High-Risk Pregnancy

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Obstetrics and Gynecology".

Deadline for manuscript submissions: closed (30 June 2022) | Viewed by 70301

Special Issue Editors

Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 010164 Bucharest, Romania
Interests: fetal cardiac disease; coronavirus; cytomegalovirus; coxsackievirus; Toxoplasma gondii; flu viruses; HIV; rubella virus; Streptococcus; parvovirus B19; herpes virus
Special Issues, Collections and Topics in MDPI journals
Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
Interests: gynecology; gynecologic oncology; laparoscopy; endometriosis and fertility preservation in women with cancer
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

The fields of pregnancy care and obstetrics have evolved rapidly in the last few decades consequent to quality research being undertaken. Pregnancy, childbirth and postpartum are now safer than ever, with high-risk conditions being early anticipated and managed.

The aim of this Special Issue of Medicina is to explore the current advances in the field of obstetrics, including maternal morbidity and mortality, short and long-term outcomes after complicated pregnancy, maternal disease, fetal abnormalities, intrapartum complications, management of pregnancies following assisted reproductive techniques and twin pregnancies. Submission of unpublished original studies is welcome, including fundamental and clinical research studies, observational and interventional studies, randomized controlled trials and reviews, with an emphasis on relevant clinical questions and quantitative syntheses (meta-analyses) of pooled data. Authors are invited to contact the Editorial Team in advance if they require assistance for the preparation of their manuscript.    

Dr. Anca Maria Panaitescu
Dr. Nicolae Gica
Guest Editors

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Keywords

  • maternal disease
  • fetal abnormalities
  • twin pregnancy
  • outcomes of complicated pregnancy
  • clinical implementation
  • assisted reproductive techniques
  • high-risk pregnancy
  • postpartum hemorrhage
  • emergency peripartum hysterectomy
  • abnormal placentation
  • operative vaginal delivery

Published Papers (21 papers)

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Research

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9 pages, 309 KiB  
Article
The Effect of Von Willebrand Disease on Pregnancy, Delivery, and Postpartum Period: A Retrospective Observational Study
by Mateja Sladič, Ivan Verdenik and Špela Smrkolj
Medicina 2022, 58(6), 774; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58060774 - 07 Jun 2022
Cited by 3 | Viewed by 2630
Abstract
Background and Objectives Several reports indicate that women with von Willebrand disease (VWD) are at an increased risk of bleeding and other complications during pregnancy and childbirth. The aim of this study was to investigate the effect of VWD on the course of [...] Read more.
Background and Objectives Several reports indicate that women with von Willebrand disease (VWD) are at an increased risk of bleeding and other complications during pregnancy and childbirth. The aim of this study was to investigate the effect of VWD on the course of pregnancy, childbirth, and the postpartum period. Materials and Methods This was a retrospective study that compared many variables between women with VWD (n = 26) and women without VWD (n = 297,111) who gave birth between 2002 and 2016 in Slovenia. Data were obtained from the Slovenian National Perinatal Information System. Results Women with VWD were not more likely to have a miscarriage, vaginal bleeding during pregnancy, anemia, intrauterine growth restriction, or imminent premature labor. However, women with VWD were more likely to experience childbirth trauma-related bleeding (OR, 10.7; 95% CI: 1.4, 78.9), primary postpartum hemorrhage (OR, 3.7; 95% CI: 0.9, 15.8), and require blood transfusion after childbirth (OR, 16.3; 95% CI: 2.2, 120.3). No cases of stillbirth or early neonatal death were observed in women with VWD. Conclusion Although women with VWD did not demonstrate an increased risk of vaginal bleeding during pregnancy or poor fetal outcomes, they had a higher risk of primary postpartum hemorrhage and requiring blood transfusion. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
14 pages, 355 KiB  
Article
Body Image Dissatisfaction as a Risk Factor for Postpartum Depression
by Francisco Javier Riesco-González, Irene Antúnez-Calvente, Juana María Vázquez-Lara, Luciano Rodríguez-Díaz, Rocío Palomo-Gómez, Juan Gómez-Salgado, Juan Jesús García-Iglesias, Tesifón Parrón-Carreño and Francisco Javier Fernández-Carrasco
Medicina 2022, 58(6), 752; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58060752 - 31 May 2022
Cited by 5 | Viewed by 3413
Abstract
Background and Objectives: Pregnancy and postpartum are periods that imply numerous physical and psychological changes that could lead to mental health consequences. The aim of the present study is to identify whether women who had body image dissatisfaction had a higher incidence [...] Read more.
Background and Objectives: Pregnancy and postpartum are periods that imply numerous physical and psychological changes that could lead to mental health consequences. The aim of the present study is to identify whether women who had body image dissatisfaction had a higher incidence of postpartum depression 6 months after birth than women who did not have body image dissatisfaction. Materials and Methods: A descriptive cross-sectional study was designed with a sample of 450 women from two hospitals in Andalusia. Quantitative variables were age and scores on the Edinburgh Postnatal Depression Scale (EPDS) and the Body Shape Questionnaire (BSQ) for body image dissatisfaction. The qualitative variables used were marital status, self-perceived health status, diet or physical exercise, type of delivery, and others. Results: Body dissatisfaction was positively correlated with the symptomatology of postpartum depression. Thus, for each point increased in body dissatisfaction, the occurrence of depression also increased. There was a relationship between the study variables, so women who were more dissatisfied with their body image were more frequently depressed. Conclusions: In conclusion, it can be established that postpartum depression seems to be related to the presence of poor body image. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
10 pages, 8871 KiB  
Article
Cesarean Scar Thickness Decreases during Pregnancy: A Prospective Longitudinal Study
by Egle Savukyne, Egle Machtejeviene, Mindaugas Kliucinskas and Saulius Paskauskas
Medicina 2022, 58(3), 407; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58030407 - 09 Mar 2022
Cited by 4 | Viewed by 12664
Abstract
Background and Objectives: The aim of this study is to evaluate changes in uterine scar thickness after previous cesarean delivery longitudinally during pregnancy, and to correlate cesarean section (CS) scar myometrial thickness in the first trimester in two participants groups (CS scar with [...] Read more.
Background and Objectives: The aim of this study is to evaluate changes in uterine scar thickness after previous cesarean delivery longitudinally during pregnancy, and to correlate cesarean section (CS) scar myometrial thickness in the first trimester in two participants groups (CS scar with a niche and CS scar without a niche) with the low uterine segment (LUS) myometrial thickness changes between the second and third trimesters. Materials and Methods: In this prospective longitudinal study, pregnant women aged 18–41 years after at least one previous CS were included. Transvaginal sonography (TVS) was used to examine uterine scars after CS at 11–14 weeks. The CS scar niche (“defect”) was defined as an indentation at the site of the CS scar with a depth of at least 2 mm in the sagittal plane. Scar myometrial thickness was measured, and scars were classified subjectively as a scar with a niche (niche group) or without a niche (non-niche group). In the CS scar niche group, RMT (distance from the serosal surface of the uterus to the apex of the niche) was measured and presented as CS scar myometrial thickness in the first trimester. The myometrial thickness at the internal cervical os was measured in the non-niche group. The full LUS and myometrial LUS thickness at 18–20 and 32–35 weeks of gestation were measured in the thinnest part of the scar area using TVS. Friedman’s ANOVA test was used to analyse scar thickness during pregnancy and Mann–Whitney test to compare scar changes between CS scar niche and non-niche women groups. For a pairwise comparison in CS scar thickness measurements in the second and third trimesters, we used Wilcoxon Signed Ranks test. Results: A total of 122 eligible participants were recruited to the study during the first trimester of pregnancy. The scar niche was visible in 40.2% of cases. Uterine scar myometrial thickness decreases during pregnancy from 9.9 (IQR, 5.0–12.9) at the first trimester to 2.1 (IQR, 1.7–2.7) at the third trimester of pregnancy in the study population (p = 0.001). The myometrial CS scar thickness in the first trimester (over the niche) was thinner in the women’s group with CS scar niche compared with the non-niche group (at internal cervical os) (p < 0.001). The median difference between measurements in the CS scar niche group and non-niche group between the second and third trimester was 2.4 (IQR, 0.8–3.4) and 1.1 (IQR, 0.2–2.6) (p = 0.019), respectively. Myometrial LUS thickness as percentage decreases significantly between the second and third trimester in the CS scar niche group compared to the non-niche group (U = 1225; z = −2.438; p = 0.015). Conclusions: CS scar myometrial thickness changes throughout pregnancy and the appearance of the CS scar niche was associated with a more significant decrease in LUS myometrial thickness between the second and third trimesters. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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11 pages, 298 KiB  
Article
Risk Factors for Urological Complications Associated with Caesarean Section—A Case-Control Study
by Viorel Dragos Radu, Anda Ioana Pristavu, Angela Vinturache, Pavel Onofrei, Demetra Gabriela Socolov, Alexandru Carauleanu, Lucian Boiculese, Sadyie Ioana Scripcariu and Radu Cristian Costache
Medicina 2022, 58(1), 123; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58010123 - 14 Jan 2022
Cited by 2 | Viewed by 2133
Abstract
Background and Objectives: Acute urologic complications, including bladder and/or ureteric injury, are rare but known events occurring at the time of caesarean section (CS). Delayed or inadequate management is associated with increased morbidity and poor long-term outcomes. We conducted this study to identify [...] Read more.
Background and Objectives: Acute urologic complications, including bladder and/or ureteric injury, are rare but known events occurring at the time of caesarean section (CS). Delayed or inadequate management is associated with increased morbidity and poor long-term outcomes. We conducted this study to identify the risk factors for urologic injuries at CS in order to inform obstetricians and patients of the risks and allow management planning to mitigate these risks. Materials and Methods: We reviewed all cases of urological injuries that occurred at CS surgeries in a tertiary university centre over a period of four years, from January 2016 to December 2019. To assess the risk factors of urologic injuries, a case-control study of women undergoing caesarean delivery was designed, matched 1:3 to randomly selected women who had an uncomplicated CS. Electronic medical records and operative reports were reviewed for socio-demographic and clinical information. Descriptive and univariate analyses were used to characterize the study population and identify the risk factors for urologic complications. Results: There were 36 patients with urologic complications out of 14,340 CS patients, with an incidence of 0.25%. The patients in the case group were older, had a lower gestational age at time of delivery and their newborns had a lower birth weight. Prior CS was more prevalent among the study group (88.2 vs. 66.7%), as was the incidence of placenta accreta and central praevia. In comparison with the control group, the intraoperative blood loss was higher in the case group, although there was no difference among the two groups regarding the type of surgery (emergency vs. elective), uterine rupture, or other obstetrical indications for CS. Prior CS and caesarean hysterectomy were risk factors for urologic injuries at CS. Conclusions: The major risk factor for urological injuries at the time of CS surgery is prior CS. Among patients with previous CS, those who undergo caesarean hysterectomy for placenta previa central and placenta accreta are at higher risk of surgical haemostasis and complex urologic injuries involving the bladder and the ureters. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
8 pages, 2220 KiB  
Article
Incidence of Emergency Peripartum Hysterectomy in a Tertiary Obstetrics Unit in Romania
by Nicolae Gică, Carina Ragea, Radu Botezatu, Gheorghe Peltecu, Corina Gică and Anca Maria Panaitescu
Medicina 2022, 58(1), 111; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58010111 - 12 Jan 2022
Cited by 6 | Viewed by 2318
Abstract
Background and Objectives: Emergency peripartum hysterectomy (EPH) is a life-saving surgical procedure performed when medical and surgical conservative measures fail to control postpartum hemorrhage. The objective of this study was to estimate the incidence of EPH and to determine the factors leading to [...] Read more.
Background and Objectives: Emergency peripartum hysterectomy (EPH) is a life-saving surgical procedure performed when medical and surgical conservative measures fail to control postpartum hemorrhage. The objective of this study was to estimate the incidence of EPH and to determine the factors leading to this procedure and the maternal outcomes. Materials and Methods: A retrospective cohort study with all cases of EPH performed at Filantropia Clinical Hospital in Bucharest between January 2012 and May 2021. Results: There were 36 EPH, from a total of 36,099 births recorded. The overall incidence of EPH was 0.99 per 1000 deliveries, most cases being related to placenta accreta spectrum disorder and uterine atony. Conclusions: Peripartum hysterectomy is associated with an important maternal morbidity rate and severe complications. Efforts should be made to reduce the number of unnecessary cesarean deliveries. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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7 pages, 629 KiB  
Article
Platelet Changes in Pregnancies with Severe Early Fetal Intrauterine Growth Restriction
by Anca Marina Ciobanu, Anca Maria Panaitescu, Nicolae Gica, Ana Maria Scutelnicu, Alexandra Bouariu and Mihaela Roxana Popescu
Medicina 2021, 57(12), 1355; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57121355 - 12 Dec 2021
Viewed by 2753
Abstract
Background and Objectives: In this study, we investigated the changes of platelet count and other platelet indices, such as mean platelet volume (MPV), in cases with severe early intrauterine fetal growth restriction (IUGR). Materials and Methods: We retrospectively analyzed all pregnancies diagnosed [...] Read more.
Background and Objectives: In this study, we investigated the changes of platelet count and other platelet indices, such as mean platelet volume (MPV), in cases with severe early intrauterine fetal growth restriction (IUGR). Materials and Methods: We retrospectively analyzed all pregnancies diagnosed with severe early onset IUGR, that were followed up in our hospital between 2010 and 2015 (before implementation of screening and prophylaxis with aspirin). Pregnancies which resulted in birth of a newborn with a birthweight less than 5th percentile for gestational age, that required delivery for fetal or maternal indication before 32 weeks, were selected for the IUGR group. The IUGR cases were divided into two groups according to preeclampsia (PE) association. All cases with a complete blood count (CBC) performed within 7 days prior to delivery were included in the study, as the IUGR group. The control group included normal singleton pregnancies, delivered at term, with birthweight above 10th centile and a CBC taken at 30–32 weeks. Results: There was a significant difference in platelet count and MPV values between the IUGR group and control. Cases with IUGR presented lower platelet count and higher MPV values; there was no significant difference of these parameters when PE was associated with IUGR. Conclusions: Our results suggest that in cases of severe early IUGR, even in the absence of clinically diagnosed PE, there may be maternal endothelial damage and platelet consumption in the systemic and uteroplacental circulation. Platelet count and MPV values are simple and widely available laboratory tests that might be used as indicator of placental insufficiency; however, prospective data are required to establish the mechanistic link and to which extent these parameters are good predictors of severity or adverse perinatal outcomes. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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14 pages, 1385 KiB  
Article
The Influence of Maternal Obesity on Cell-Free Fetal DNA and Blood Pressure Regulation in Pregnancies with Hypertensive Disorders
by Aleksandra Stupak, Wojciech Kwaśniewski, Anna Goździcka-Józefiak and Anna Kwaśniewska
Medicina 2021, 57(9), 962; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57090962 - 12 Sep 2021
Cited by 2 | Viewed by 1846
Abstract
Background and Objectives: obesity and blood pressure disorders are one of the main risk factors for antenatal, intra, postpartum, and neonatal complications. In preeclampsia (PE), the placental hypoxia leads to vascular endothelium dysfunction, cell necrosis, and apoptosis. This condition is associated with the [...] Read more.
Background and Objectives: obesity and blood pressure disorders are one of the main risk factors for antenatal, intra, postpartum, and neonatal complications. In preeclampsia (PE), the placental hypoxia leads to vascular endothelium dysfunction, cell necrosis, and apoptosis. This condition is associated with the release of free fetal DNA (cffDNA) circulating in plasma. The disturbance of the efficiency of vasodilatation and blood pressure regulation in PE can be confirmed by analyzing the apelin, salusin, and prosalusin. This study aimed to assess the influence of obesity on cffDNA, and the effectiveness of maintaining normal blood pressure in patients with preeclampsia and gestational hypertension. Material and Methods: the research material was blood serum and oral mucosa swabs, obtained from 168 patients. Pregnant women were divided into the following: a control group (C)—67 women; a gestational hypertension group (GH)—35 patients; a preeclampsia with obesity group (PE + O) (pre-gravid BMI > 30)—23 patients. The rest were lean preeclamptic women (PE)—66 patients—(pre-gravid BMI < 25 in 43 women). Results: the cffDNA was observed in 1.50% of women in the C group, in 2.45% in the GH group, but in 18.18% of lean patients with preeclampsia. The cffDNA was detected in 58% of obese pregnant women with PE. The greater the placental hypoxia was in preeclampsia, the less efficient the hypotensive mechanisms, according to an analysis of the studied adipokines. The prosalusin concentration was significantly lower in the PE group with cffDNA than in the PE group without it (p = 0.008). Apelin was higher in the PE group with cffDNA (p = 0.006) compared to other groups. The same results were also observed in the subgroup with obesity. Conclusion: in preeclamptic women, obesity seems to act as an additive factor of placental damage by means of the dysregulation of hypotensive mechanisms. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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Review

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8 pages, 996 KiB  
Review
Pulmonary Alveolar Proteinosis and Pregnancy: A Review of the Literature and Case Presentation
by Brindusa Ana Cimpoca Raptis, Anca Maria Panaitescu, Gheorghe Peltecu, Nicolae Gica, Radu Botezatu, Mihaela Roxana Popescu, Anca Macri, Ana Constantin and Bogdan Pavel
Medicina 2022, 58(8), 984; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58080984 - 23 Jul 2022
Cited by 2 | Viewed by 2996
Abstract
Pulmonary Alveolar Proteinosis (PAP) is a rare, usually autoimmune, disease, where surfactant accumulates within alveoli due to decreased clearance, causing dyspnea and hypoxemia. The disease is even more rare in pregnancy; nevertheless, it has been reported in pregnant women and can even appear [...] Read more.
Pulmonary Alveolar Proteinosis (PAP) is a rare, usually autoimmune, disease, where surfactant accumulates within alveoli due to decreased clearance, causing dyspnea and hypoxemia. The disease is even more rare in pregnancy; nevertheless, it has been reported in pregnant women and can even appear for the first time during pregnancy as an asthma-like illness. Therefore, awareness is important. Similarly to many autoimmune diseases, it can worsen during pregnancy and postpartum, causing maternal and fetal/neonatal complications. This paper offers a narrative literature review of PAP and pregnancy, while illustrating a case of a pregnant patient with known PAP who developed preeclampsia in the third trimester but had an overall fortunate maternal and neonatal outcome. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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7 pages, 254 KiB  
Review
First Trimester Prediction of Adverse Pregnancy Outcomes—Identifying Pregnancies at Risk from as Early as 11–13 Weeks
by Alexandra Bouariu, Anca Maria Panaitescu and Kypros H. Nicolaides
Medicina 2022, 58(3), 332; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58030332 - 22 Feb 2022
Cited by 6 | Viewed by 2872
Abstract
There is consistent evidence that many of the pregnancy complications that occur late in the second and third trimester can be predicted from an integrated 11–13 weeks visit, where a maternal and fetal assessment are comprehensively performed. The traditional aims of the 11–13 [...] Read more.
There is consistent evidence that many of the pregnancy complications that occur late in the second and third trimester can be predicted from an integrated 11–13 weeks visit, where a maternal and fetal assessment are comprehensively performed. The traditional aims of the 11–13 weeks visit have been: establishing fetal viability, chorionicity and dating of the pregnancy, and performing the combined screening test for common chromosomal abnormalities. Recent studies have shown that the first trimester provides important information that may help to predict pregnancy complications, such as preeclampsia and fetal growth restriction, stillbirth, preterm birth, gestational diabetes mellitus and placenta accreta spectrum disorder. The aim of this manuscript is to review the methods available to identify pregnancies at risk for adverse outcomes after screening at 11–13 weeks. Effective screening in the first trimester improves pregnancy outcomes by allowing specific interventions such as administering aspirin and directing patients to specialist clinics for regular monitoring. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
14 pages, 2147 KiB  
Review
Pregnancy Complications Lead to Subclinical Maternal Heart Dysfunction—The Importance and Benefits of Follow-Up Using Speckle Tracking Echocardiography
by Mihaela Roxana Popescu, Alexandra Bouariu, Anca Marina Ciobanu, Nicolae Gică and Anca Maria Panaitescu
Medicina 2022, 58(2), 296; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58020296 - 15 Feb 2022
Cited by 5 | Viewed by 2512
Abstract
Pregnancy complications such as gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) are frequent and influence not only fetal outcomes but also the maternal cardiac function. GDM and HDP may act as a proxy for increased metabolic and cardiovascular risk later in [...] Read more.
Pregnancy complications such as gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) are frequent and influence not only fetal outcomes but also the maternal cardiac function. GDM and HDP may act as a proxy for increased metabolic and cardiovascular risk later in life. Speckle tracking echocardiography (STE) is a relatively new imaging technique that provides more sensitive assessment than conventional echocardiography of the maternal cardiac function. Recent research suggests that STE can be used during pregnancy and postpartum as a useful method of early detection of subclinical maternal cardiac changes related to pregnancy complications, such as GDM and HDP, and as an indicator for future maternal cardiovascular disorders. The aim of this review was to underline the current value of STE in the follow-up protocol of high-risk pregnant women, as a mean for pre- and postpartum monitoring. A review of the literature was conducted in the PubMed database to select relevant articles regarding the association of STE changes and HDP or GDM in the prenatal and postpartum maternal evaluations. Both GDM and HDP are associated with subtle myocardial changes in shape, size and function; these preclinical cardiac changes, often missed by conventional evaluation, can be detected using STE. Left ventricular global circumferential strain might be an important predictor of maternal cardiovascular disorders and might help to define a high-risk group that requires regular monitoring later in life and timely intervention. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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8 pages, 6391 KiB  
Review
Malignant Phyllodes Tumor of the Breast and Pregnancy: A Rare Case Report and Literature Review
by Laura Mustață, Nicolae Gică, Radu Botezatu, Raluca Chirculescu, Corina Gică, Gheorghe Peltecu and Anca Maria Panaitescu
Medicina 2022, 58(1), 36; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58010036 - 26 Dec 2021
Cited by 4 | Viewed by 3668
Abstract
Phyllodes Tumor (PT) is a rare fibroepithelial breast tumor that can behave differently depending on its biologic features. Traditionally, PTs are classified by their histologic features into benign, borderline, and malignant. In most cases that were reported, all PTs may recur, but only [...] Read more.
Phyllodes Tumor (PT) is a rare fibroepithelial breast tumor that can behave differently depending on its biologic features. Traditionally, PTs are classified by their histologic features into benign, borderline, and malignant. In most cases that were reported, all PTs may recur, but only the borderline and malignant PT can metastasize. PT usually occurs as a breast lump or accidental finding on ultrasound (US) examination. The clinical features include a well-defined breast mass, regular or lobulated. The diagnosis is based on the integration of morphology features, but remains challenging, particularly in the distinction from fibroadenomas. We report a case of a 36-year-old patient who presented for a voluminous breast mass, rapidly growing in the past 3–4 months. At presentation, the patient was 19 weeks pregnant. The breast tumor had the clinical and US aspect of PT. A core needle biopsy was obtained, confirming a benign PT, and local excision was performed with no postoperative complications. The final pathology report showed a borderline PT with close resection margins of 1 mm. Immunohistochemistry (IHC) established the diagnosis of malignant PT with heterologous sarcomatous differentiation. The case was discussed in the multidisciplinary tumor board (MDT) and mastectomy was recommended. The patient fully consented but refused surgery at 25 weeks’ gestation, fearing premature delivery. The right breast was closely monitored by US, and at 9 weeks after the first surgery, signs of local recurrence were detected. At 35 weeks’ gestation, right mastectomy was performed, with no perioperative complications. The pregnancy was closely followed up and no complication were found. The final pathology report describes multiples PT recurrences with heterologous sarcomatous differentiation. The pregnancy outcome was uneventful, and the patient delivered a healthy child vaginally at term with no peripartum complication. Postpartum, a computer tomography (CT) examination of the head, thorax, abdomen and pelvis was performed, with no evidence of metastases. Adjuvant chemotherapy and radiotherapy completed the treatment. The follow-up and CT scan showed no metastases or further recurrence 4 years after diagnosis. In conclusion, diagnosis of PT can be difficult, especially because of the easy confusion with fibroadenoma of the breast. There are rare cases when a pathology exam needs further assessment and IHC is recommended for accurate diagnosis. Although malignant PT is rare and accounts for <1% of all breast cancers, the diagnosis and treatment that are recommended are based on the reported cases. Moreover, when complete surgical excision is achieved, the rates of recurrence and distant metastases are low, and adjuvant therapy might not be necessary. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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12 pages, 2302 KiB  
Review
Pregnancy Complications Can Foreshadow Future Disease—Long-Term Outcomes of a Complicated Pregnancy
by Anca Maria Panaitescu, Mihaela Roxana Popescu, Anca Marina Ciobanu, Nicolae Gica and Brindusa Ana Cimpoca-Raptis
Medicina 2021, 57(12), 1320; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57121320 - 01 Dec 2021
Cited by 7 | Viewed by 3047
Abstract
During gestation, the maternal body should increase its activity to fulfil the demands of the developing fetus as pregnancy progresses. Each maternal organ adapts in a unique manner and at a different time during pregnancy. In an organ or system that was already [...] Read more.
During gestation, the maternal body should increase its activity to fulfil the demands of the developing fetus as pregnancy progresses. Each maternal organ adapts in a unique manner and at a different time during pregnancy. In an organ or system that was already vulnerable before pregnancy, the burden of pregnancy can trigger overt clinical manifestations. After delivery, symptoms usually reside; however, in time, because of the age-related metabolic and pro-atherogenic changes, they reappear. Therefore, it is believed that pregnancy acts as a medical stress test for mothers. Pregnancy complications such as gestational hypertension, preeclampsia and gestational diabetes mellitus foreshadow cardiovascular disease and/or diabetes later in life. Affected women are encouraged to modify their lifestyle after birth by adjusting their diet and exercise habits. Blood pressure and plasmatic glucose level checking are recommended so that early therapeutic intervention can reduce long-term morbidity. Currently, the knowledge of the long-term consequences in women who have had pregnancy-related syndromes is still incomplete. A past obstetric history may, however, be useful in determining the risk of diseases later in life and allow timely intervention. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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9 pages, 1013 KiB  
Review
Fetal Surveillance in Pregnancies with Myasthenia Gravis
by Brîndușa Ana Cimpoca-Raptis, Anca Marina Ciobanu, Nicolae Gica, Gheorghe Peltecu, Dan Mitrea and Anca Maria Panaitescu
Medicina 2021, 57(11), 1277; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57111277 - 20 Nov 2021
Cited by 5 | Viewed by 2793
Abstract
Myasthenia gravis (MG) is an autoimmune condition, that commonly impacts adult women of reproductive age. Myasthenia gravis in pregnancy is rare, but the incidence is higher in different geographical areas. Pregnancies in mothers with MG can have an unfortunate outcome. Acetylcholine receptor antibodies [...] Read more.
Myasthenia gravis (MG) is an autoimmune condition, that commonly impacts adult women of reproductive age. Myasthenia gravis in pregnancy is rare, but the incidence is higher in different geographical areas. Pregnancies in mothers with MG can have an unfortunate outcome. Acetylcholine receptor antibodies may pass into the fetal circulation and can affect the fetal neuromuscular junction, generating transient MG or even fetal arthrogryposis. The 2016 and 2021 International Consensus Guidance for Management of Myasthenia Gravis issued by Myasthenia Gravis Foundation of America is lacking in recommendation for fetal surveillance for pregnancies in women with MG. The aim of this paper is to highlight fetal and neonatal complications in mothers with MG and to offer antenatal care insights. Close maternal and pregnancy monitoring can improve pregnancy outcome. Patients with MG should be encouraged to conceive, to avoid triggers for exacerbations of the disease during pregnancy and a multidisciplinary team should be established to ensure the optimal support and therapy. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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Other

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8 pages, 947 KiB  
Case Report
Caesarean Scar Pregnancy: A Case Report and a Literature Review
by George Valasoulis, Ioulia Magaliou, Dimitrios Koufidis, Antonios Garas and Alexandros Daponte
Medicina 2022, 58(6), 740; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58060740 - 30 May 2022
Cited by 3 | Viewed by 3833
Abstract
Background and Objectives: Caesarean scar pregnancy (CSP) refers to placental implantation on or in the scar of a previous caesarean section and represents a potentially life-threatening condition. CSP is considered a diagnostic challenge in obstetrics, with the diagnosis relying mainly on transvaginal [...] Read more.
Background and Objectives: Caesarean scar pregnancy (CSP) refers to placental implantation on or in the scar of a previous caesarean section and represents a potentially life-threatening condition. CSP is considered a diagnostic challenge in obstetrics, with the diagnosis relying mainly on transvaginal ultrasound (TVS) and the management depending upon case presentation and available healthcare infrastructures. Case Presentation: We present a case of 34-year-old G3P2 with a history of two-previous caesarean sections referred to the outpatient gynaecology clinic of our Department at the 7th week (7/40) of gestation with abnormal early pregnancy TVS findings, illustrating the gestational sac attached to the caesarean scar and a foetal pole with evidence of foetal cardiac activity. We discuss the outcome of an alternative combined medical and surgical approach we followed as well as an updated review of the current literature. Conclusions: The ideal management of CSP requires tertiary centers, equipment availability and experienced healthcare professionals capable of dealing with any possible complication, as well as individualized treatment based on each case presentation. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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6 pages, 1569 KiB  
Case Report
Umbilical Cord Knots: Is the Number Related to Fetal Risk?
by Guglielmo Stabile, Stefania Carlucci, Lucia De Bonis, Felice Sorrentino, Luigi Nappi and Giuseppe Ricci
Medicina 2022, 58(6), 703; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58060703 - 25 May 2022
Cited by 4 | Viewed by 4497
Abstract
True knots of the umbilical cord (UC) are a rare occurrence and are reported in 0.4–1.2% of deliveries. The compression of true knot of the UC can cause obstruction of the fetal circulation, leading to intra-uterine growth retardation or fetal death. Predisposing factors [...] Read more.
True knots of the umbilical cord (UC) are a rare occurrence and are reported in 0.4–1.2% of deliveries. The compression of true knot of the UC can cause obstruction of the fetal circulation, leading to intra-uterine growth retardation or fetal death. Predisposing factors for the genesis of the true UC knot are numerous and include all the conditions, which lead to a relatively large uterine volume. This situation may predispose to free and excessive fetal movements. Although not all true knots lead to perinatal complications, they have been associated with adverse pregnancy outcomes, including fetal distress, fetal hypoxia, intra-uterine growth restriction (IUGR), long-term neurological damage, caesarean delivery and stillbirth. We present a rare case of operative delivery with vacuum in a multiparous woman at term of pregnancy with a double true knot of the UC. As in most cases, the diagnosis was made after delivery, as there were no fetal symptoms during pregnancy. Some authors assume that 3D power sonography may be useful in the diagnosis of true UC knots. However, 3D power Doppler cannot be considered as a definitive method. There are no specific prenatal indications to induce the physician to look for ultrasound signs suggestive of umbilical true knot. Some studies argue that cases of fetal death and fetal risk are directly related to the number of knots. We also support this thesis, even if further observational and retrospective studies are needed to demonstrate it. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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7 pages, 987 KiB  
Case Report
Medulloblastoma Presenting as Severe Headache during Pregnancy: A Case Report and Review of the Literature
by Francesca Gabriela Paslaru, Anca Maria Panaitescu, Elena Nestian, George Iancu, Alina Veduta, Alexandru Catalin Paslaru, Lucian Gheorghe Pop and Radu Mircea Gorgan
Medicina 2022, 58(1), 127; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina58010127 - 14 Jan 2022
Viewed by 1941
Abstract
Headache is a common complaint during pregnancy and the puerperium. The differentiation between a benign headache and a headache that has an underlying more endangering cause, such as an intracranial tumor, can be difficult and often requires diagnostic procedures and brain imaging techniques. [...] Read more.
Headache is a common complaint during pregnancy and the puerperium. The differentiation between a benign headache and a headache that has an underlying more endangering cause, such as an intracranial tumor, can be difficult and often requires diagnostic procedures and brain imaging techniques. We report the case of an 18-year-old female patient who developed clinical symptoms—persistent headache followed by neurological deficit—in the last part of her pregnancy. A medulloblastoma (MB) was diagnosed and treated after delivery. We review 11 other cases of MB in pregnancy reported in the literature. The most common clinical manifestation at diagnosis was headache followed by neurological deficits. We discuss the association of brain tumor growth with physiological changes during pregnancy. We conclude that clinical features of intracranial tumors can be misinterpreted as pregnancy-related symptoms and should not be dismissed. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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11 pages, 9237 KiB  
Systematic Review
Maternal and Fetal Outcomes after Prior Mid-Trimester Uterine Rupture: A Systematic Review with Our Experience
by Shinya Matsuzaki, Tsuyoshi Takiuchi, Takeshi Kanagawa, Satoko Matsuzaki, Misooja Lee, Michihide Maeda, Masayuki Endo and Tadashi Kimura
Medicina 2021, 57(12), 1294; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57121294 - 24 Nov 2021
Cited by 3 | Viewed by 1981
Abstract
Background and Objectives: Since spontaneous uterine rupture in the mid-trimester is rare, maternal and fetal outcomes in subsequent pregnancies remain unclear. Therefore, this study aimed to examine the maternal and fetal outcomes of subsequent pregnancies after prior mid-trimester uterine rupture. Materials and [...] Read more.
Background and Objectives: Since spontaneous uterine rupture in the mid-trimester is rare, maternal and fetal outcomes in subsequent pregnancies remain unclear. Therefore, this study aimed to examine the maternal and fetal outcomes of subsequent pregnancies after prior mid-trimester uterine rupture. Materials and Methods: A systematic review using PubMed, the Cochrane Central Register of Controlled Trials, and Scopus until 30 September 2021, was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The studies that clarified the maternal and fetal outcomes after prior mid-trimester uterine rupture and our case (n = 1) were included in the analysis. Results: Among the eligible cases, there were five women with eight subsequent pregnancies after prior mid-trimester uterine rupture. The timing of prior mid-trimester uterine rupture ranged from 15 to 26 weeks of gestation. The gestational age at delivery in subsequent pregnancies was 23–38 gestational weeks. Among the included cases (n = 8), those involving prior mid-trimester uterine rupture appeared to be associated with an increased prevalence of placenta accreta spectrum (PAS) (n = 3, 37.5%) compared with those involving term uterine rupture published in the literature; moreover, one case exhibited recurrent uterine rupture at 23 weeks of gestation (12.5%). No maternal deaths have been reported in subsequent pregnancies following prior mid-trimester uterine rupture. Fetal outcomes were feasible, except for one pregnancy with recurrent mid-trimester uterine rupture at 23 weeks of gestation, whose fetus was alive complicated by cerebral palsy. Conclusions: Our findings suggest that clinicians should be aware of the possibility of PAS and possible uterine rupture in pregnancies after prior mid-trimester uterine rupture. Further case studies are warranted to assess maternal and fetal outcomes in pregnancies following prior mid-trimester prior uterine rupture. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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8 pages, 1900 KiB  
Case Report
Severe Neonatal Anemia Due to Spontaneous Massive Fetomaternal Hemorrhage at Term: An Illustrative Case with Suspected Antenatal Diagnosis and Brief Review of Current Knowledge
by Nicolae Gică, Radu Botezatu, Mihaela Demetrian, Ana Maria Vayna, Brîndușa Ana Cimpoca-Raptis, Anca Marina Ciobanu, Corina Gica, Gheorghe Peltecu and Anca Maria Panaitescu
Medicina 2021, 57(12), 1285; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57121285 - 23 Nov 2021
Cited by 2 | Viewed by 2975
Abstract
Fetomaternal hemorrhage is defined as transfer of fetal blood into placental circulation and therefore into maternal circulation during pregnancy, and represents an important contributor to intrauterine fetal demise and neonatal death. The condition is rarely diagnosed prenatally because clinical findings are often nonspecific, [...] Read more.
Fetomaternal hemorrhage is defined as transfer of fetal blood into placental circulation and therefore into maternal circulation during pregnancy, and represents an important contributor to intrauterine fetal demise and neonatal death. The condition is rarely diagnosed prenatally because clinical findings are often nonspecific, and it is unpredictable. In this paper we present an illustrative case of massive spontaneous fetomaternal hemorrhage where the diagnosis was highly suspected antenatally based on maternal reported reduced fetal movements, abnormal suggestive cardiotocographic trace, and increased peak systolic velocity in the fetal middle cerebral artery. We discuss obstetrical and neonatal management and review the current knowledge in the literature. Maintaining a high index of suspicion for this condition allows the obstetrician to plan for adequate diagnostic tests, arrange intrauterine treatment or delivery, and prepare the neonatal team. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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6 pages, 2361 KiB  
Case Report
Absence of Wharton’s Jelly at the Abdominal Site of the Umbilical Cord Insertion. Rare Case Report and Review of the Literature
by Radu Botezatu, Sandra Raduteanu, Anca Marina Ciobanu, Nicolae Gica, Gheorghe Peltecu and Anca Maria Panaitescu
Medicina 2021, 57(11), 1268; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57111268 - 18 Nov 2021
Cited by 3 | Viewed by 2415
Abstract
Wharton’s jelly is a specialized connective tissue surrounding and protecting umbilical cord vessels. In its absence, the vessels are exposed to the risk of compression or rupture. Because the condition is very rare and there are no available antepartum investigation methods for diagnosis, [...] Read more.
Wharton’s jelly is a specialized connective tissue surrounding and protecting umbilical cord vessels. In its absence, the vessels are exposed to the risk of compression or rupture. Because the condition is very rare and there are no available antepartum investigation methods for diagnosis, these cases are usually discovered after delivery, frequently after in utero fetal demise. We report the fortunate case of a 29-year-old nulliparous woman, with an uncomplicated pregnancy, admitted at 39 weeks in labor where a persistently abnormal cardiotocographic trace led to delivery by cesarean section of a healthy 3500 g newborn. After delivery, a Wharton’s jelly anomaly was identified at the abdominal umbilical insertion (umbilical cord vessels, approximately 1 cm in length, were completely uncovered by Wharton’s jelly), which required surgical thread elective ligation. In the presence of a persistently abnormal CTG trace, in a pregnancy with no clinical settings suggestive of either chronic or acute fetal hypoxemia, the absence of Wharton’s jelly should be taken into consideration in the differential diagnosis. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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6 pages, 2927 KiB  
Case Report
Transcatheter Arterial Embolization for Spontaneous Hepatic Rupture Associated with HELLP Syndrome: A Case Report
by In-Chul Nam, Jung-Ho Won, Sungbin Kim, Kyungsoo Bae, Kyung-Nyeo Jeon, Jin-Il Moon, Eun Cho, Ji-Eun Park, Jae-Yool Jang and Sung-Eun Park
Medicina 2021, 57(10), 1055; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57101055 - 02 Oct 2021
Cited by 2 | Viewed by 1627
Abstract
Background: Spontaneous hepatic rupture associated with the syndrome characterized by hemolysis, elevated liver enzymes, and a low platelet count (HELLP syndrome) is a rare and life-threatening condition, and only a few cases regarding the management of this condition through transcatheter arterial embolization (TAE) [...] Read more.
Background: Spontaneous hepatic rupture associated with the syndrome characterized by hemolysis, elevated liver enzymes, and a low platelet count (HELLP syndrome) is a rare and life-threatening condition, and only a few cases regarding the management of this condition through transcatheter arterial embolization (TAE) have been previously reported. Case summary: Herein, we report a case involving a 35-year-old pregnant woman who presented at 28 weeks of gestation with right upper quadrant pain, hypotension, and elevated levels of liver enzymes. Transabdominal ultrasound revealed fetal death. She required an emergency cesarean section, and hepatic rupture was identified after the fetus had been delivered. Hepatic packing and TAE were performed. The postprocedural course was uneventful, and the patient was discharged 14 days after she had been admitted to our hospital. Conclusions: Spontaneous hepatic rupture associated with HELLP syndrome is a very serious condition that requires prompt and decisive management. The high maternal and fetal mortality rates associated with this condition can be reduced through early accurate diagnosis and adequate management. The findings in the reported case indicate that TAE may be an attractive alternative to surgery for the management of spontaneous hepatic rupture associated with HELLP syndrome. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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7 pages, 2786 KiB  
Case Report
Secondary Amenorrhea and Infertility Due to an Inhibin B Producing Granulosa Cell Tumor of the Ovary. A Rare Case Report and Literature Review
by Corina Gică, Ruxandra-Gabriela Cigăran, Radu Botezatu, Anca Maria Panaitescu, Brîndușa Cimpoca, Gheorghe Peltecu and Nicolae Gică
Medicina 2021, 57(8), 829; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57080829 - 17 Aug 2021
Cited by 7 | Viewed by 3170
Abstract
Granulosa cell tumor of the ovary (GCT) is a rare ovarian tumor with nonspecific symptoms. Studies reported that GCT are usually secreting estrogens and inhibins, especially inhibin B. It is considered that, in premenopausal women, irregular menses or secondary amenorrhea may be an [...] Read more.
Granulosa cell tumor of the ovary (GCT) is a rare ovarian tumor with nonspecific symptoms. Studies reported that GCT are usually secreting estrogens and inhibins, especially inhibin B. It is considered that, in premenopausal women, irregular menses or secondary amenorrhea may be an early symptom of GCT and, in postmenopausal women, the most common manifestation is vaginal bleeding. Additionally, endometrial abnormalities can be associated due to estrogenic secretion. At reproductive age, high levels of inhibin, lead to low levels of FSH and secondary amenorrhea causing infertility. At times, increased levels of LH in women with GCT are observed and the pathogenesis is still unclear. Therefore, inhibin B level can differentiate GCT from other causes of secondary amenorrhea. We report the case of a 26-year-old nulliparous, women who presented in our clinic with secondary infertility lasting longer than 2 years, secondary amenorrhea, polycystic ovarian syndrome, and suspicion of right ovarian endometrioma on CT scan. The ultrasound examination revealed that the right ovary was transformed in an anechoic mass with increased peripheral vascularity having a volume of 10 cm3. This patient had high serum levels of inhibin B and LH but normal levels of FSH and estradiol. The preliminary diagnosis of granulosa cell tumor of the ovary was made. After counseling, the informed consent for treatment was obtained and the patient agreed to undergo surgery. An uneventful laparoscopy was performed with right oophorectomy and multiple peritoneal sampling. The histological diagnosis confirmed adult GCT limited to right ovary, with negative peritoneal biopsies (FIGO IA). After surgery the patient recovered fully and had normal menstrual cycles with normal serum levels of hormones. Two months later she conceived spontaneously and had an uneventful pregnancy. In conclusion, for cases with secondary amenorrhea, the evaluation of inhibin B level is essential. Elevated inhibin B level may be a sign for the presence of an unsuspected tumor. With early diagnosis and treatment, the prognosis is generally good and the fertility may be preserved, especially in young patients with GCT. Full article
(This article belongs to the Special Issue High-Risk Pregnancy)
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