OBJECTIVE:This study aimed to report the outcomes between patients who underwent emergency supracervical abdominal hysterectomy and those who underwent emergency total hysterectomy for postpartum hemorrhage. DATA SOURCES:A systematic search was performed on Medline, Embase, and Cochrane Library from January 2000 to December 2024 using Medical Subject Headings terms and key words related to peripartum hysterectomy and maternal outcomes. STUDY ELIGIBILITY CRITERIA:This study included observational cohort and case-control studies of patients who underwent supracervical hysterectomy vs total hysterectomy for postpartum hemorrhage within 24 hours of delivery and studies exclusively reporting cases with placenta accreta spectrum, case reports, conference abstracts, and studies with <10 cases per arm. METHODS:This study had 2 independent reviewers to screen studies, extract data, and assess the quality of studies using the Newcastle-Ottawa Scale. Head-to-head meta-analyses were performed using random-effects models. Heterogeneity (I2) and publication bias were assessed. RESULTS:A total of 25 studies were included, analyzing 1478 patients (715 patients in the supracervical hysterectomy group and 763 patients in the total hysterectomy group). No significant difference was found in maternal mortality (P=.532), intensive care unit admission (P=.415), reoperation (P=.884), or major complications (P>.05). Supracervical hysterectomy was associated with a lower risk of ureteric injuries (odds ratio, 0.38 [95% confidence interval, 0.18-0.77]; P=.007), reduced estimated blood loss (mean difference, -446.03 mL [95% confidence interval, -747.72 to -144.35]; P=.004), fewer blood transfusions (mean difference, -1.46 units [95% confidence interval, -2.37 to -1.14]; P=.002), and shorter operative time (mean difference, -53.22 minutes [95% confidence interval, -86.48 to -19.95]; P=.002). CONCLUSION:Supracervical hysterectomy seems to offer advantages over total hysterectomy in postpartum hemorrhage cases, particularly in reducing ureteric injuries, operative time, and blood loss. However, heterogeneity and lack of standardized placenta accreta spectrum diagnostic criteria limit the generalizability of the findings. Future research with standardized protocols is required to refine surgical decision-making.

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 report the outcome of cesarean scar pregnancy (CSP) undergoing treatment. METHODS:MEDLINE, Embase and CINAHL databases were searched. Inclusion criteria were women with CSP undergoing treatment. The primary outcome was successful treatment for CSP, defined as no need for additional medical or surgical strategies. Secondary outcomes were the type of additional treatment (surgical or medical), need for blood transfusion, emergency laparotomy, hysterectomy, post-treatment complications.All these outcomes were explored in women undergoing single and compound treatments for CSP. Furthermore, we performed a separate sub-group analysis only including studies which reported on the outcomes of elective treatments. Random effects meta-analyses were used to analyze the data and results reported as pooled proportions or odd ratio (OR). RESULTS:176 studies (13431 women with CSP undergoing treatment) were included.Successful treatment after primary intervention was achieved in 86.2% (95% CI 82.3-89.7) of women with CSP undergoing treatment with ultrasound guided suction curettage, 72.4% (95% CI 64.8-79.3) with systemic MTX, 81.6% (95% CI 72.3-89.3) with local MTX, 83.9% (95% CI 66.7-95.6) with interventional radiology, 90.42% (95% CI 82.9-96.0) with hysteroscopy, 96.1% (95% CI (92.3-98.6) with laparoscopy and 92.6 with high intensity focused ultrasound (95% CI 78.2-99.6). Post-treatments complications were reported in 3.5% (95% CI 1.7-6.0) of women treated with systemic MTX, 5.9% (95% CI 0.8-15.1) with local MTX or KCl, 1.2% (95% CI 0.1-3.5) with interventional radiology, 1.4% (95% CI 0.4-2.9) with hysteroscopy, 5.5% (95% CI 0.4-25.7) with high intensity focused ultrasound and in none of the cases treated with ultrasound guided suction curettage.When considering compound treatments, successful resolution of CSP was achieved in 91.9% (95% CI 88.0-95.10) of women treated with interventional radiology followed by curettage, 83.3% (95% CI 68.8-93.8) with systemic MTX and curettage, 79.4% (95% CI 56.3-95.2) with local MTX and curettage, 96.2% (95% CI 92.3-98.7) with curettage followed by single or double balloon insertion in the uterine cavity, 98.3% (95% CI 95.9-99.7) with high intensity focused ultrasound followed by curettage, 91.1% (95% CI 3.4-97.0) with interventional radiology followed by removal of CSP with hysteroscopy, 64.3% (95% CI 13.8-99.2) with interventional radiology and systemic MTX and in 95.5% (95% CI 92.9-97.5) with curettage and hysteroscopy.When considering studies reporting a comparison between different treatments, there was no difference between systemic vs local MTX in the primary outcome. Curettage was associated with a higher chance of achieving a successful treatment. CONCLUSIONS:A multitude of treatments for CSP have been reported in the published literature. All treatments described for CSP are apparently equally effective in treating this condition. The findings from this systematic review highlight the need for adopting a common definition and outcome reporting of CSP to better elucidate its natural history, estimate the magnitude of maternal complication after treatment and design appropriately powered RCT to elucidate the optimal treatment of CSP according to its ultrasound phenotype and gestational age at treatment, in terms of effective resolution of the condition and risk of post-intervention complications.

INTRODUCTION the occurrence of PAS has been recently associated with the presence of twin pregnancy. Aim of this review is to report the risk factors, histopathological correlation, diagnostic accuracy of prenatal ultrasound and clinical outcome of twin pregnancies complicated by placenta accreta spectrum (PAS) disorders. EVIDENCE ACQUISITION Pubmed, Embase, Cinahl, Clinical Trial.Gov and Google Scholar databases were searched. Inclusion criteria were studies on twin pregnancies complicated by PAS. The outcomes explored were risk factors for PAS (including placenta previa, prior uterine surgery or assisted reproductive technology, ART), histopathology (placenta accreta and increta/percreta), detection rate of prenatal ultrasound and clinical outcome, including need for blood transfusion, hysterectomy, emergency or scheduled cesarean delivery (CD), and maternal death. Random effect meta-analyses of proportions were sued to combine the data. EVIDENCE SYNTHESIS Two studies considering 103 pregnancies were included in this systematic review: 41.86% (95% CI 27.0-57.9) of twin pregnancies complicated by PAS disorders had a prior CD, 28.22% (95% CI 13.4-46.0) presented placenta previa and 58.14% (95% CI 42.1-73.0) of twin pregnancies were conceived by ART. 74.49% (95% CI 41.6-96.5) of PAS in twin pregnancies were placenta accreta, while 25.51% (95% CI 3.5-58.4) were placenta increta or percreta. Prenatal diagnosis of PAS in twin pregnancies was accomplished only in 27.91% (95% CI 15.3-43.7) of cases. Finally, only one study consistently reported the clinical outcome of PAS in twins. 31.67% (95% CI 20.3-45.0) of women required blood transfusion, 26.67% (95% CI 16.1- 39.7) had hysterectomy, while there was no case of maternal death. 44.19% of women had an emergency CD. CONCLUSIONS There is still limited evidence on the clinical course of PAS disorders in twin pregnancies. Placenta previa, prior uterine surgery (mainly CD), and ART are the most commonly risk factors for PAS disorders in twins. Prenatal diagnosis of PAS in twins is lower compared to what reported in singleton. Finally, about 30% of women with a twin pregnancy complicated by PAS required blood transfusion and hysterectomy.

Drongelen-What is the success rate of trial of labor in monochorionic

OBJECTIVE: This study aimed to investigate the potential role of aspirin in reducing the risk of preeclampsia and adverse maternal and perinatal out-comes in twin pregnancies.DATA SOURCES: Medline, Embase, Google Scholar, Cochrane, and ClinicalTrial.gov databases were searched.STUDY ELIGIBILITY CRITERIA: The search and selection criteria were restricted to the English language.METHODS: The primary outcome was the incidence of preeclampsia. The secondary outcomes included gestational hypertension; fetal growth restriction; preterm birth, either spontaneous or iatrogenic, before 34 weeks of gestation; gestational age at birth; neonatal birthweight; and adverse events secondary to the administration of aspirin, including antepartum and postpartum hemorrhage. In addition, subgroup analyses according to chorionicity (dichorionic vs monochorionic), aspirin dose, and gestational age at administration of aspirin (<16 vs >= 16 weeks of gestation) and considering only studies with a daily aspirin dose of >= 100 mg/d were performed. Head-to-head meta-analyses reporting results as summary odds ratios and mean differences were used to ana-lyze categorical and continuous variables, respectively. Quality assessment for randomized controlled trials was independently performed by 2 researchers based on the risk of bias that was assessed using the revised Cochrane risk-of-bias tool for randomized trials. The conclusion of the meta-analysis on the primary outcome was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation.RESULTS: Overall, 9 studies (2273 twin pregnancies) were included. When considering all studies, the risk of preeclampsia was lower in twin pregnancies treated with aspirin than in those not treated with aspirin (odds ratio, 0.64; 95% confidence interval, 0.48-0.85; P=.003), although there was no signifi-cant difference in the risk of gestational hypertension (P=.987), fetal growth restriction (P=.9), or adverse maternal and perinatal events (P=.9) in twin preg-nancies treated with aspirin compared with those not treated with aspirin. There was no significant difference in the gestational age at birth (P=.2) and neonatal birthweight (P=.06) between women receiving aspirin and those not receiving aspirin. When considering only studies with an aspirin dose of >100 mg/d, the risk of preeclampsia (odds ratio, 0.45; 95% confidence interval, 0.23-0.86; P=.02) was significantly lower in pregnancies receiving aspi-rin than in those not receiving aspirin, Conversely, there was no significant difference in the risk of gestational hypertension (P=.20), fetal growth restriction (P=.1), gestational age at birth (P=.06), and neonatal weight (P=.05) between the 2 groups. Furthermore, there was no significant difference in the risk of preeclampsia when considering only studies with an aspirin dose of >80 mg/d (P=.611). The association between the administration of aspirin and pre-eclampsia persisted when considering an aspirin dose of >100 mg/day or when the medication was started before 16 weeks of gestation. The overall qual-ity of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation assessment was low.CONCLUSION: The administration of aspirin in women with twin pregnancies reduced the risk of preeclampsia. The findings from this study highlighted the need for randomized controlled trials elucidating the actual role of aspirin in affecting maternal and perinatal outcomes in twin pregnancies.

Objective.To establish a possible link between intrauterine fetal death in fetus > 36 weeks in low risk pregnancies and the use of antepartum CTG.To evaluate the correct timing of first access to GAT (ambulatory for full-term pregnancy) for patients with a low-risk pregnancy (currently at about 37-38 weeks after telephone evaluation).To assess medical checks (at present at 40 week+1 day and 41 week+1 day with eco office TA and CTG) and timing of induction of labor after term.Materials and Methods.We selected all patients with a lowrisk pregnancy afferent to the Gynecology and Obstetrics Department of the University of Chieti, from 1 st June 2018 to 31 st August 2022 from 37-38 weeks of pregnancy.After a first

ObjectivesTo objectively assess the quality of the published clinical practice guidelines (CPGs) on the management of pregnancies complicated by placenta accreta spectrum (PAS)disorders. MethodsMEDLINE, Embase, Scopus, and ISI Web of Science databases were searched. The following aspects related to the management of pregnancies with suspected PAS disorders were evaluated: risk factors for PAS, prenatal diagnosis, role of interventional radiology and ureteral stenting, and optimal surgical management. The assessment of risk of bias and quality assessment of the CPGs were performed using the (AGREE II) tool (Brouwers et al., 2010). To define a CPG as of good quality we adopted a cut-off score >60%. ResultsNine CPGs were included. Specific risk factors for referral were assessed by 44.4% (4/9) of CPGs, mainly consisting in the presence of placenta previa and a prior cesarean delivery or uterine surgery. About 55.6% of CPGs (5/9) suggested ultrasound assessment of women with risk factors for PAS in the second and third trimester of pregnancy and 33.3% (3/9) recommended magnetic resonance imaging (MRI); 88.9% (8/9) of CPGs recommended cesarean delivery at 34-37 weeks of gestation. There was not generally consensus on the use of interventional radiology and ureteral stenting before surgery for PAS. Finally, hysterectomy was the recommend surgical approach by 77.8% (7/9) of the included CPGs. ConclusionMost of the published CPGs on PAS are generally of good quality. There was general agreement among the different CPGs on PAS as a regard as risk stratification, timing at diagnosis and delivery but not on the indication for MRI, use of interventional radiology and ureteral stenting.

OBJECTIVE: The World Health Organization has recently declared a monkeypox outbreak as a public health emergency of global concern. The main aim of this systematic review was to ascertain the maternal and perinatal outcomes of pregnancies complicated by monkeypox infection.DATA SOURCES: The Medline, Embase, and Cochrane databases were searched on June 25, 2022 utilizing combinations of the relevant medical subject heading terms, key words, and word variants for "monkeypox" and "pregnancy."STUDY ELIGIBILITY CRITERIA: The search and selection criteria were restricted to the English language.METHODS: The outcomes observed were miscarriage; intrauterine, neonatal, and perinatal death; preterm birth, vertical transmission, and maternal symptoms. A metaanalysis of propor-tions was used to analyze the data.RESULTS: Four studies were included. All the cases in the present systematic review pre-sented with symptoms and signs of monkeypox infection. There was no case of maternal death. Miscarriage occurred in 39% of cases (95% confidence interval, 0-89.0), whereas intrauterine fetal death occurred in 23.0% (95% confidence interval, 0-74.0) of cases. The overall incidence of late fetal and perinatal loss was 77.0% (95% confidence interval, 26.0 -100), whereas only 23% (95% confidence interval, 0-74.0) of the included fetuses sur-vived to birth. The incidence of preterm birth before 37 weeks of gestation was 8.0% (95% confidence interval, 0-62.0). Vertical transmission occurred in 62.0% (95% confidence inter -val, 3.0-100) of cases. When stratifying the analysis according to gestational age at infection, fetal loss was found to occur in 67.0% (95% confidence interval, 9.0-99.0) of cases with first-trimester infection and in 82.0% (95% confidence interval, 17.0-100) of those with sec-ond-trimester infection.CONCLUSION: Monkeypox infection in pregnancy is associated with a high risk of perinatal loss and vertical transmission. The preliminary results from this systematic review affected by a very small number of included cases highlight the need for thorough maternal and fetal sur-veillance in pregnancies complicated by monkeypox infection.

Data sharing not applicable to this article as no datasets were generated or analysed during the current study. Table S1 Search strategy Table S2 General characteristics of included studies reporting outcome of pregnancies complicated by smallpox, monkeypox or molluscum contagiosum infection Table S3 Excluded studies and reasons for exclusion Table S4 Quality assessment of included studies Figure S1 Forest plots of pooled proportions (with 95% CI) of maternal death in pregnancies complicated by smallpox (a) and monkeypox (b). 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.

OBJECTIVES:To compare transvaginal (TV) and trans-abdominal (TA) ultrasound assessment of cervical length (CL) at the time of the second-trimester scan for fetal anomalies. METHODS:This was a prospective study including consecutive pregnant women attending the low-risk ultrasound clinic of two fetal medicine centres in Italy. The inclusion criteria were women between 19 + 0 and 22 + 0 weeks of gestation, attending the prenatal ultrasound clinic for the routine second trimester screening for fetal anomalies. The primary outcome was to compare the CL measurement obtained at TV compared to TA ultrasound; the secondary outcome was to report the inter and intra-observer variability of CL measured with the two different approaches. All women underwent TV and TA assessment of the cervix performed by two experienced certified operators, blinded to each other. Intra-class correlation coefficients (ICC) and Bland-Altman analyses were used to analyse the data. RESULTS:Two hundred and fifty women were included in the analysis. All women had anteverted uterus. The mean gestational age at ultrasound was 20.7 ± 0.7 weeks; 1.2 % (3/250) scans were performed at 19 weeks, 49.2 % (123/250) at 20 weeks, 44.8 % (112/250) at 21 weeks and 4.8 % (12/250) at 22 weeks of gestations. Identification of the major landmarks of CL at TA ultrasound was achieved in all the included cases. There was good reliability between CL measured at TA (ICC 0.95, 95 % CI 0.93-0.97 for observer 1 and 0.92 %, 95 % CI 0.89-0.94 for observer 2) and TV ultrasound 0.97, 95 % CI 0.96-0.98 for observer 1 and 0.96, 95 % CI 0.95-0.97 for observer 2). There was also good reliability between the two observers for both the TA and TV assessment of the CL. Mean TA CL was 41.4 ± 5.5 for observer 1 and 40.5 ± 4.8 for observer 2 with no significant differences between the two measurements (mean difference 0.92 mm, 95 % CI -9.7 to 11.2). Likewise, there was no difference between the CL measured at TV ultrasound between the two observers (mean difference -0.83 mm, 95 % CI -5.97 to 4.30). Finally, there was no difference in the mean CL measured at TA compared to TV, either considering the overall population of women (mean difference: -0.43, 955 CI -8.65 to 7.79), or when stratifying the analysis according to the parity status and the operator. CONCLUSIONS:Among experienced operators, there was no difference between TV and TA ultrasound assessment of the CL at the time of the routine anomaly scan for fetal anomaly.

Objectives: Extracellular vesicles (EVs) are cell-derived particles released during different pathophysiological processes and emerging as relevant players in inter-cellular crosstalk. Previous studies have highlighted the role of EVs as potential biomarkers for several pregnancy complications, including miscarriage, pre-eclampsia and gestational diabetes. Despite that, the actual distribution of EVs through gestation has not been reported yet. The aim of this study was to report the concentration of different sub-types of EVs in the first, second and third trimester of pregnancy and to correlate them with different pregnancy and ultrasound characteristics.Study designs: Prospective observational study including uncomplicated pregnancies in the first, second and third trimester of pregnancy. The first aim of the study was to report the concentration of the EVs derived from endothelial, epithelial, platelet and leukocyte cells of maternal peripheral blood samples in the first, second and third trimester pregnancy using polychromatic flow cytometry. The secondary aim was to correlate EVs with neonatal birthweight and fetal Dopplers, including uterine and umbilical arteries. Un and multivariate analyses were used to compute the data.Results: 64 women (20 in the first, 22 in the second and 22 in the third trimester of pregnancies) were included in the analysis. There was no difference in the median concentration of either platelet, leukocyte and endothelial EVs between the first, second and third trimester of pregnancy. The concentration of epithelial derived EVs was higher in the third compared to first and second trimester of pregnancy. When analyzing the percentage of EV vesicles through gestation, there was no difference in the percentage of either leukocyte or endothelial EVs through gestation. Conversely, the median percentage of platelet derived vesicles was higher in the first (48.7 %, IQR 34.1-58.5) compared to second (34.0 %, IQR 22.7-44.9) and third (9.13 %, IQR 5.01-12.1) trimester of pregnancy, while the median percentage of third trimester (6.01, IQR 2.42-7.34) epithelial derived vesicles was higher than that of the second (1.53 %, IQR 0.65-2.98), but not of the first (4.45 %, IQR 1.44-6.07) trimester. Finally, we found no association between the median concentration or percentage of endothelial, epithelial, leukocyte vesicles, neonatal birthweight and fetal or maternal Dopplers.Conclusions: Distribution of EVs examined does not change during the three trimesters of pregnancy and is not influenced by neonatal birthweight or maternal and fetal Dopplers. The findings from this study allows a more objective interpretation of studies comparing EVs in pregnancies with compared to those without obstetric complication. EVs in future can be used for "liquid biopsy" for the early diagnosis of pathological pregnancies up to the development of possible screening protocols.

OBJECTIVE: To systematically identify and critically assess the quality of clinical practice guidelines for the management of SARS-CoV-2 infection in pregnancy. DATA SOURCES: Medline, Scopus, and ISI Web of Science databases were searched until February 15, 2022. STUDY ELIGIBILITY CRITERIA: Inclusion criteria were clinical practice guidelines on the management of SARS-CoV-2 infection in pregnancy. The risk of bias and quality assessments of the included clinical practice guidelines were performed using the Appraisal of Guidelines for REsearch and Evaluation II tool, which is considered the gold standard for quality assessment of clinical practice guidelines. To define a clinical practice guideline as of good quality, we adopted the cutoff score proposed by Amer et al: if the overall clinical practice guideline score was >60%, it was recommended. METHODS: The following clinical points related to the management of pregnant women with SARS-CoV-2 infection were addressed: criteria for maternal hospitalization, recommendations for follow-up fetal growth scan, specific recommendations against invasive procedures, management of labor, timing of delivery, postpartum care, and vaccination strategy. RESULTS: A total of 28 clinical practice guidelines were included. All recommended hospitalization only for severe disease; 46.1% (6/13) suggested a fetal growth scan after SARS-CoV-2 infection, whereas 23.1% (3/13) did not support this practice. Thromboprophylaxis with low-molecular-weight heparin was recommended in symptomatic women by 77.1% (7/9) of the clinical practice guidelines. None of the guidelines recommended administering corticosteroids only for the presence of SARS-CoV-2 infection in preterm gestation, unless specific obstetrical indication exists. Elective induction of labor from 39 weeks of gestation was suggested by 18.1% (2/11) of the clinical practice guidelines included in the present review, whereas 45.4% (5/11) did not recommend elective induction unless other obstetrical indications coexisted. There were 27% (3/11) of clinical practice guidelines that suggested shortening of the second stage of labor, and active pushing was supported by 18.1% (2/11). There was general agreement among the clinical practice guidelines in not recommending cesarean delivery only for the presence of maternal infection and in recommending vaccine boosters at least 6 months after the primary series of vaccination. The Appraisal of Guidelines for REsearch and Evaluation II standardized domain scores for the first overall assessment of clinical practice guidelines had a mean of 50% (standard deviation +/- 21.82%), and 9 clinical practice guidelines scored >60%. CONCLUSION: A significant heterogeneity was found in some of the main aspects of the management of SARS-CoV-2 infection in pregnancy, as reported by the published clinical practice guidelines.

Objective: To report the pregnancy outcomes of women with prior endometrial cancer and endometrial hyperplasia managed with fertility-sparing treatments. Methods: Medline and Embase databases were searched. Inclusion criteria were studies reporting the pregnancy outcomes of women who had undergone fertility-sparing treatments for endometrial hyperplasia or early endometrioid endometrial cancer. Outcomes explored were pregnancy, miscarriage and livebirth rates according to the type of progestin treatment used. Subgroup analyses according to the type of diagnostic follow-up were also performed. Meta-analyses of proportions using a random effects model were used to combine data. Results: Twenty-nine studies (1036 women) were included, and 82.8% [95% confidence interval (CI) 72.3-91.2] of women achieved complete remission. Pregnancy rates were 56.3% (95% CI 41.6-70.5) with megestrol (MA) or medroxyprogesterone acetate (MPA), 63.1% (95% CI 37.0-85.6) with levonorgestrel-releasing intrauterine de-vice (LNG-IUD), 57.9% (95% CI 37.7-76.8) with MA or MPA and metformin, 59.8% (95% CI 48.3-70.7) with MPA and LNG-IUD, 15.4% (95% CI 4.3-42.2) with gonadotropin-releasing hormone analogue (GnRHa) combined with LNG-IUD or letrozole, and 40.7% (95% CI 24.5-59.3) with LNG-IUD and GnRHa. Miscarriage rates were 17.4% (95% CI 12.2-23.4), 14.3% (95% CI 6.4-24.7), 57.9% (95% CI 37.7-76.8), 26.9% (95% CI 14.6-39.3), 100% (95% CI 34.0-100) and 18.2% (95% CI 5.1-47.7), respectively, and livebirth rates were 68.8% (95% CI 56.0-80.3), 80.8% (95% CI 69.5-90.0), 69.9% (95% CI 56.1-82.0), 25.97 (95% CI 14.6-39.3), 0% (95% CI 0-66.0) and 81.8% (95% CI 52.3-94.8), respectively. Finally, stratifying the analysis considering the endo-metrial sampling method alone, the pregnancy rate was 68.6% (95% CI 51.2-83.6; 10 studies, I-2 = 83.5%) in women who underwent hysteroscopy and 60.5% (95% CI 53.4-67.5; 13 studies, I-2 = 39.8%) in women managed with dilatation and curettage biopsy; the miscarriage and livebirth rates were 13.2% (95% CI 8.0-19.5; I-2 = 0%) and 81.2% (95% CI 67.4-91.8; I-2 = 67.3%), respectively, for hysteroscopy, and 25.2% (95% CI 17.8-33.3; I-2 = 15.5%) and 67.5% (95% CI 58.8-75.5; I-2 = 0%), respectively, for dilatation and curettage biopsy. Conclusion: Fertility-sparing treatment in women with endometrial cancer or hyperplasia is associated with an overall good response to therapy, good chance of achieving pregnancy and a good livebirth rate. Diagnostic follow-up with hysteroscopy was associated with a higher pregnancy rate, although this requires confirmation in adequately powered randomized trials.

Background: Management of unusual not scar ectopic pregnancies (UNSEPs) is an unexplored clinical field because of their low incidence and lack of guidelines. Objective: To report the clinical presentation, the first- and second-line treatment and outcomes of UNSEPs. Methods: We retrospectively collected patients treated for UNSEP (namely cervical, interstitial, ovarian, angular, abdominal, cornual and intramural), their baseline characteristics, risk factors, symptoms, diagnostic pathway and the type of first-line treatment (medical, surgical or combined). We further collected treatment failures and the type of second- line treatment. We assessed treatment outcomes, time to serum beta human chorionic gonadotropin (β-hCG) level negativity, length of recovery, follow up and return to a normal menstrual cycle. Results: From 2009 to 2019, we collected 79 cases. Of them, 27 (34%), 23 (29%), 12 (15%), 8 (10%), 6 (8%) and 3 (4%) were cervical, interstitial, ovarian, angular, abdominal and cornual, respectively. Forty women (50.6%) were submitted to medical treatment, mostly methotrexate based; conversely, 36 patients (45.6%) underwent surgery and only 3 women (3.8%) received a combined treatment. The success of first-line treatment rate, regardless of UNSEP location, was 53% and 89% for medical and surgical treatment, respectively. Treatment failures (21 patients) were submitted to second-line treatment, respectively 47.6% and 52.4% to medical and surgical approach. Of interest, cervical pregnancies achieved the lowest rate of first-line medical treatment success (22%) and received more frequently (69%) a subsequent surgical approach with no hysterectomy. Interstitial pregnancies were submitted to surgery mostly for a matter of urgency (71%), otherwise, they were treated with a medical approach both at first- and second-line treatment. Ovarian pregnancies were treated with ovariectomy in 44% of the cases submitted to surgery. Angular pregnancies underwent surgery more often, while all the abdominal pregnancies underwent endoscopic or open surgery. Cornual pregnancies received cornuostomy in 75% of the cases. Overall, the need for blood transfusion was 23.1% among the patients submitted to surgery. The median length of hospitalisation was shorter for women submitted to surgical first-line treatment (5 vs. 10 days; p = 0.002). In case of first-line medical treatment and in case of failure, we found an increase of 3 days (CI95% 0.6-5.5; p = 0.01) and of 3.6 days (CI95% 0.89-6.30; p = 0.01) in the length of hospitalisation, respectively. Negative β-HCG levels were obtained earlier in the surgical group (median 25 vs. 51 days; p = 0.001), as well as the return to normal menstrual cycle (median 31 vs. 67 days; p < 0.000). Post-treatment follow-up, regardless of the failure of first-line treatment was shorter in the surgical group (median 32 versus 68 days; p= 0.003). Conclusion: Cervical pregnancies were successfully managed with a surgical approach without hysterectomy, and hence, we suggest avoiding medical treatment. No consensus emerged for other UNSEPs. Ovarian, angular and interstitial pregnancies are burdened by a non-conservative approach on the utero-ovarian structures. The surgical approach led to shorter recovery, earlier β-hCG negativity and shorter follow-up, even though there is an increased risk for blood transfusion.

Recent reports suggested a potential association between twin pregnancy and the occurrence of placenta accreta spectrum (PAS) disorders. Despite this, scarce data on PAS disorders in twins has been reported in the published literature. We present a series of twelve twin pregnancies complicated by PAS from two large institutions over 5 years. A systematic review of the literature was also conducted in order to find studies reporting on the risk factors, prenatal diagnosis using ultrasound and clinical outcomes of PAS in twin pregnancies.

INTRODUCTION: The aim of this systematic review was to report the role of lactoferrin supplementation for the pre-vention of preterm birth (PTB) in women at risk.EVIDENCE ACQUISITION: PubMed and Embase databases were searched. Inclusion criteria were studies exploring maternal and perinatal outcomes in women at high-risk for preterm birth receiving compared to those not receiving lacto-ferrin during pregnancy. The primary outcome was preterm PTB<37 weeks; the secondary outcomes were gestational age at birth, PTB<34 and 28 weeks, preterm premature rupture of the membranes (PPROM), chorioamnionitis and admission to Neonatal Intensive Care Unit. Random effect meta-analyses were used to analyze the data.EVIDENCE SYNTHESIS: Six studies (333 pregnancies) were included. Overall, women taking lactoferrin had a lower risk of PTB<37 weeks of gestation with an OR of 0.43 (95% CI: 0.2-0.9). Likewise, gestational age at delivery was higher in women-taking compared to those not-taking lactoferrin (MD=0.46 weeks, SD=0.17, P=0.006). The other included studies explored the role of lactoferrin in affecting the inflammatory profile in the amniotic fluid of women undergoing invasive test, without reporting its actual role in preventing PTB.CONCLUSIONS: Prophylactic administration of lactoferrin can reduce the risk of PTB in women at risk. Further large and adequately powered randomized trial are needed in order to elucidate the actual role of lactoferrin in reducing the risk of preterm birth and in affecting perinatal outcomes in women at risk.

To evaluate the methodology of studies reporting reference ranges for fetal brain structures on magnetic resonance imaging (MRI).

Objective: Extracellular Vesicles (EVs) are cell-derived particles released during different pathophysiological processes, circulating in many body fluids and mediating the inter-cellular crosstalk. We have analyzed, for the first time, different EV phenotypes and concentrations in the peripheral blood of uncomplicated pregnant women.Study design: In this prospective case-control study, uncomplicated singleton pregnant women at term (N = 59) and aged matched non-pregnant women (N = 21) were enrolled. Freshly drowned peripheral blood samples were stained for flow cytometry analyses of EVs.Results: EVs derived from platelets, leukocytes, endothelial and epithelial cells were identified and counted. Platelet-derived EVs were higher in pregnant compared to non-pregnant women, both in terms of absolute counts (2064.4 +/- 1156.3 vs 701.1 +/- 378.8; p < 0.0001) and percentages (27.6 +/- 17.2 vs 10.7 +/- 5.9; p < 0.0001). The opposite pattern was observed both for concentrations of endothelial-EV counts (525.8 +/- 499.6 vs 844.7 +/- 652.9; p = 0.007) and percentages (6.1 +/- 5.5 vs 11.8 +/- 8.0; p < 0.0001) and leukocyte-derived EV percentages (10.2 +/- 7.4 vs 17.9 +/- 11.2; p = 0.002) EVs. Conclusions: Uncomplicated pregnancies are characterized by a specific EV signature. These cell-derived particles may therefore represent promising biomarkers of different pathological conditions complicating pregnancies, such as preeclampsia or preterm birth.