pathology of pregnancy associated with the occurrence of gestational diabetes and pre-eclampsia. Salicylic acid may find use in the treatment of pregnant women exposed to both phenomena, as well as in overweight and obese women found before pregnancy. Diets rich in natural salicylates, methods of administration, and pharmacotherapy and dosage need further study. Some of the mediators (lipoxin, prostaglandin and leucotrien) may be new diagnostic markers in pregnancy pathology and intervention pathways in the future. Full article

The French College of Gynecologists and Obstetricians (CNGOF) recommends the use of intrauterine tamponade balloon (IUTB) in postpartum haemorrhage for bleeding that is refractory after sulprostone before either surgery or interventional radiology. However, the elapsed time between uterotonic drug injection and the insertion of intrauterine tamponade balloon was not reliably assessed. Objective: To evaluate the role of the timing of IUTB insertion and to assess the correlation between the time of insertion and outcome. Methods: A retrospective study in two tertiary care centres, including patients transferred for severe PPH management. Results: A total of 81 patients were included: 52 patients with IUTB inserted before 15 min (group 1) and 29 patients with IUTB inserted after 15 min (group 2). The mean volume of blood loss in the group of patients with IUTB inserted before 15 min was significantly lower than in group of patients with IUTB set after 15 min. Conclusion: An IUTB could be inserted simultaneously with a uterotonic agent, within 15 min and not after 15 min as suggested by local guidelines, but further prospective studies are required to confirm this. Full article

Background: Gestational diabetes mellitus (GDM) is a form of diabetes that develops during pregnancy. The incidence of GDM has been on the rise in tandem with the increasing prevalence of obesity worldwide. We focused on the study of what causes premature births and if there are methods to prevent these events that can result in long-term complications. Methods: This study was a prospective, non-interventional study that lasted for 4 years from December 2018 to December 2022. From the group of women enrolled in the study, we selected and analyzed the characteristics of women who gave birth prematurely. Additionally, we performed a systematic review examining the association between GDM and the frequency of adverse pregnancy outcomes. Results: In total, 78% underwent an emergency caesarean and had polyhydramnios. The results indicate that women who had a preterm delivery had a significantly higher maternal age compared to those who had a term delivery (p < 0.001). Conversely, there was no significant difference in preconception BMI between the two groups (p = 0.12). Conclusions: In terms of the understanding of GDM and preterm birth, several gaps in our knowledge remain. The association between GDM and preterm birth is likely multifactorial, involving various maternal factors. Full article

Adequate control of blood pressure (BP) is essential to prevent complications in pregnant women with a history of eclampsia or pre-eclampsia. However, the importance of office (OBPM), home (HBPM), and ambulatory (ABPM) BP measurements for proper control and prognosis in high-risk pregnancy is unknown. The present study aimed to compare BP values obtained during these three different BP measurements in women with a history of eclampsia or pre-eclampsia. This study included 79 pregnant women with chronic hypertension and a documented history of eclampsia or pre-eclampsia in previous pregnancy/pregnancies. Every fifth week of the study, all participants underwent ABPM, HBPM and OBPM. BP values from the 10th, 25th, and 37th weeks of pregnancy were evaluated. Therapy was intended to meet the ABPM treatment goal of <130/80 mmHg. Day, night, and 24 h ABPM systolic BP values were lower than HBPM and OBPM values at each study visit. Night and 24 h ABPM diastolic BP values were lower than HBPM and OBPM values, while day 24 h ABPM values were slightly higher than HBPM and OBPM values. ABPM provides different BP values than OBPM and HBPM. Target BP for ABPM in high-risk pregnancy hypertension should be estimated based on the predictive value of adverse pregnancy outcomes. Full article

Pregnancy causes physiological changes in the woman’s body, which can also affect oral health. Therefore, pregnant women may manifest gingival inflammation that is favored by their hormonal increase. This clinical trial (ClinicalTrials.gov Identifier: NCT04140643) evaluated the variation in the plaque index (PI) or bleeding index (BOP) in pregnant women after daily use of an ozonated water irrigator and proper home oral hygiene, compared to a control group who only performed home oral hygiene. The inclusion criteria were the gestation period from the 14th week to the 30th week, a diagnosis of gingivitis, and a minimum number of teeth equal to 20. The PI and BOP index were evaluated at T0, fifteen days after T0 (T1), and two months after T1 (T2). The PI values systematically decreased over time (F (1.19) = 41.82) in both groups, with a systematic difference in PI values between the two groups (F (1.19) = 6.28, p = 0.021). A statistically significant difference was assessed in the BOP index at T2 between the two groups, with the control group suffering a higher BOP index. The results show that the patients in the study group showed a decrease in the BOP index over the three time points, in contrast to the control group, due to the beneficial properties of ozonated water. Full article

Background: The International Diabetes Federation estimates that 16.2% of livebirths in 2017 were affected by hyperglycemia in pregnancy, with 85.1% due to gestational diabetes mellitus (GDM). Daily blood glucose monitoring compared with alternate day testing in mild GDM is associated with similar pregnancy outcomes. Data are sparse on the ideal frequency for self-monitoring of blood glucose (SMBG) in mild GDM for glycemic control. A higher HbA1c at late pregnancy is associated with adverse pregnancy outcomes. We sought to evaluate three days compared to one day per week of four-point self-monitoring of blood glucose (SMBG) in gestational diabetes mellitus (GDM) controlled by lifestyle changes for glycemic control. Methods: This randomized trial was conducted from February–December 2018. A total of 106 women with lifestyle-controlled GDM were randomized to three days (SMBG3) or one day (SMBG1) per week of four-point (fasting and two-hours post-meal) SMBG. The primary outcome was the change in the HbA1c level at recruitment and 36-weeks gestation within and across trial arms. The student t-test was used for between-arm analyses and a paired t-test for within-arm analyses. Results: The HbA1c level through pregnancy increased significantly in both trial arms: mean increase of 0.21% ± 0.26%, p < 0.001 (SMBG3), and 0.19% ± 0.24%, p < 0.001 (SMBG1), but the 0.02% difference across trial arms was not significant (p = 0.79). Maternal weight gain (3.1 ± 2.1 kg vs. 3.3 ± 3.0 kg, p = 0.72), cesarean delivery (24/52 (48%) vs. 23/53 (43%), RR 1.06, 95% CI: 0.69–1.62, p = 0.77), neonatal birthweight (3.1 ± 0.4 kg vs. 3.0 ± 0.4 kg, p = 0.53) and neonatal intensive care unit admission (4/52 (8%) vs. 3/53 (6%), RR 1.36, 95% CI: 0.32–5.78, p = 0.68) were not significantly different for SMBG3 vs. SMBG1, respectively. Other maternal and neonatal secondary outcomes were not significantly different. Conclusion: In mild GDM, three days compared to one day per week showed a similar HbA1c levels change at 36-weeks gestation. Maternal and neonatal outcomes were also not significantly different. Less frequent monitoring of SMBG as a standard of care in mild GDM deserves further study and consideration. Full article

Triplet pregnancies are rare events that affect approximately 93 in 100,000 deliveries in the world, especially due to the increased use of assisted reproductive techniques and older maternal age. Triplet pregnancies are associated with a higher risk of fetal and maternal morbidity and mortality compared to twins and singletons. Chorionicity has been proposed as a major determinant of perinatal and maternal outcomes in triplet pregnancies, although further evidence is needed to clarify the extent and real influence of this factor. Thus, the aim of this study was to conduct a systematic review of the literature and a meta-analysis of the maternal and perinatal outcomes of triplet pregnancies, evaluating how chorionicity may influence these results. A total of 46 studies with 43,653 triplet pregnancies and 128,145 live births were included. Among the main results of our study, we found a broad spectrum of fetal and maternal complications, especially in the group of monochorionic and dichorionic pregnancies. Risk of admission to NICU, respiratory distress, sepsis, necrotizing enterocolitis, perinatal and intrauterine mortality were all found to be higher in non-TCTA pregnancies than in TCTA pregnancies. To date, our meta-analysis includes the largest population sample and number of studies conducted in this field, evaluating a wide variety of outcome measures. The heterogeneity and retrospective design of the studies included in our research represent the main limitations of this review. More evidence is needed to fully assess outcome measures that could not be studied in this review due to scarcity of publications or insufficient sample size. Full article

In pregnancy, several physiological changes affect maternal circulating thyroid hormone levels. The most common causes of hyperthyroidism in pregnancy are Graves’ disease and hCG-mediated hyperthyroidism. Therefore, evaluating and managing thyroid dysfunction in women during pregnancy should ensure favorable maternal and fetal outcomes. Currently, there is no consensus regarding an optimal method to treat hyperthyroidism in pregnancy. The term “hyperthyroidism in pregnancy” was searched in the PubMed and Google Scholar databases to identify relevant articles published between 1 January 2010 and 31 December 2021. All of the resulting abstracts that met the inclusion period were evaluated. Antithyroid drugs are the main therapeutic form administered in pregnant women. Treatment initiation aims to achieve a subclinical hyperthyroidism state, and a multidisciplinary approach can facilitate this process. Other treatment options, such as radioactive iodine therapy, are contraindicated during pregnancy, and thyroidectomy should be limited to severe non-responsive thyroid dysfunction pregnant patients. In light of this events, even in the absence of guidelines certifying screening, it is recommended that all pregnant and childbearing women should be screened for thyroid conditions. Full article

Gossypiboma or textiloma is a rare medical situation that can complicate the favorable evolution of a surgical case, with repercussions for the patient’s prognosis. The diagnosis can be difficult due to various clinical symptoms, the time elapsed since the surgical intervention, and the imaging often not being precise in detecting textilomas. Due to the medicolegal implications, the reporting of this event is inconsistent. We present a rare case of a 28-year-old woman who presented with vague pain in the left iliac fossa 11 months after an emergency cesarean hysterectomy was performed. The preoperative imaging examination identified the presence of a subhepatic mass with dimensions of 10 × 8 cm² and another formation in the right iliac fossa with dimensions of 11 × 9 cm². Exploratory laparotomy found the presence of a large subhepatic gossypiboma, intimately adherent to the hepatic angle of the colon and omentum and a second one adherent to the sigmoid colon, small intestine, and parietal peritoneum. The particularity of this case is given by the simultaneous presence of two textilomas with inconclusive evolution, which can make the differential diagnosis difficult to achieve. For a better assessment of the risk of occurrence of this pathology and the identification of a correct prevention strategy, we performed an extensive search and a review of all the articles published in the PubMed database, identifying 57 articles. In conclusion, emergency surgery increases the risk of this complication, and, as a result, prevention can be achieved by following existing protocols in the operating room. Full article

Background and Objectives: Women with a history of cesarean section are a high-risk group because they are likely to develop uterine rupture during their next pregnancy. Current evidence suggests that a vaginal birth after cesarean section (VBAC) is associated with lower maternal mortality and morbidity than elective repeat cesarean delivery (ERCD). Additionally, research suggests that uterine rupture can occur in 0.47% of cases of trial of labor after cesarean section (TOLAC). Case Description: A healthy 32-year-old woman at 41 weeks of gestation, in her fourth pregnancy, was admitted to the hospital due to a dubious CTG record. Following this, the patient gave birth vaginally, underwent a cesarean section, and successfully underwent a VBAC. Due to her advanced gestational age and favorable cervix, the patient qualified for a trial of vaginal labor (TOL). During labor induction, she displayed a pathological CTG pattern and presented symptoms such as abdominal pain and heavy vaginal bleeding. Suspecting a violent uterine rupture, an emergency cesarean section was performed. The presumed diagnosis was confirmed during the procedure—a full-thickness rupture of the pregnant uterus was found. The fetus was delivered without signs of life and successfully resuscitated after 3 min. The newborn girl of weight 3150 g had an Apgar score of 0/6/8/8 at 1, 3, 5, and 10 min. The uterine wall rupture was closed with two layers of sutures. The patient was discharged 4 days after the cesarean section without significant complications, with a healthy newborn girl. Conclusions: Uterine rupture is a rare but severe obstetric emergency and can be associated with maternal and neonatal fatal outcomes. The risk of uterine rupture during a TOLAC attempt should always be considered, even if it is a subsequent TOLAC. Full article

Ovarian pregnancy is a rare but well-known pathology. However, pathophysiology, diagnosis and treatment are not established. Therefore, all case reports on ovarian pregnancy published in PubMed from November 2011 till November 2022 were reviewed and two case reports were added. In these 84 case reports, 8% of ovarian pregnancies occurred in women without or with blocked oviducts and 23% were localised on the other side than the corpus luteum. Since symptoms are not specific, ovarian pregnancy has to be suspected in all women with abdominal bleeding. Surgical excision is the preferred treatment. However, since an associated intra-uterine pregnancy cannot be excluded, care should be taken not to interrupt this intra-uterine pregnancy with the uterine cannula or by damaging the corpus luteum. In conclusion, in women with abdominal bleeding, an ovarian pregnancy cannot be excluded, even in women with a negative pregnancy test or an empty uterus on transvaginal ultrasonography. Therefore, a laparoscopy is indicated but the surgeon should realise that an associated intra-uterine pregnancy also cannot be excluded and that therefore care should be taken not to interrupt this intra-uterine pregnancy by the uterine cannula or by damaging the corpus luteum. Full article