OBJECTIVE:Caesarean section (CS) rates are rising worldwide, with previous CS being the primary indication. The CS rate in Italy is among the highest in the western world. Repeat CS is associated with significant morbidities. Although evidence is abundant regarding the safety of a trial of labour after one CS, there is a paucity of data regarding a trial of labour after two CSs. The objective of this study was to examine maternal and neonatal outcomes among women with two previous CSs who underwent either repeat CS or a trial of labour within two different inclusion protocols. METHODS:This retrospective cohort study covered the period from 2015 to 2025 in a large teaching hospital. From 2015 to 2020, a new protocol allowed a trial of labour after two previous CSs (TOLA2C) in selected women (Period 1). Starting in 2021 (Period 2), a revised protocol allowed induction of labour (either mechanical or pharmacological) and epidural pain control. Patients undergoing CS were classified as elective, urgent or emergency. Maternal birth mode, and maternal and neonatal outcomes were recorded. RESULTS:Between 2015 and 2025, 23,094 women delivered at Santo Spirito Hospital, Pescara (Italy). Of these, 489 patients who delivered at ≥ 34 weeks of gestation who had undergone two previous CSs were eligible for inclusion in this study: 268 patients in Period 1 (2015-2020) and 221 patients in Period 2 (2021-2025). The rate of TOLA2C rose from 9% in Period 1 to 23% in Period 2 (p ≤ 0.0001). Indications for previous CS and emergency CS rates did not differ significantly between the two periods within the elective CS and TOLA2C groups. Uterine rupture occurred in one labouring patients in the TOLA2C group during Period 1, and in a patient enrolled for an elective CS in Period 2. Two fetal demises occurred in Period 2 in the elective CS group: one due to uterine rupture in an eclamptic patient, and one due to cord thrombosis. CONCLUSION:This study compared two protocols for TOLA2C in women requesting a vaginal birth, and showed increased rates for TOLA2C and vaginal birth after two caesarean sections (i.e. successful TOLA2C) with a more liberal protocol. Although underpowered to detect rare adverse outcomes, this study suggests that TOLA2C can be a reasonably safe option and should be offered to women.

OBJECTIVE:Despite the increasing trend in cesarean section rates in multiple pregnancies, vaginal delivery in twin pregnancies appears both possible and safe. METHODS:This retrospective multicenter study compared outcomes before and after the implementation of a vaginal twin intervention in two Italian hospitals. In January 2021 in Pescara and in July 2022 in Florence, physicians with expertise in twin and breech vaginal birth started working in each center, and clinicians and midwives started quarterly training in these skills. The study period was divided into two equal time intervals and lasted 8 years in Pescara and 5 years in Florence. Providers were also surveyed about how the intervention affected their confidence, skill, and knowledge levels. Diamniotic pregnancies with two viable twins, ≥34 weeks of gestation, and cephalic presentation of the first twin were included. A total of 278 women were evaluated, split into pre-intervention (n = 131) and post-intervention (n = 147) periods. RESULTS:Vaginal birth rates increased from 9.2% to 40.8% overall, with no negative effect on maternal or neonatal outcomes. Participating providers felt more skilled, knowledgeable, and confident and agreed that the training improved vaginal birth rates as well as their vaginal breech skills. CONCLUSION:In settings with a high background cesarean section rate, a rapid increase in the vaginal birth rate of twins is possible without adversely affecting maternal or neonatal outcomes, via either staff-wide training or specialist teams. Simulation and skills training can improve provider confidence, knowledge, and skill levels as well as impact clinical practice in the labor ward.

BACKGROUND: Vaginal delivery in twins is feasible but challenging. Successful vaginal delivery of a non-vertex sec- ond twin depends on knowledge of specific obstetrical maneuvers. Skill acquisition at the patient's bedside is difficult, making simulation training an integral part of obstetrics , gynecology residency programs. METHODS: This prospective, randomized, controlled, single-center study involved obstetrics and gynecology residents. Group A attended a frontal lecture followed by practical simulation; Group B received digital home learning. One month later, both groups underwent a simulation test to identify fetal small parts using a birth simulator with a fetus model placed in a simulated amniotic cavity. Training was conducted with an actor facilitator and supervised by six special- ists, focusing on obtaining information, using external and internal hands. A 25-question Likert scale questionnaire was administered via Google Forms. Metrics evaluated included time to reach foot/feet, number of attempts , answers on Kirkpatrick levels 1-4. RESULTS: Twenty-four participants were recruited and randomized into two groups, with five lost to follow-up at the time of the simulation test. Group A required less time for internal podalic version and breech extraction of the second twin (P=0.02) and fewer attempts to reach the foot/feet of the second twin (P=0.01). Supervisor evaluations of "asking information" and "internal hand use" were better in Group A. CONCLUSIONS: Simulation training for the vaginal delivery of a non-vertex second twin is feasible and has a favorable impact on resident performance.

OBJECTIVE(S):A critical area of obstetrics that demands proficient training is the management of breech deliveries. There was a notable decline in the number of vaginal breech deliveries in the following years, establishing CS as the preferred method of delivery for such cases. Cohort studies using targeted screening and skilled practitioners demonstrated little differences between the two delivery. Skills acquisition at the patient's bedside is very difficult to obtain, particularly in the youngest trainees. Simulation teaching has largely become a part of the training curricula for many obstetrics and gynecology residency programs. STUDY DESIGN:This was a prospective, randomized, controlled, single-center study. Residents were randomly assigned in two groups with similar characteristics. Group A attended a formal lecture. Group B received the study material and recording of the lecture as digital home learning. Lecture and simulation focused on vaginal breech delivery. After one month both groups underwent a simulation test addressed to assist a vaginal breech birth. Four supervisors evaluated all videos. Time needed for birth, and evaluation scales as Objective Structured Clinical Examination were recorded. A questionnaire was completed online using Google Forms with 6 questions. The primary outcome was to compare the evaluation for each item and globally within groups. A secondary outcome was the evaluation of questionnaire results within the two groups. RESULTS:Thirty-two participants were recruited and randomized. None of the participants withdrew from the study. For the primary outcome, all examined variables (Time, Rumping, Legs, Body, Arms, Head, Total Point) did not present differences in supervisors' evaluations. For the secondary outcome, Group B showed higher values in two questions. CONCLUSION(S):The major finding of our study is that digital learning and formal lecture presented similar results on resident knowledge. Teaching programs involving mannequin simulation - both high and low fidelity - are reproducible and efficient for skill retain in obstetric emergencies, particularly in low incidence emergencies. The main limitation of our study was the small sample size. In addition, it is possible that a scenario without deviation or a lecture more focused on possible deviation from normal could modify residents' results facing breech delivery.

BACKGROUND AND PURPOSE:The human auditory system develops early in fetal life. This retrospective MR imaging study describes the in vivo prenatal anatomic development of the transverse temporal gyrus (Heschl gyrus) site of the primary auditory cortex.MATERIALS AND METHODS:Two hundred seventy-two MR imaging studies of the fetal brain (19-39 weeks' gestational age) acquired from a single institution's 1.5T scanner were retrospectively examined by 2 neuroradiologists. MR imaging with pathologic findings and extreme motion artifacts was excluded. Postnatal Heschl gyrus landmarks were used as a reference on T2-weighted ssFSE sequences in the 3 orthogonal planes. The frequency of the Heschl gyrus was reported for gestational age, hemisphere, and planes. Descriptive statistics and a McNemar test were performed.RESULTS:Two hundred thirty MR imaging studies were finally included. Fetal brains were divided by gestational age (in weeks) into 8 groups (parentheses indicate the number of observations): 19-21 (29), 22-23 (32), 24-25 (21), 26-27 (18), 28-29 (35), 30-31 (30), 32-33 (33) and >34 (32). The Heschl gyrus appeared on MR imaging between 24 and 25 weeks' gestational age (14/21 fetuses, 67%) and was visible in all fetuses after the 28th week of gestation. By its appearance (24-28 weeks' gestational age), the sagittal plane was the most sensitive in its detectability. After 28-29 weeks' gestational age, the Heschl gyrus was evident in all acquisition planes and fetuses. Results did not differ between hemispheres.CONCLUSIONS:The Heschl gyrus appears on MR imaging at 24-25 weeks' gestational age, paralleling the functional activation of the auditory system. We propose the Heschl gyrus as an early additional MR imaging marker of fetal brain development.

OBJECTIVE:To assess the effect of two modalities of simulation training on acquisition/retention of skills for performing operative vaginal delivery. DESIGN:Randomized, controlled, single-centre study. SETTING:A tertiary referral hospital in Italy. PARTICIPANTS:Twenty residents from a single university programme and two young specialists. INTERVENTION:Group 1 had an individual training session with a single senior specialist using a fixed simulator model. After the session, trainees watched a pre-recorded 1-h lecture on vacuum-assisted operative vaginal delivery. Group 1 repeated the simulator session using the same test after 8-12 weeks and 12 months. Group 2 watched the pre-recorded lecture then undertook the same sessions as Group 1. Video recordings of all test performances were evaluated by five specialists in a blinded manner. MAIN OUTCOME MEASURE:Each procedure was evaluated using a Global Rating Scale (GRS), scored with 0-5 points for each item on an Objective Structured Assessment of Technical Skills (OSATS) dataset with seven items (total 35 points). OSATS were evaluated over time, compared for the whole population, and weighted for route and year of residency. The primary outcome was comparison of the effectiveness of training between the two groups based on year of residency by assessing videos of the baseline test and GRS for OSATS scores. The secondary outcome was overall retention of skills at 8-12 weeks and 12 months. RESULTS:Twenty-two participants were recruited and randomized to either Group 1 (n = 11) or Group 2 (n = 11). Five participants did not complete follow-up. The primary outcome of GRS for OSATS scores at time 0 differed significantly between groups for total GRS score, and 'Call for help' and 'Explanation to woman and relatives' item scores (p = 0.002 and p = 0.007, respectively). In a multiple linear regression analysis, OSATS scores were not independently influenced by year of residency. At 8-12-week follow-up, the 'Call for help' item score showed a significant improvement in Group 1 (p = 0.018), although this was not confirmed when year of residency was included as an independent variable. At 12-month follow-up, none of the item scores demonstrated a significant change (p = 0.033). Year of residency did not influence the difference between groups. One-way analysis of variance found significant differences between the groups for 'Localization of the flexion point' (p = 0.005), 'Traction of vacuum cup' (p = 0.039) and 'Use of second hand of the operator' (p = 0.009) item scores and total GRS score (p = 0.007). The values weighted by year of residency did not demonstrate any significant difference. The secondary outcomes evaluated all the candidates of both groups for retention of technical skills over time. A significant effect of time was found for total GRS score (p < 0.001) and OSATS item scores. CONCLUSIONS:Independent of the sequence of theoretical teaching and simulation training, trainees demonstrated high retention - and, actually, improvement - of technical skills for operative vaginal delivery at 12-month follow-up.

To report the rate of additional anomalies detected exclusively on prenatal MRI in fetuses affected by isolated mild or moderate VM undergoing dedicated neurosonography and to explore whether the diagnostic performance of MRI in detecting such anomalies is affected by gestational age or laterality of ventricular dilatation. This was a retrospective study involving 24 fetal medicine centres in Europe. The primary aim was to report the rate of additional anomalies detected exclusively on prenatal MRI in fetuses affected by isolated mild and moderate VM (ventricular dilatation between 10-12 and 13-15 mm respectively) undergoing dedicated neurosonography, as defined by ISUOG guidelines. Furthermore, we calculated the rate of CNS anomalies missed at MRI and detected only at birth in fetuses who underwent MRI before or after 24 weeks of gestation. A sub-analysis was performed according to the laterality and the degree of ventricular dilatation. 490 fetuses with mild to moderate VM undergoing fetal neurosonography were included. Overall, fetal MRI detected 5.3% (95% CI 6.2-11.2) of fetal anomalies not detected on ultrasound. The overall rate of additional anomalies detected only at birth and missed at prenatal MRI was 0.5% (95% CI 0.04-1.5). There was no difference in the rate of associated anomalies detected only after birth when fetal MRI was carried out before compared to after 24 weeks of gestation (p = 0.355). The risk of detecting associated CNS abnormalities on MRI was higher for fetuses with moderate compared to mild VM (p = 0.001), while there was no difference for those presenting with bilateral compared to unilateral (p = 0.323) dilatation. This is the largest study exploring the actual role of MRI in detecting associated anomalies not diagnosed on ultrasound in fetuses affected by isolated VM undergoing fetal neurosonography. The rate of fetal anomalies not diagnosed on ultrasound in fetuses undergoing detailed neurosonography is lower compared to that previously reported by the MERIDIAN study.

To investigate the diagnostic accuracy of MRI for placenta accreta spectrum (PAS) and clinical outcome prediction in women with placenta previa, using a novel MRI-based predictive model.

Objective: To identify the effects of different dietary inositol stereoisomers on insulin resistance and the development of gestational diabetes mellitus (GDM) in women at high risk for this disorder.Design: A preliminary, prospective, randomized, placebo controlled clinical trial.Participants: Nonobese singleton pregnant women with an elevated fasting glucose in the first or early second trimester were studied throughout pregnancy.Intervention: Supplementation with myo-inositol, d-chiro-inositol, combined myo- and d-chiro-inositol or placebo.Main outcome measure: Development of GDM on a 75 grams oral glucose tolerance test at 24-28 weeks' gestation. Secondary outcome measures were increase in BMI, need for maternal insulin therapy, macrosomia, polyhydramnios, neonatal birthweight and hypoglycemia.Results: The group of women allocated to receive myo-inositol alone had a lower incidence of abnormal oral glucose tolerance test (OGTT). Nine women in the control group (C), one of the myo-inositol (MI), five in d-chiro-inositol (DCI), three in the myo-inositol/D-chiro-inositol group (MI/DCI) required insulin (p = .134). Basal, 1-hour, and 2 hours glycemic controls were significantly lower in exposed groups (p < .001, .011, and .037, respectively). The relative risk reduction related to primary outcome was 0.083, 0.559, and 0.621 for MI, DCI, and MI/DCI groups.Conclusions: This study compared the different inositol stereoisomers in pregnancy to prevent GDM. Noninferiority analysis demonstrated the largest benefit in the myo-inositol group. The relevance of our findings is mainly related to the possibility of an effective approach in GDM. Our study confirmed the efficacy of inositol supplementation in pregnant women at risk for GDM.

AIM:Gestational diabetes mellitus (GDM) is the most frequent metabolic disorder in pregnancy and it can be considered a silent risk associated to T2DM and CVD later in life. The aim of this study was to investigate the association of clinical parameters with nine single nucleotide polymorphisms (SNPs) involved with nutrients and metabolism in women with or without GDM in order to identify potential routine clinical markers for early prevention. METHODS:Nine gene variants associated with nutrients and metabolism, namely PPARG2 rs1801282 (C > G); PPARGC1A rs8192678 (C > T); TCF7L2 rs7903146 (C > T); LDLR rs2228671 (C > T); MTHFR rs1801133 (C > T); APOA5 rs662799 (T > C); GCKR rs1260326 (C > T); FTO rs9939609 (T > A); MC4R rs17782313 (T > C) were genotyped in 104 GDM cases and 124 controls using High Resolution Melting (HRM) analysis. RESULTS:The genetic variant rs7903146 (C > T) in TCF7L2 gene showed a strong association with GDM risk (OR: 2.56; 95% CI: [1.24-5.29]). Moreover, a significant correlation was observed between lipid parameters and polymorphisms in other genes, namely PPARG2 [p = 0,03], APOA5 [p = 0,02], MC4R [p = 0,03], LDLR [p = 0,04] and FTO [p = 0,03]. In addition, rs17782313 variant, mapped close to MC4R gene, was associated to BMI in pre-pregnancy [p = 0,02] and at the end of pregnancy [p = 0,03] in GDM group. CONCLUSION:In our study, we found significant associations between routine clinical parameters and some gene variants connected with nutrients and metabolism in women with GDM. These results can provide useful information to develop effective tools and possible personalized intervention strategies in a timely manner.

Gestational diabetes mellitus (GDM) is the most common metabolic disorder of pregnancy. The aim of the study is to compare the effect of different dosages of inositol stereoisomers supplementation on insulin resistance levels and several maternal-fetal outcomes in GDM women.

Gestational diabetes mellitus (GDM) can be considered a silent risk for out-of-pregnancy diabetes mellitus (DM) and cardiovascular disease (CVD) later in life. We aimed to assess the predictive role of 3rd trimester lipid profile during pregnancy for the susceptibility to markers of subclinical atherosclerosis (CVD susceptibility) at 3 years in a cohort of women with history of GDM. A secondary aim is to evaluate the usefulness of novel nutrigenetic markers, in addition to traditional parameters, for predicting early subclinical atherosclerosis in such women in order to plan adequate early prevention interventions. We assessed 28 consecutive GDM women in whom we collected socio-demographic characteristics and clinical and anthropometric parameters at the 3rd trimester of pregnancy. In a single blood sample, from each patient, we assessed 9 single nucleotide polymorphisms (SNPs) from 9 genes related to nutrients and metabolism, which were genotyped by High Resolution Melting analysis. All women then attended a 3-year-postpartum follow-up and on that occasion performed an oral glucose tolerance test (OGTT, with 75 g oral glucose), the measurement of carotid artery intima-media thickness (cIMT), and analyses of metabolic parameters. In addition, we evaluated the physical activity level and the adherence to Mediterranean diet (MedDiet) using the International Physical Activity Questionnaire (IPAQ-short version) and PREDIMED questionnaires. We found an association between 3rd trimester triglycerides and cIMT (p=0.014). We also found significant associations between the APOA5 CC genotype and cIMT after adjustments for age and body mass index (p=0.045) and between the interaction CC APOA5/CC LDLR and cIMT (p=0.010). At the follow-up, the cohort also featured a mean BMI in the overweight range and a high mean waist circumference. We found no difference in the MedDiet adherence, physical activity, and smoking but an inverse correlation between the PREDIMED and the IPAQ scores with the IMT. In conclusion, this preliminary study provides insight into the predictive role of lipid profile during pregnancy and of some genetic variants on cIMT taken as a parameter of subclinical CVD susceptibility in GDM.

ABSTRACTObjectiveTo explore the outcomes associated with fetal hepatobiliary cysts.MethodsMEDLINE and EMBASE were searched for studies reporting on outcomes of fetal hepatobiliary cysts. Outcomes observed were resolution/reduction and increase in cyst size, associated congenital anomalies of the biliary tract and liver, abnormal postnatal liver function tests, clinical symptoms, need for surgery, postsurgical complications and predictive accuracy of prenatal ultrasound in identifying correctly hepatobiliary cysts. Meta‐analysis of proportions was used to analyze the data.ResultsThe search identified 1498 articles, and 22 studies (252 fetuses) were included in the systematic review. For fetal hepatic cysts, resolution or reduction in cyst size either pre‐ or postnatally occurred in 59.3% (95% CI, 30.9–84.7%) of cases, while an increase in cyst size occurred in 8.7% (95% CI, 1.1–22.4%). No case of hepatic cyst had associated malformations of the biliary tract at birth. Clinical symptoms occurred in 14.8% (95% CI, 6.3–26.1%) of cases and, in 5.4% (95% CI, 0.9–13.6%), they were related to the presence of bile obstruction due to compression of the cyst on the biliary tract. No case of hepatic cyst had abnormal liver function at birth. For fetal biliary cysts, resolution or reduction in cyst size occurred in 8.7% (95% CI, 2.7–17.5%) of cases and an increase in size occurred in 34.4% (95% CI, 20.5–49.8%). Congenital anomalies of the biliary tract and liver, such as fibrosis, occurred in 21.5% (95% CI, 10.2–35.6%) and 17.4% (95% CI, 5.4–34.4%) of cases, respectively. 57.3% (95% CI, 33.9–79.0%) of cases showed impairment in liver function after birth, while 55.0% (95% CI, 37.5–71.9%) showed clinical symptoms, mainly due to bile obstruction (47.9% (95% CI, 29.4–66.7%)). Postsurgical complications occurred in 10.9% (95% CI, 3.7–21.3%) of operated cases. Risk assessment according to different cut‐offs of cyst size could not be performed in view of the very small number of included studies.ConclusionsFetal hepatic cysts are benign, with a low likelihood of associated anomalies of the hepatobiliary tract, abnormal liver function or clinical symptoms. Congenital biliary cysts are associated with a high rate of progression, abnormal liver function after birth and clinical symptoms. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Poster: ECR 2017 / C-2992 / Diagnostic performance of MRI in the assessment of invasive placenta previa: can the reader's experience make the difference? by: Tavoletta, R. Basilico, A. Delli Pizzi, E. Di Campli, B. Seccia, R. Cianci, C. Celentano, A. R. Cotroneo; Chieti/IT

Gestational diabetes mellitus (GDM) is the most frequent metabolic disorder in pregnancy. Women with a GDM history are at increased risk of developing diabetes and cardiovascular diseases. Studies have demonstrated a significant correlation between several genes involved in the metabolic pathway of insulin and environmental factors. The aim of this study was to investigate the relationship between clinical parameters in GDM and variants in genes involved with nutrients and metabolism. Several variants PPARG2 rs1801282 (C>G); PPARGC1A rs8192678 (C>T); TCF7L2 rs7903146 (C>T); LDLR rs2228671 (C>T); MTHFR rs1801133 (C>T); APOA5 rs662799 (T>C); GCKR rs1260326 (C>T); FTO rs9939609 (T>A); MC4R rs17782313 (T>C) were genotyped in 168 pregnant Caucasian women with or without GDM by High Resolution Melting (HRM) analysis. A significant correlation was observed between TT genotype of TCF7L2 gene and increased risk of GDM (OR 5.4 [95% CI 1.5-19.3]). Moreover, a significant correlation was observed between lipid parameters and genetic variations in additional genes, namely, PPARG2 [p = 0,02], APOA5 [p = 0,02], MC4R [p = 0,03], LDLR [p = 0,01], and FTO [p = 0,02]. Our findings support the association between TCF7L2 rs7903146 variant and an increased GDMrisk. Results about the investigated genetic variants provide important information about cardiometabolic risk in GDM and help to plan future prevention studies.

A prenatal case of a de novo interstitial deletion distal to 8q24 was reported. Ultrasound examination and postmortem evaluation demonstrated no apparent phenotypic alterations. Array CGH showed an 11.4-Mb loss in chromosome 8 ranging from 8q24.13 to 8q24.23. This case partially overlaps the 2 cases previously described in the literature.

Background A long sought goal in medical genetics has been the replacement of invasive procedures for the detection of chromosomal aneuploidies by isolating and analyzing fetal cells or free fetal DNA from maternal blood, avoiding risk to the fetus. However, a rapid, simple, consistent, and low-cost procedure suitable for routine clinical practice has not yet been achieved. The purpose of this study was to assess the feasibility of predicting fetal aneuploidy by applying our recently established dual-probe FISH protocol to fetal cells isolated and enriched from maternal blood.Methods A total of 172 pregnant women underwent prospective testing for fetal aneuploidy by FISH analysis of fetal cells isolated from maternal blood.Results were compared with the karyotype determined through invasive procedures or at birth. Results Seven of the samples exhibited fetal aneuploidy, which was confirmed by invasive prenatal diagnosis procedures. After enrichment for fetal cells, the frequency of trisomic cells was at least double in samples from aneuploid pregnancies (range 0.38-0.90%) compared to samples from normal pregnancies (<= 0.18%). One false negative result was also obtained.Conclusions Noninvasive prenatal aneuploidy screening using fetal cells isolated from maternal blood is feasible and could substantially reduce the need for invasive procedures.