Over the past 50 years, therapeutic advances have significantly improved the management of cystic fibrosis (CF). Recently, cystic fibrosis transmembrane conductance regulator (CFTR) modulators have been widely regarded as a therapeutic revolution, and their use is associated with a marked increase in pregnancies among affected women. However, pregnant women were excluded from clinical trials, limiting what is known about maternal and fetal safety. Maternal and fetal outcome tend to be poorer when the disease is severe, but there is limited data on such pregnancies exposed to CFTR modulators. While available data suggest a low risk of birth defects, information on neurological development is lacking and concerns remain regarding lung abnormalities in animal studies, as well as a few cases of congenital cataracts reported in humans. For fetuses affected by CF, the transplacental transfer of CFTR modulators could potentially prevent severe complications, such as meconium ileus, opening promising therapeutic avenues.

Placenta accreta spectrum (PAS) is an obstetrical complication in which the placenta abnormally invades the uterine wall, increasing the risk of hemorrhage, surgical morbidity, and maternal mortality. Management is often complex and multidisciplinary, particularly when invasion extends beyond the uterus. For this reason, standardized guidelines are essential to support early diagnosis and coordinated care across specialties. Significant variations in clinical practice guidelines (CPGs) remain, especially between countries with differing levels of income. This systematic review evaluates national and international CPGs published within the last decade to identify areas of agreement, disagreement, and insufficient evidence across all stages of PAS care. To identify CPGs related to PAS, a comprehensive search of professional society websites, PubMed, the GIN Library, and the ECRI Guidelines Trust was conducted. Two independent reviewers evaluated the sources to extract relevant clinical recommendations, which were then sent to a panel of 15 to 18 experts who had authored their own PAS guidelines. During 2 rounds of structured feedback, the panel could comment on, clarify, or revise their own guidelines before the committee would evaluate them for consensus and sufficiency of evidence. Each guideline was categorized as demonstrating high agreement, poor consensus, or high levels of insufficient evidence. The data were visualized by quantifying the level of agreement and sorting each guideline into categories of epidemiology, diagnosis, antenatal management, surgical management, and postnatal care. A total of 18 articles from 14 national or international societies were included. There was high agreement on epidemiologic risk factors, diagnostic principles, and key elements of antenatal management. A history of cesarean delivery consistently emerged as a major risk factor, especially in patients with concurrent placenta previa. All guidelines supported ultrasound as the primary diagnostic tool, with most recommending standardized descriptors to enhance accuracy. Targeted second-trimester imaging was widely endorsed, with some guidelines supporting first-trimester screening for high-risk patients. There was also strong consensus surrounding antenatal management and the need for specialized care, emphasizing referral to tertiary centers with multidisciplinary expertise, adequate surgical and transfusion resources, and planned delivery around 34 to 35 weeks. In contrast, surgical and peripartum recommendations showed substantial variability and limited evidence, including uncertainty regarding optimal incision type, use of balloon occlusion catheters, anesthesia approaches, and conservative management strategies. Only 1 guideline offered specific recommendations for low- and middle-income countries. These findings indicate that while some aspects of PAS management, such as diagnosis and antenatal care, have a broad consensus, other areas remain under-investigated and lacking consensus. This is especially true for surgical and conservative management in the peripartum period and indicates a need for comparative research and international collaboration to develop standardization. In addition, PAS management in low- and middle-income countries, which often face resource limitations that require flexible and unique practices, is significantly limited. While further research and discussion are needed, this study provides a roadmap for global improvement in PAS management.

Spinal muscular atrophy is a severe neuromuscular disorder in which early treatment significantly improves outcomes. Prenatal diagnosis, particularly in fetuses with two SMN2 copies, presents unique challenges. We report a late-preterm infant diagnosed in utero with homozygous SMN1 deletion and two SMN2 copies, whose older sibling developed motor deficits despite early postnatal treatment. Following multidisciplinary consultation, delivery was planned at 35+4 weeks to enable immediate therapy. The infant received oral risdiplam on day 2 of life, followed by intravenous onasemnogene abeparvovec on day 59. Neurofilament light chain levels were normal at birth and remained low, except for a transient rise after gene therapy. Initial motor development was normal until 2 months, when hypotonia appeared, followed by recovery and normalization by 5 months. This case suggests that planned preterm delivery with rapid postnatal treatment may be a pragmatic alternative to in utero therapy for high-risk spinal muscular atrophy, pending further longitudinal data.

Importance:Placenta accreta spectrum (PAS) is a complex, life-threatening condition that demands a multidisciplinary approach involving obstetrics, maternal-fetal medicine, and various surgical and medical specialties. Effective management relies on multispecialty collaboration and consensus, supported by standardized protocols, to optimize outcomes, guide informed clinical decisions, and mitigate the risks associated with PAS. Objective:To examine clinical practice guidelines for PAS inclusive of high-income countries and low- to middle-income countries (LMICs) identifying areas of consensus and gaps in guidance. Evidence Review:A comprehensive search of PubMed, GIN Library, and ECRI Guidelines Trust identified all PAS-related clinical practice guidelines published from January 1, 2014, to January 31, 2024. Additional searches included professional societies' designated websites and cited references. Two independent reviewers screened the guidelines, resolving conflicts through cross-referencing. Initially, 2 independent reviewers provided structured review and feedback to refine, correct, or highlight areas of consensus, disagreement, or insufficient evidence. Any instances of nonagreement were adjudicated by majority panel agreement, arising from a panel of 15 to 18 experts, all authors of PAS guidelines. Agreement scores for each recommendation area (eg, epidemiology, diagnosis, and antenatal management) were categorized as high agreement (≥75%), poor consensus (<50% or ≥30% insufficient evidence), and high levels of insufficient evidence (≥50% of recommendations with insufficient evidence) based on a priori score criteria. Findings:A total of 14 guidelines from 18 articles from national and international societies were included. High agreement was noted in areas such as specialized expertise (100%), antenatal management (88.9%), diagnosis (76.9%), and epidemiology (75.0%). Poor consensus characterized cesarean hysterectomy management (38.5% insufficient evidence and 23.0% disagreement), conservative techniques (33.3% insufficient evidence and 11.1% disagreement), and fertility counseling (30.0% insufficient evidence and 10.0% disagreement). Despite the high risk of anemia, consensus was lacking on iron supplementation strategies. Recommendations for thromboembolism prevention varied, with some guidelines favoring pharmacologic interventions and others advocating for nonpharmacologic measures. Hemorrhage management and postnatal management recommendations, including iron supplementation and thromboembolism prevention, were characterized by high levels of insufficient evidence (55.6% and 57.1%, respectively). Only 1 article (5.6%) specifically addressed LMICs, highlighting substantial underrepresentation. Conclusions and Relevance:This systematic review of PAS guidelines identified significant discrepancies and insufficient evidence in key aspects of care. The findings underscore the urgent need for further research and quality measures to enhance standardized approaches and improve patient outcomes. The limited availability of recommendations applicable to LMICs highlights the critical need for tailored guidance that accounts for resource constraints and clinical access challenges unique to these settings.

Bariatric surgery, while beneficial for managing obesity and improving fertility, can lead to serious nutritional deficiencies that impact maternal and fetal health. We report the case of a 31-year-old woman with a history of gastric bypass who developed Kwashiorkor, a rare and severe complication of malnutrition, during the second trimester of her twin pregnancy. This condition was associated with severe intrauterine growth restriction. Kwashiorkor, typically seen in young children suffering from famine in low-income regions, is characterized by severe protein deficiency. In this case, parenteral nutrition led to rapid maternal improvement and a noticeable resumption of fetal growth within days. This case highlights the importance of tailored monitoring and nutritional management for pregnant women with a history of bariatric surgery.

Placenta Accreta Spectrum (PAS) disorder is a condition characterized by abnormal adherence and various levels of invasive placentation, whereas the physiopathology of pre-eclampsia (PE) involves insufficient trophoblast invasion of maternal blood vessels in early pregnancy and subsequent placental insufficiency. In this case report, we elaborate on these two pathologies and describe the case of a patient with PAS disorder, who developed term PE.

We report the case of a 36-year-old female whose dysphagia revealed a congenital anomaly of the thoracic aorta: the right aortic arch with mirror image branching. This is a rare embryonic developmental anomaly where the aorta wraps around the right bronchus and the supra-aortic trunks emerge from the arch in the opposite order to normal. Most of the patients are asymptomatic unless there is a significant compression of mediastinal structures. Major compression of the esophagus or trachea, aneurysmal disease, dissection of the thoracic aorta, or the presence of a Kommerell diverticulum larger than 2 cm may require a surgical repair. There is no standard treatment and it must be adapted to the clinical presentation and the anatomic configuration of each patient. Our patient did not receive any treatment for her condition.

Introduction Pregnancies resulting from in vitro fertilisation are associated with an increased risk of developing hypertensive disorders of pregnancy, such as preeclampsia, when compared with naturally conceived pregnancies.Objective The efficacy of aspirin prophylaxis to reduce the incidence of preeclampsia is well established in naturally conceived pregnancies identified as high risk for developing preeclampsia. However, the efficacy of aspirin to reduce the rate of preeclampsia for all pregnancies resulting from in vitro fertilisation remains uncertain, although in vitro fertilisation conception is a well-known risk factor for preeclampsia. Therefore, the purpose of this scoping review is to provide a comprehensive overview of the current literature regarding the use of low-dose aspirin to prevent hypertensive disorders of pregnancy after in vitro fertilisation.Inclusion criteria This review will identify all peer-reviewed published articles including pregnant women who underwent embryo transfer after in vitro fertilisation and were prescribed low-dose aspirin to reduce the risk of hypertensive disorders of pregnancy.Methods We have devised a comprehensive search strategy to systematically identify pertinent studies published from January 2000 until May 2024, within the Medline (PubMed interface), Embase and Scopus databases. The search strategy is based on the keywords ‘aspirin,’ ‘pregnancy-induced hypertension,’ and (‘in vitro fertilization’ OR ‘oocyte donation’ OR ‘embryo transfer’ OR ‘donor conception’). Two reviewers will independently screen the titles, abstracts and full-text articles to select the relevant articles, using the Covidence software.Ethics and dissemination No patients are involved in this study. This study aims to be published in a peer-reviewed journal and could be presented at a conference.

Introduction Pre-eclampsia affects ~5%–7% of pregnancies. Although improved obstetric care has significantly diminished its associated maternal mortality, it remains a leading cause of maternal morbidity and mortality in the world. Term pre-eclampsia accounts for 70% of all cases and a large proportion of maternal–fetal morbidity related to this condition. Unlike in preterm pre-eclampsia, the prediction and prevention of term pre-eclampsia remain unsolved. Previously proposed approaches are based on combined third-trimester screening and/or prophylactic drugs, but these policies are unlikely to be widely implementable in many world settings. Recent evidence shows that the soluble fms-like tyrosine kinase-1 (s-Flt-1) to placental growth factor (PlGF) ratio measured at 35–37 weeks’ gestation predicts term pre-eclampsia with an 80% detection rate. Likewise, recent studies demonstrate that induction of labour beyond 37 weeks is safe and well accepted by women. We hypothesise that a single-step universal screening for term pre-eclampsia based on sFlt1/PlGF ratio at 35–37 weeks followed by planned delivery beyond 37 weeks reduces the prevalence of term pre-eclampsia without increasing the caesarean section rates or worsening the neonatal outcomes.Methods and analysis We propose an open-label randomised clinical trial to evaluate the impact of a screening of term pre-eclampsia with the sFlt-1/PlGF ratio followed by planned delivery in asymptomatic nulliparous women at 35–37 weeks. Women will be assigned 1:1 to revealed (sFlt-1/PlGF known to clinicians) versus concealed (unknown) arms. A cut-off of >90th centile is used to define the high risk of subsequent pre-eclampsia and offer planned delivery from 37 weeks. The efficacy variables will be analysed and compared between groups primarily following an intention-to-treat approach, by ORs and their 95% CI. This value will be computed using a Generalised Linear Mixed Model for binary response (study group as fixed effect and the centre as intercept random effect).Ethics and dissemination The study is conducted under the principles of Good Clinical Practice. This study was accepted by the Clinical Research Ethics Committee of Hospital Clinic Barcelona on 20 November 2020. Subsequent approval by individual ethical committees and competent authorities was granted. The study results will be published in peer-reviewed journals and disseminated at international conferences.Trial registration number NCT04766866.

Prematurity remains one of the main causes of neonatal morbidity and mortality. Approximately two thirds of preterm births are spontaneous, i.e. secondary to preterm labour, preterm prelabour rupture of membranes (PPROM) or cervical insufficiency. Etiologically, the vaginal microbiome plays an important role in spontaneous preterm birth (sPTB). Vaginal dysbiosis and bacterial vaginosis are well-known risk factors for ascending lower genital tract infections and sPTB, while a Lactobacillus crispatus-dominated vaginal microbiome is associated with term deliveries. Synbiotics may help to achieve and/or maintain a normal, Lactobacillus-dominated vaginal microbiome. We will perform a multi-centre, double-blind, randomised, placebo-controlled trial. Women aged 18 years or older with a singleton pregnancy are eligible for inclusion at 80/7–106/7 weeks gestational age if they have one or more of the following risk factors for sPTB: previous sPTB at 240/7–356/7 weeks, prior PPROM before 360/7 weeks, or spontaneous pregnancy loss at 140/7–236/7 weeks of gestation. Exclusion criteria are multiple gestation, cervix conisation, inflammatory bowel disease, uterine anomaly, and the use of pro-/pre-/synbiotics. Patients will be randomised to oral synbiotics or placebo, starting before 11 weeks of gestation until delivery. The oral synbiotic consists of eight Lactobacillus species (including L. crispatus) and prebiotics. The primary outcome is the gestational age at delivery. Vaginal microbiome analysis once per trimester (at approximately 9, 20, and 30 weeks) and delivery will be performed using metataxonomic sequencing (16S rRNA gene) and microbial culture. Secondary outcomes include PPROM, the use of antibiotics, antenatal admission information, and neonatal outcomes. This study will evaluate the effect of oral synbiotics on the vaginal microbiome during pregnancy in a high-risk population and correlate the microbial changes with the gestational age at delivery and relevant pregnancy outcomes. ClinicalTrials.gov, NCT05966649. Registered on April 5, 2024.

Expectant management of a cesarean scar pregnancy (CSP) is associated with a high risk of severe maternal morbidity. Therefore, most experts recommend immediate termination after the diagnosis of a CSP. However, there is no consensus about the optimal management of a CSP in terms of efficacy, safety, and preservation of future fertility. Methotrexate (MTX) is a folic acid antagonist that has been largely used to treat tubal ectopic pregnancies. This review summarizes the current knowledge and uncertainties about the administration of MTX as a medical or non-invasive option to terminate a CSP; the preferred injection route (systemic or local/intragestational), the comparison with other treatment modalities, and the prognostic factors for MTX success will be discussed, as well as the recommendations from scientific societies.

Background and Objective: The aim of this retrospective cohort study is to evaluate the impact of assisted reproductive treatment (ART) on adverse maternal outcomes and the rate of hospitalization in maternal intensive care (MIC) in a tertiary university center in Liege, Belgium. Materials and Methods: This is a retrospective cohort study comparing two groups, 6557 patients who achieved pregnancy spontaneously and 330 patients who achieved pregnancy after ART, between January 2020 and December 2022. These patients were followed in the academic obstetrics department of Citadelle Hospital, Liège. The database of the ART center was compared with the database of the delivery unit to determine the cohort of patients who conceived after ART. Adverse maternal outcomes and MIC hospitalization rates were compared with between spontaneous pregnancies and ART groups. ART groups were also compared with each other. Results: The rate of hospitalization in maternal intensive care for patients who achieved pregnancy spontaneously was 12.1%, compared to 17.3% after ART. Comparing the rate of pre-eclampsia, 3.5% of spontaneous pregnancies were complicated by pre-eclampsia, while after ART, 10.9% of patients developed this complication during pregnancy. This rate was higher after IVF (12%) compared to intrauterine insemination and particularly after frozen embryo transfer (FET) in artificial cycle (17.9%). The birthweight of newborns after ART was also analyzed. A significant difference was obtained when comparing fresh embryo transfer with FET. Conclusions: Our study confirmed that FET in artificial cycle is a risk factor for pre-eclampsia and that fresh embryo transfer is associated with a higher rate of newborns with a lower percentile of birthweight. Our data showed that the rate of MIC hospitalization was significantly higher after ART but did not differ between groups.

Foot drop during the swing phase of gait and at initial foot contact is a current kinematic abnormality that can occur following an upper motor neuron (UMN) lesion. Functional electrical stimulation (FES) of the common peroneal nerve through an assistive device is often used in neuro-rehabilitation to help patients regain mobility. Although there are FES-specific guideline recommendations, it remains a challenge for clinicians to appropriately select patients eligible for the daily use of FES devices, as very few health insurance systems cover its cost in Europe. In Luxembourg, since 2018, successfully completing an FES clinical pathway called CHECGAIT is a prerequisite to receiving financial coverage for FES devices from the national health fund (Caisse Nationale de Santé-CNS). This study describes the structure and steps of CHECGAIT and reports our experience with a cohort of 100 patients enrolled over a three-year period. The clinical and gait outcomes of all patients were retrospectively quantified, and a specific analysis was performed to highlight differences between patients with and without an FES device prescription at the end of a CHECGAIT. Several significant gait differences were found between these groups. These results and CHECGAIT may help clinicians to better select patients who can most benefit from this technology in their daily lives. In addition, CHECGAIT could provide significant savings to public health systems by avoiding unnecessary deliveries of FES devices.

Apgar score was 9/9/9, birthweight was 1.4/3.7/6.4%ile,birth height was 2.6/4.0/6.5%ile, and birth head circumference was 13.6/13.2/25.9%ile.Statistically, early FGR had significantly higher rates of preterm delivery, earlier GA at delivery, and lower rates of vaginal delivery compared to late FGR and SGA.Late FGR significantly lower maternal weight gain during pregnancy, earlier GA at delivery compared to SGA.Conclusions: Fetus diagnosed with FGR by Japanese criteria were reclassified using ISUOG definition.This study shows that prenatal outcomes were statistically different.

ABSTRACT Objective To determine, by expert consensus through a modified Delphi process, the role of standardized and new ultrasound signs in the prenatal evaluation of patients at high risk of placenta accreta spectrum (PAS). Methods A systematic review of articles providing information on ultrasound imaging signs or markers associated with PAS was performed before the development of questionnaires for the first round of the Delphi process. Only peer‐reviewed original research studies in the English language describing one or more new ultrasound sign(s) for the prenatal evaluation of PAS were included. A three‐round consensus‐building Delphi method was then conducted under the guidance of a steering group, which included nine experts who invited an international panel of experts in obstetric ultrasound imaging in the evaluation of patients at high risk for PAS. Consensus was defined as agreement of ≥ 70% between participants. Results The systematic review identified 15 articles describing eight new ultrasound signs for the prenatal evaluation of PAS. A total of 35 external experts were approached, of whom 31 agreed and participated in the first round. Thirty external experts (97%) and seven experts from the steering group completed all three Delphi rounds. A consensus was reached that a prior history of at least one Cesarean delivery, myomectomy or PAS should be an indication for detailed PAS ultrasound assessment. The panelists also reached a consensus that seven of the 11 conventional signs of PAS should be included in the examination of high‐risk patients and the routine mid‐gestation scan report: (1) loss of the ‘clear zone’, (2) myometrial thinning, (3) bladder‐wall interruption, (4) placental bulge, (5) uterovesical hypervascularity, (6) placental lacunae and (7) bridging vessels. A consensus was not reached for any of the eight new signs identified by the systematic review. With respect to other ultrasound features that are not specific to PAS but increase the probability of PAS at birth, the panelists reached a consensus for the finding of anterior placenta previa or placenta previa with cervical involvement. The experts were also asked to determine which PAS signs should be quantified and consensus was reached only for the quantification of placental lacunae using an existing score. For predicting surgical outcome in patients with a high probability of PAS at delivery, a consensus was obtained for loss of the clear zone, bladder‐wall interruption, presence of placental lacunae and presence of placenta previa involving the cervix. Conclusions We have confirmed the continued importance of seven established standardized ultrasound signs of PAS, highlighted the role of transvaginal ultrasound in evaluating the placental position and anatomy of the cervix, and identified new ultrasound signs that may become useful in the future prenatal evaluation and management of patients at high risk for PAS at birth. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

About 12 percent of women require assisted reproductive technology (ART) to get pregnant as infertility concerns more and more couples. Recent studies highlight obstetrical complications after ART such as preeclampsia, gestational diabetes or placenta accrete spectrum. Pre-eclampsia is a specific pathology of the pregnancy which can lead to materno-fetal complications including prematurity and intrauterine growth restriction. The aim of this article is to summarize preeclampsia risk factors during ART. We performed a narrative review based on articles published since 2010. Preeclampsia rate is increased after frozen embryo transfer, especially in case of artificial cycle, multiple pregnancies and gamete donation.

Congenital high airway obstruction syndrome is a rare malformation whose prognosis is very poor resulting in foetal or perinatal death if no perinatal intervention is performed. However, ultrasound and magnetic resonance enable an accurate prenatal diagnosis and optimal choice of interventional foetal medicine techniques (transtracheal puncture, fetoscopy). These approaches reduce foetal side effects related to the pathological process, and avoid the mother ex utero intrapartal treatment and its deleterious effects. If it becomes indispensable ex utero intrapartal treatment allows optimal management of the new born by securing the foetal airways while minimizing risk for hypoxic damage through the maintenance of maternal-foetal circulation. We present the story of a couple with a suspected case of CHAOS at 21 weeks of amenorrhea, the diagnostic and the management until the birth of the child.

Caesarean scar pregnancy is a rare form of ectopic pregnancy, but it is increasingly common due to the increasing number of caesarean sections and advances in medical imaging. There are two types of cesarean scar pregnancy depending on the depth of the implantation : endogenous type I and exogenous type II. In the case of a pregnancy resulting from a type II caesarean scar, the main complication is uterine rupture, which could be life-threatening for the patient. Early diagnosis and treatment are therefore essential for the woman. We report the case of a patient in early pregnancy with a history of cesarean section who presented with severe pelvic pain due to uterine rupture.