Abstract Advancements in health promotion and prenatal medicine have made noninvasive prenatal testing (NIPT) a common practice during pregnancy, but understanding prenatal health information becomes crucial not only for the well-being of the mother but also for that of the unborn child. Analyze health-related information during pregnancy is fundamental, and this work fits perfectly with this topic, reporting preliminary results from the pilot study “SaperePer”. A health-related questionnaire was administered to 358 women in the first trimester of pregnancy, aiming to study different outcomes: 1.level of knowledge of NIPT; 2.number of screening tests undergone; 3.willingness to undergo a diagnostic test with a high outcome risk of screening test; 4.willingness to end the pregnancy following a diagnosis of pathology. The questionnaire was divided into 3 sections: personal characteristics and lifestyle habits, prenatal health behavior scale (PHBS), and knowledge of NIPT. Preliminary results showed that the level of knowledge of NIPT was higher in older, atheist, working, wealthy highly educated, and preliminary informed women, as well as the higher number of screening tests undergone and the propensity to undergo an invasive diagnostic test after a high-risk screening result (KS and MW tests p < 0.05). On the contrary, women with lower education, faithful and, even more, not preliminary and appropriately informed during prenatal counseling showed lower knowledge of NIPT, lower number of tests undergone, and meager chances to undergo an invasive diagnostic test or to end the pregnancy after a positive diagnosis of pathology (KS and MW tests p < 0.05). In conclusion, this study evaluated health-related information during the first but crucial stages of pregnancy, opening a new understanding of how health literacy and correct prenatal counseling could increase awareness and health promotion in pregnant women, particularly in those women with lower cultural tools. Key messages • Health literacy and correct prenatal counseling could increase awareness and health promotion in pregnant women. • Understanding prenatal health information becomes crucial both for maternal and prenatal well-being.

Objectives To investigate the rate and outcome of emergency Cesarean delivery (CD) in women with placenta previa with or without placenta accreta spectrum disorders (PAS) and to elucidate the diagnostic accuracy of ultrasound in predicting emergency CD. Methods This was a secondary analysis of a multicenter prospective study involving 16 referral hospitals in Italy (ADoPAD study). Inclusion criteria were women with placenta previa minor (< 20 mm from the internal cervical os) or placenta previa major (covering the os), aged >= 18 years, who underwent transabdominal and transvaginal ultrasound assessment at >= 26 + 0 weeks of gestation. The primary outcome was the occurrence of emergency CD, defined as the need for immediate surgical intervention performed for emergency maternal or fetal indication, including active labor, cumulative maternal bleeding > 500 mL, severe and persistent vaginal bleeding such that maternal hemodynamic stability could not be achieved or maintained, or category-III fetal heart rate tracing unresponsive to resuscitative measures. The primary outcome was reported separately in the population of women with placenta previa and no PAS confirmed after birth and in those with PAS. The secondary aim was to report on the strength of association and to test the diagnostic accuracy of ultrasound in predicting emergency CD. Univariate, multivariate and diagnostic accuracy analyses were used to analyze the data. Results A total of 450 women, including 97 women with placenta previa and PAS and 353 with placenta previa only, were analyzed. In women with placenta previa and PAS, emergency CD was required in 20.6% (95% CI, 14-30%), and 60.0% (12/20) delivered before 34 weeks of gestation. The mean gestational age at delivery was 32.3 +/- 2.7 weeks in women undergoing emergency CD and 34.9 +/- 1.8 weeks in those undergoing elective CD (P < 0.001). Women undergoing emergency CD had a higher median estimated blood loss (2500 (interquartile range (IQR), 1350-4500) vs 1100 (IQR, 625-2500) mL; P = 0.012), mean units of blood transfused (7.3 +/- 8.8 vs 2.5 +/- 3.4; P = 0.02) and more frequent placement of a mechanical balloon (50.0% vs 16.9%; P = 0.002) compared with those undergoing elective CD. On univariate analysis, the presence of interrupted retroplacental space, interrupted bladder line and placental lacunae was more common in women not experiencing emergency CD. No comprehensive multivariate analysis could be performed in this subgroup of women. Ultrasound signs of PAS, including presence of interrupted retroplacental space, interrupted bladder line and placental lacunae, were not predictive of emergency CD. In women with placenta previa but no PAS, emergency CD was required in 31.2% (95% CI, 26.6-36.2%), and 32.7% (36/110) delivered before 34 weeks of gestation. The mean gestational age at delivery was lower in women undergoing emergency CD compared with those undergoing elective CD (34.2 +/- 2.9 vs 36.7 +/- 1.6 weeks; P < 0.001). Pregnancies complicated by emergency CD were associated with a lower birth weight (2330 +/- 620 vs 2800 +/- 480 g; P < 0.001) and had a higher risk of need for blood transfusion (22.7% vs 10.7%; P = 0.003) compared with those who underwent elective CD. On multivariate analysis, only placental thickness (odds ratio (OR), 1.02 (95% CI, 1.00-1.03); P = 0.046) and cervical length < 25 mm (OR, 3.89 (95% CI, 1.33-11.33); P = 0.01) were associated with emergency CD. However, a short cervical length showed low diagnostic accuracy for predicting emergency CD in these women. Conclusion Emergency CD occurred in about 20% of women with placenta previa and PAS and 30% of those with placenta previa only and was associated with worse maternal outcome compared with elective intervention. Prenatal ultrasound is not predictive of the risk of emergency CD in women with these disorders. (c) 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Objective To evaluate the performance of third-trimester ultrasound for the diagnosis of clinically significant placenta accreta spectrum disorder (PAS) in women with low-lying placenta or placenta previa. Methods This was a prospective multicenter study of pregnant women aged >= 18 years who were diagnosed with low-lying placenta (< 20 mm from the internal cervical os) or placenta previa (covering the internal cervical os) on ultrasound at >= 26 + 0 weeks' gestation, between October 2014 and January 2019. Ultrasound suspicion of PAS was raised in the presence of at least one of these signs on grayscale ultrasound: (1) obliteration of the hypoechogenic space between the uterus and the placenta; (2) interruption of the hyperechogenic interface between the uterine serosa and the bladder wall; (3) abnormal placental lacunae. Histopathological examinations were performed according to a predefined protocol, with pathologists blinded to the ultrasound findings. To assess the ability of ultrasound to detect clinically significant PAS, a composite outcome comprising the need for active management at delivery and histopathological confirmation of PAS was considered the reference standard. PAS was considered to be clinically significant if, in addition to histological confirmation, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation or uterine artery embolization. The diagnostic performance of each ultrasound sign for clinically significant PAS was evaluated in all women and in the subgroup who had at least one previous Cesarean section and anterior placenta. Post-test probability was assessed using Fagan nomograms. Results A total of 568 women underwent transabdominal and transvaginal ultrasound examinations during the study period. Of these, 95 delivered in local hospitals, and placental pathology according to the study protocol was therefore not available. Among the 473 women for whom placental pathology was available, clinically significant PAS was diagnosed in 99 (21%), comprising 36 cases of placenta accreta, 19 of placenta increta and 44 of placenta percreta. The median gestational age at the time of ultrasound assessment was 31.4 (interquartile range, 28.6-34.4) weeks. A normal hypoechogenic space between the uterus and the placenta reduced the post-test probability of clinically significant PAS from 21% to 5% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 9% in the subgroup with previous Cesarean section and anterior placenta. The absence of placental lacunae reduced the post-test probability of clinically significant PAS from 21% to 9% in women with low-lying placenta or placenta previa in the third trimester of pregnancy and from 62% to 36% in the subgroup with previous Cesarean section and anterior placenta. When abnormal placental lacunae were seen on ultrasound, the post-test probability of clinically significant PAS increased from 21% to 59% in the whole cohort and from 62% to 78% in the subgroup with previous Cesarean section and anterior placenta. An interrupted hyperechogenic interface between the uterine serosa and bladder wall increased the post-test probability for clinically significant PAS from 21% to 85% in women with low-lying placenta or placenta previa and from 62% to 88% in the subgroup with previous Cesarean section and anterior placenta. When all three sonographic markers were present, the post-test probability for clinically significant PAS increased from 21% to 89% in the whole cohort and from 62% to 92% in the subgroup with previous Cesarean section and anterior placenta. Conclusions Grayscale ultrasound has good diagnostic performance to identify pregnancies at low risk of PAS in a high-risk population of women with low-lying placenta or placenta previa. Ultrasound may be safely used to guide management decisions and concentrate resources on patients with higher risk of clinically significant PAS. (c) 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Although there is a consensus on offering the obstetrical referral scan in case of fetal risk factors (i.e. suspicion of fetal anomaly, nuchal translucency ≥ 3.5 mm, and early-onset fetal growth restriction), indications are not well established in cases where the high risk is derived from anamnestic or family/maternal risk factors. In order to answer this question, we built guidelines by GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology on the best available evidence. The GRADE methodology for guidelines and recommendations building was followed within a project of Italian Ministry of Health and Italian Society of Ultrasound in Obstetrics and Gynecology (SIEOG) guidelines building. PICO (Patient Intervention Comparison Outcomes) related to referral scan was defined. A systematic search of the available guidelines, systematic reviews, meta-analyses, and primary studies from June 2020 to June 2021 was conducted through PubMed, Cochrane Library, and Epistemonikos. Results and selection process were described using PRISMA criteria. AGREE II tool was adopted to define the methodological quality of the selected guidelines. Systematic research identified 73 guidelines, 69 systematic reviews, and 41 primary studies. Figure 1 reports identified indications for referral scan according to family history, maternal and fetal risk factors. Following a rigorous GRADE methodology for guidelines and recommendations building, we provide the up-to-date best evidence on indications for referral scan based on maternal and fetal risk factors with the aim to provide a useful tool for clinicians as well as for health decision-makers. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

A 32-year-old woman nullipara at 8 weeks of gestation presented with moderate cramping abdominal pain and light metrorrhagia. Her obstetric history was significant for IVF. On examination, her vital signs were within normal limits and she demonstrated pain only on deep palpation in lower quadrants. Her blood test was compatible with the gestational age. A transvaginal ultrasound was performed and showed: intrauterine pregnancy with cardiac activity and two enlarged ovaries, compatible with stimulation (figure 1). We scheduled an early recheck 10 days after in radiology with trans abdominal and transvaginal ultrasound. Heterotopic pregnancy. Ultrasonography showed a live intrauterine fetus at 11 weeks of gestation and an additional left-sided adnexal extrauterine pregnancy, both with cardiac activity (figures 2, 3). The patient underwent laparoscopic left-sided salpingectomy and the intrauterine pregnancy progressed without problems (figures 4, 5). Heterotopic pregnancy is defined by the presence of both intrauterine and extrauterine pregnancy. It is extremely rare in absence of risk factors, with any assisted reproduction, rates increase to a range of 1 in 100 to 1 in 500. (1,2) Early diagnosis is often challenging because of the absence of clinical symptoms (3), because the size of the stimulated ovaries is bigger than normal (average measures 40 × 30 × 20 mm in fertile women) and the follicles are very vascularised and grown up (4).These patients require pelvic ultrasonography and follow-up, like in our case, to definitively exclude heterotopic pregnancy. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Introduction/Background The ADNEX (Assessment of Different NEoplasias in the adneXa) model was developed using parameters collected by experienced (level III) ultrasound examiners. Our primary aim was to externally validate the ADNEX model, when applied by level II examiners in an academic-women-hospital. The discriminatory performance of ADNEX was compared with the two-step strategy and subjective assessment by an experienced ultrasound operator. Methodology From February 2013 to January 2017, all patients who were scheduled for surgery for an adnexal mass at the Sant'Anna Hospital in Turin were enrolled. Preoperative transvaginal sonography was performed, and the two-step strategy was applied. Two ultrasound examiners applied the ADNEX model to all the collected masses based on the ultrasound reports. Finally, an experienced operator assigned the subjective assessment based on recorded ultrasound images. The discrimination and calibration performance of ADNEX were evaluated. The AUC was calculated for the basic discrimination between benign and malignant tumours Results A total of 577 patients were included in the analysis: the overall prevalence of malignancy was 25%. With ADNEX, the AUC to differentiate between benign and malignant masses was 0.9111 (95% CI 0. 8788–0.9389). At risk cut-offs of 1%, 10% and 30%, sensitivities were 100%, 89.6% and 79.2%, respectively, and specificities were 2.8%, 76.2% and 89.6%, respectively. Discrimination between benign and stage II–IV tumours was good (AUC 0.935). The model had the most difficulties discriminating between borderline and stage I tumours, and between stages II-IV invasive and secondary metastatic tumours. ADNEX proved to be equally or more accurate than the subjective assessment or the two-step strategy in the discrimination between benign and malignant adnexal masses. Conclusion The ADNEX model could probably be successfully applied when a level III examiner is not available and, therefore both a subjective assessment and the two-step strategy cannot be performed. Disclosure Nothing to disclose.

Objectives: To compare the different classifications in use for mullerian anomalies (ASRM, Salim, ESHRE/ESGE, CUME) in the diagnosis of normal/ arcuate/ septate uterus and to correlate the diagnosis with reproductive outcomes. Methods: Retrospective observational study conducted on 664 patients with 3D ultrasound diagnosis of arcuate/subseptate uterus (3-30 mm indentation). For each patient the uterine morphology was evaluated offline on the coronal plane and the following measurements were recorded: uterine cavity width (W); septal length (L); uterine wall thickness (M); fundal indentation angle (α). Each uterus was subsequently subclassified according to the following classifications: ASRM (1988), Salim (2003), ESHRE/ESGE (2013), CUME (2018). The reproductive history of each patient was correlated to the cavitary measurements and the type of malformation according to the four classifications. Results: 38% of patients were infertile, 62% had at least one pregnancy with 75% of abortion, 23% of secondary infertility and 13% of preterm labour. Primary infertility was greater in patients with narrow cavities (W), less uterine wall thickness (M) and greater indentation angle (α). Preterm birth was associated with longer septa (L), recurrent abortion with small and narrow septa (L, W). The current classifications are not homogeneous in the definition of subseptate uterus and are not correlated with reproductive outcomes. This correlation becomes significant by imposing an indentation cutoff ≥ 5mm to the ESHRE classification. Conclusions: According to our results the presence of a partial septum carries a negative effect on reproductive impacts. We identified certain uterine morphological features that seem to have a greater association with negative outcomes. Current classifications don’t seem to correlate with reproductive outcomes. In our opinion, the determination of a minimum indentation cut-off could standardise the existing classifications by clearly defining the criteria for corrective surgery.

To evaluate the diagnostic performance of obstetric ultrasound in detecting clinically significant placenta accreta spectrum disorder (PAS) in women with placenta previa (PP; < 2 cm from the internal orifice of the uterus, 26+0/7gestational weeks) and at least two previous Caesarean sections. Prospective observational multicentric study. PAS was suspected in presence of at least one of the the following ultrasound signs: irregularity of the hypoechoic space between uterus and placenta, disruption of the hyperechoic uterine/bladder wall interface, turbulent placental lacunae with high-speed flow (> 15 cm/s). PAS was defined clinically significant if, in addiction to histological confirmation of placenta accreta, at least one of the following procedures was performed: haemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation, uterine artery embolisation. 64 women were included in the study. The diagnostic performances of ultrasound for PAS are reported in table 1. With at least two Caesarean sections and anterior PP the normality of the hypoechoic space is superior to the other signs to rule out PAS. With posterior PP the simultaneous finding of lacunae and irregularity of the hypoechoic space is superior to the other signs for the diagnosis of PAS. OC30.02: Table 1.

To evaluate the diagnostic performance of different ultrasound signs in the 3rd trimester, for the diagnosis of clinically significant placenta accreta spectrum (PAS) disorders in women with placenta previa (< 2 cm from the internal uterine orifice, > 26+0/7gestational weeks) without previous Caesarean section. Prospective observational multicentre study. Ultrasound suspicion of placental accretism was raised in the presence of at least one of: obliteration/irregularities of the hypoechogenic space between uterus and placenta, interruption of the hyperechogenic interface between uterine serous-membrane and bladder wall or turbulent placental lacunae with high speed flow (> 15cm/sec). The placental accretism was defined as clinically significant if, in addiction to histological confirmation of placenta accreta, at least one of these procedures was carried out after delivery: use of hemostatic intrauterine balloon, compressive uterine suture, peripartum hysterectomy, uterine/hypogastric artery ligation, uterine artery embolisation. For each ultrasound sign and their combination we calculated diagnostic performance. 258 women were included. Diagnostic performances of ultrasound for PAS are shown in table 1. In case of anterior placenta previa, the presence of all of three ultrasound signs is the best way to confirm the presence of PAS, whereas a normal hypoechogenic space between uterus and placenta is more suitable than the other ultrasound signs to exclude the presence of PAS. In case of posterior placenta previa, turbulent placental lacunae are the best predictor for the diagnosis of PAS.

The aim of this study was to evaluate the role of HE4 in the management of adnexal masses in women in pre- and post-menopause. This was a retrospective study. It considered patients with a suspect of adnexal mass or treated for ovarian pathology. 392 patients were included: they were examined on ultrasound between April 1st 2015 and March 1st 2016. Ovarian masses were described using the terms and definitions of IOTA group; the examiner classified every mass using simple rules when applicable. After ultrasound examination we evaluated the peripheric blood circulating level of HE4. Of 392 patients, 285 pz (73%) were eligible for evaluation. Examiner didn't apply simple rules in 27% of women (underwent surgery before, patients in follow-up for ovarian cancer, patient during chemotherapy for ovarian cancer, women without adnexal mass). 141 (50,5%) patients were in pre-menopause: 103 masses were classified as benign lesion and 22 as malignant lesion. 144 patients were in menopause: 85 masses were classified as benign lesion and 45 as malignant lesion. Simple rules were inconclusive in 30 pz (10.5%, 16 patients in pre-menopause and 14 patients in menopause). In these patients we evaluated level of HE4. The cut off for malignancy was ≥ 70 pmol/L in pre menopause and ≥ 140 pmol/L in menopause. In pre menopause the value of HE4 was correlated with histological diagnosis in 92% of cases. Among the group of women in menopause HE4 didn't found a significant correlation with final pathological diagnosis. In this group we founded a correlation between diagnosis of malignancy with simple rules and value of HE4 (VPP 60%). In the management of adnexal masse we can use tumour marker HE4 in pre menopause when simple rules were non applicable: it can help to formulate a diagnosis, to decide the ultrasound follow up and to reduce the over treatment. HE4 in our study seems to be not reliable among the group of menopause to orient diagnosis when simple rules were inconclusive.

OBJECTIVE:To evaluate whether prenatal diagnosis of intestinal midgut volvulus (a rare condition due to the small bowel loops twisting) can improve the prognosis of the newborns.METHODS:In our Prenatal Diagnosis Center, eight cases of intestinal volvulus observed between 2007 and 2014 were retrospectively considered. Ultrasonographic signs can be direct and specific (whirlpool sign, coffee bean sign) or indirect and non-specific (abdominal mass, dilated bowel loops, pseudocysts, ascites, polyhydramnios).RESULTS:Prenatal diagnosis was performed at 20-34 weeks of gestation. All newborns were exposed to an emergency surgery: the major complication was due to cystic fibrosis.CONCLUSIONS:An early suspicion of intestinal volvulus allows the clinician to refer the patient to a tertiary center so to confirm the diagnosis and perform an appropriate follow-up in order to identify the proper time of delivery. The prognosis of the babies with prenatal intestinal volvulus depends on the length of the segment involved, on the level of intestinal obstruction, on the presence of meconium peritonitis and on the gestational age at birth. Our experience, according with the literature, suggests that ascites and absence of abdominal peristalsis are ultrasonographic signs that, in the third trimester of pregnancy, correctly lead to an immediate delivery intervention.

Objectives To evaluate the accuracy of ultrasound in the diagnosis of placenta accreta and its variants, and to assess the impact of prenatal diagnosis in our population.Methods A total of 314 women with placenta previa were enrolled prospectively and underwent transabdominal and transvaginal ultrasound examinations. An ultrasound diagnosis (grayscale and color/power Doppler) of placental attachment disorder (PAD) was based on the detection of at least two of the following ('two-criteria system'): loss/irregularity of the retroplacental clear zone, thinning/interruption of the uterine serosa-bladder wall interface, turbulent placental lacunae with high velocity flow, myometrial thickness <1 mm, increased vascularity of the uterine serosa-bladder wall interface, loss of vascular arch parallel to the basal plate and/or irregular intraplacental vascularization. Definitive diagnosis was made at delivery by Cesarean section. Maternal outcome in cases diagnosed antenatally was compared with that in cases diagnosed at delivery.Results There were 37/314 cases of PAD (29 anterior and eight posterior). The two-criteria system identified 30 cases of placenta accreta, providing a sensitivity of 81.1% and specificity of 98.9%. When anterior and posterior placentae were considered separately, the detection rates of PADwere 89.7 and 50.0%, respectively. Maternal outcome was better in women with prenatal diagnosis of PAD, as seen by less blood loss and shorter hospitalization.Conclusions Our data confirmed that gray-scale and color Doppler ultrasound have good performance in the diagnosis of PAD and that prenatal diagnosis improves maternal outcome. Copyright (C) 2015 ISUOG. Published by John Wiley & Sons Ltd.

The 3 winners of the 1,500 Euros prizes are: Natural History of Cesarean Scar Pregnancy: Can We Predict Outcome? Minneci G, Timor-Tritsch IE, D’Antonio F, Foti F, Izzo T, Forlani F, Calì G Amniocentesis in Dichorionic Twin Pregnancies does not Increase the Risk of Adverse Outcome Until 24 weeks Caramellino L, Viora E, Pertusio A, Sciarrone A, Volpi E, Gaglioti P, Todros T Double Stimulation in a Single Menstrual Cycle Increases the Number of Oocytes Collected in Poor Prognosis Patients undergoing Ivf Treatment. Prospective Study with Historical Control Vaiarelli A, Rienzi L, Colamaria S, Alviggi C, Trabucco E, Zullo F, Giuliani M, Gravotta E, Sapienza F, Cimadomo D, Capalbo A, Ubaldi FM