End Of 1st Trimester Research Articles

Fetus in Ovary, Balloon in Uterus: A Serious Missed Diagnosis

Ovarian ectopic pregnancy is one of the non-tubal ectopic pregnancies. It is a very rare, with an estimated incidence of 1/7000-1/40,000 live births and 0.5- 3% of all ectopic Pregnancies. In primary ovarian pregnancy, ovum is fertilized within the follicle itself before being released. Spiegelberg criteria for the diagnosis of ovarian pregnancy are Tube on the involved site should be intact, Gestational sac has to be located in the ovary, The ectopic pregnancy has to be connected to the uterus by the uteroovarian ligament and Ovarian tissue in the wall of the gestational sac should be proven by histopathology. Ovarian Follicle can accommodate the expanding ectopic gestation more readily than the tube but 75% of ovarian gestation rupture in the early first trimester and are usually misdiagnosed as corpus luteal haemorrhage. Advanced ovarian pregnancies with fetal death have been reported. 91% of OEP rupture before the end of 1st trimester. we present a case of Ovarian Ectopic Pregnancy, who reported to our hospital as failed termination of early pregnancy and ongoing second attempt of termination. USG detected a gestational sac with a live fetus of 12 weeks behind the uterus and a foley’s catheter balloon in empty uterine cavity. Subsequently confirmed at surgery as ovarian pregnancy. and proven by histopathology.

Neural tube defects: how many cases could have been prevented in Portugal?

Abstract Neural tube defects (NTD) occurs when the neural tube does not close properly until the 28th day of foetal life. About 70% of NTD can be prevent if women start folic acid (FA) before pregnancy and until the end of 1st trimester. Portugal has this primary prevention since 1998, however the secondary prevention of NTD with TOPFA is still high (80%). The aim of this study is to describe when FA intake was started and estimate the number of cases that would have be prevented if FA intake started before pregnancy as recommended. A cross-sectional study using data from the National Registry of Congenital Anomalies between 2004-2017 was performed. The temporal evolution of the beginning of FA intake was analysed with Cochran-Armitage test for proportions. The proportion of preventable cases was estimated considering the 70% prevention fraction and the number of NTD cases registered in RENAC that occurred in pregnancies without the recommended FA supplementation. On average, 13.8% of all women started FA before pregnancy, 46.2% during 1st trimester and 6.1% did not take folic acid. A statistically significant trend (p < 0.001) was observed in the group that started before pregnancy with increase from 6.8% in 2004 to 17.9% in 2017. The prevalence of NTD was 4.2 cases / 10,000 births, ranging from 2 cases / 10,000 births (2007) to 7 cases / 10,000 births (2014). Between women who had a pregnancy with NTD, 16.8% started FA before pregnancy, 42.2% in the 1st trimester and 9.7% did not take the supplement. If all women had started FA before pregnancy, an estimated 202 NTD cases could have been prevented. In Portugal, the proportion of women who adhere to this measure is very low, similarly to other European countries, compromising the primary prevention of NTD. Perhaps due to the high percentage of TOPFA, the idea that this anomalies continue to affect our children has been lost. Primary prevention of NTDs should be encouraged with measures that promote FA supplementation. Key messages Primary prevention of NTD is possible. Proportion of women who adhere to primary prevention is low.

The relationship of gestational weight gain and development of gestational diabetes mellitus

Objective: To assess the effect of gestational weight gain in women developing gestational diabetes mellitus (GDM). Methods: In this retrospective case control study, singleton mothers with GDM (n=51) were compared with a control group (n=153) matched for age (±2 years), parity, booking visit BMI (±2 kg/m2). They were reviewed at delivery to identify sociodemographic risk factors and treatment modality if they were found to have GDM. Maternal weight at booking visit, at the end of 1st trimester and at the time of glucose tolerance testing was extracted from maternity records. Total gestational weight gain, and rate of weight gain per week during 1st and 2nd trimesters were the primary outcome data. Results: Having a 1st degree relative with diabetes had a significant association for development of GDM. No significant difference was observed in total weight gain or 2nd trimester weight gain between case and controls. However, weight gain during 1st trimester was significantly higher among mothers diagnosed with GDM when compared with controls. This difference was most significant among normal and overweight BMI categories. Out of the GDM group, although the mean rate of weight gain was higher in the pharmacotherapy sub group, there was no statistical significance compared with the group who was only on Medical Nutrition Therapy. Conclusions and recommendations: Gestational weight gain during first trimester was significantly higher among patients with GDM who were in the normal and overweight BMI categories compared to normal glucose tolerant individuals. Mothers with excessive 1st trimester weight gain should be carefully followed up for development of GDM.

Akardiyak İkiz: İki Farklı Olgu İki Farklı Prognoz

A-cardiac twin pregnancy is a rare complication occurs in 1,46 %of all monochorionic twin pregnancies. The fetus whose heart and upper body haven’t been developed and the rest of the body has its blood supply from a branch of the umbilical artery can be considered a healthy fetus? . Usually the complication can be diagnosed in the end of 1st trimester and if the anastomosis of circulation isn’t separated on time, the mortality rate for the healthy fetus who has the blood pumper role will be 55 %. So the obstetric problems such as preterm delivery increase. The death for the fetus who has no heart is certain. Therefore, stopping the blood circulation of the fetus with cardiac abnormality is the main approach to prevent problems such as the lose of the healthy fetus and preterm delivery. We aim to discuss the clinical management of two cases which have been diagnosed with TRAP Twin Reversed Arterial Transfusion in their 11th week of gestation and have had totally different prognosis

PP.24.01] SERIAL AMBULATORY BLOOD PRESSURE MONITORING, INTENSITY OF ANTIHYPERTENSIVE DRUG TREATMENT, AND PREGNANCY OUTCOMES IN WOMEN WITH HYPERTENSION FOUND EARLY DURING PREGNANCY

Objective: Few data are available on serial ambulatory blood pressure monitoring (ABPM) throughout pregnancy and antihypertensive drug treatment required for good blood pressure (BP) control in hypertensive pregnant women. Our aim was to evaluate BP control, antihypertensive drug treatment intensity, and pregnancy outcomes in patients with hypertension (HTN) found early during pregnancy. Design and method: We studied 49 consecutive pregnant patients (mean age 33.4 ± 4.8 years, BMI before pregnancy 24.5 ± 3.7 kg/m2) referred for office HTN found early during pregnancy (mostly before 5 weeks) who gave birth to 50 children (1 twin pregnancy) in 2011–2015. Gestational HTN was previously diagnosed in 39 women, and 9 women had a history of previous miscarriage or stillbirth, with multiple previous pregnancies lost in some patients. ABPM was repeated at 5–10–15–20–25–30–33–35–37 weeks of pregnancy. We calculated overall antihypertensive treatment intensity in standard daily drug doses per patient (standard doses: labetalol 200 mg, methyldopa 750 mg, metoprolol 50 mg, nifedipine 20 mg, verapamil 120 mg). Statistical analysis was performed using ANOVA. Results: All children were born alive (24 vaginal delivery, 26 cesarean section) and are well at follow-up. Gestational age was 38.0 ± 2.5 (range 29–40) weeks, and birth weight was 3215 ± 653 g (range 955–4200). Preeclampsia/eclampsia occurred in 10/3 patients. Four patients had normal BP values by ABPM throughout pregnancy and did not receive antihypertensive drugs. Most patients were treated with labetalol (100–600 mg) and methyldopa (500–2000 mg). Throughout pregnancy, BP remained well controlled (24 h mean SBP/DBP 120.3–126.0/75.3–77.1 mmHg), the number of treated patients increased from 25 at 5 weeks to 42 at 25–35 weeks, and the average number of daily antihypertensive drug doses in treated pts increased from 1.82 at 5 weeks to 2.98 at 37 weeks (p < 0.001).Conclusions: Serial ABPM-guided antihypertensive drug treatment started early during pregnancy was associated with favorable outcomes. The number of patients requiring treatment and the treatment intensity to maintain good BP control increased throughout the pregnancy. No physiological BP fall at the end of 1st trimester was observed. Our findings help estimate the expected treatment intensity required in pregnant patients with preexisting hypertension.

PP044. Differential expression of trophoblast-, endothelial- and embryonic stem cell-associated transcription factors in 1st trimester, and in 3rd trimester preeclampsia and intrauterine growth restriction

Trophoblast progenitor cells express stem cells markers (SCM) to maintain the proliferative characteristic of stem cells. Beyond blastocyst stage or in preeclampsia (PE) or intrauterine growth restriction (IUGR) little is known about expression of SCMs. We examined the expression of trophoblast and other SCMs in 1st and 3rd trimester placenta and in preeclampsia (PE) and intrauterine growth restriction (IUGR) in order to discriminate if these markers might be involved in progenitor cell functions. 8 samples each of 1st trimester placentae (elective abortions), 3rd trimester IUGR, PE and control (normal term pregnancy placentae) were stained by immunoperoxidase to detect the SCMs: CDX2 (trophectoderm SCM), SOX2, NANOG and OCT4A (embryonic SCMs) and NOTCH1 (endothelial SCM). In 1st trimester all SCM were detected, expressed homogenous in syncytio- and cytotrophoblast, and grow increasingly mosaic-like towards the end of 1st trimester. These signals are lost or diminished in 3rd trimester, whereby the syncytiotrophoblast loses these signals first. NOTCH1, however, remains highly expressed in all trophoblast subtypes of both IUGR and PE pregnancies. Both embryonic and trophoblast SCMs are expressed in 1st trimester trophoblast and appear most vivid among the villous trophoblast of very early pregnancy. Loss of stem cell transcription factor expression in term placentae indicates temporal regulation, and a so far unknown specific function.

151. PLACENTAL HtrA3 IS REGULATED BY OXYGEN TENSION AND SERUM LEVELS ARE ALTERED DURING EARLY PREGNANCY IN WOMEN DESTINED TO DEVELOP PREECLAMPSIA

The pathogenic origin of preeclampsia is defective placental development (placentation) and function. Preeclampsia is not diagnosed until later in pregnancy and reliable early detection is highly desirable. HtrA3 is a recently cloned gene with high expression during placentation in the mouse, rhesus monkey and human. In human 1st trimester placenta, HtrA3 is highly expressed in maternal decidual cells and in certain trophoblast cell types. Placental HtrA3 is secreted into the maternal circulation and clearly detectable in serum of pregnant women in the 1st trimester. The present study examined placental production and serum profile of HtrA3 across gestation in women, the potential molecular mechanisms regulating HtrA3 production, and association between maternal HtrA3 serum levels and preeclampsia. Immunohistochemistry determined HtrA3 expression pattern and cellular localization in 1st, 2nd and 3rd trimester placenta. Maternal serum HtrA3 levels were analysed by Western blotting. Regulation of placental HtrA3 production and secretion by oxygen tension was investigated in 1st trimester placental explants and trophoblast cells. Placental HtrA3 protein was maximally produced in the 1st trimester, then dramatically down-regulated, especially in the syncytiotrophoblast. HtrA3 was secreted into the maternal circulation with a serum profile reflecting placental production. Oxygen tension regulated HtrA3; low oxygen enhanced, while transition from low-to-high oxygen decreased, HtrA3 protein production in syncytiotrophoblast. Maternal serum HtrA3 levels at ~13-14 weeks of gestation were significantly higher in women who subsequently developed preeclampsia. It appeared that HtrA3 down-regulation was delayed in preeclamptic pregnancies. In conclusion, HtrA3 protein production is closely associated with oxygen tension in the placenta. The decline in HtrA3 at the end of 1st trimester may reflect the placental low-to-high oxygen switch. Abnormally high levels of serum HtrA3 at the end of 1st trimester is associated with preeclampsia.

Effectiveness of Slow-Release Lanreotide in Previously Operated and Untreated Patients with GH-Secreting Pituitary Macroadenoma

The aim of this study was to verify whether treatment with slow-release lanreotide (SRL) before surgery is useful in the management of patients with GH-secreting pituitary macroadenoma. Twenty untreated acromegalics were enrolled randomly in two groups. Ten patients (group 1: 2 males and 8 females aged 44.5 +/- 4.3 years) underwent surgery via transsphenoidal access. Only one of them was cured by surgery, whereas the other nine were treated with SRL. In the other ten patients (group 2: 3 males and 7 females aged 43.2 +/- 12.3 years), transsphenoidal surgery followed SRL treatment. Surgery induced the normalization of GH and IGF-1 levels in four group 2 patients - three of them had shown an evident shrinkage of the tumor after SRL treatment. After surgery, group 1 showed a significant decrease of mean IGF-1 (580 +/- 63 vs. 789 +/- 64 ng/ml, p < 0.02), but not of GH values (26.1 +/- 9.8 vs. 44.8 +/- 19.3 ng/ml, NS); the cured patient was excluded from the following evaluations. Group 2 showed an evident, but not significant, decrease of both GH and IGF-1 values compared to values measured at the end of medical treatment (GH: 22.4 +/- 9.7 vs. 7.7 +/- 4.7 ng/ml, NS. IGF-1: 570 +/- 69 vs. 402 +/- 58 ng/ml, NS). Gonadal, thyroid and adrenal impairment was evident in six, four and no patients in group 1 and in three, two and one patients in group 2, respectively. SRL 30 mg was administered every 14 days for three months and then every 10 days until the 6th month. Before SRL treatment, mean GH and IGF-1 levels did not differ significantly in group 1 vs. group 2 (GH: 29.3 +/- 10.5 vs. 43.4 +/- 22.0 ng/ml; IGF-1: 633 +/- 38 vs. 778 +/- 83 ng/ml). In group 1, a significant decrease of serum GH, but not of IGF-1 levels, was achieved at the end of 1st trimester of SRL (GH: 17.6 +/- 5.4 ng/ml, p < 0.05. IGF-1: 540 +/- 48 ng/ml, NS), whereas a significant decrease in both GH and IGF-1 values was evident during the 2nd trimester (GH: 6.1 +/- 3.0 ng/ml, p < 0.05. IGF-1: 433 +/- 74 ng/ml, p < 0.02). Serum GH levels, measured during the 2nd trimester of SRL therapy, were also significantly lower than levels measured at the end of the 1st trimester (p < 0.05). Group 2 serum GH and IGF-1 levels were not significantly decreased at the end of the 1st trimester (GH: 27.2 +/- 12.1 ng/ml, NS. IGF-1: 698 +/- 74 ng/ml, NS), whereas only serum IGF-1 (570 +/- 69 ng/ml, p < 0.05) was significantly reduced during the 2nd trimester of SRL (GH: 22.4 +/- 9.7 ng/ml, NS). Serum GH and IGF-I fell in the normal range in 4 patients in group 1 and one in group 2 at the end of the second trimester of SRL therapy. Independently of the trial applied, the mean clinical score level ameliorated significantly in both groups (group 1: p < 0.0005; group 2: p < 0.0001). In both groups, the proportion of patients complaining of headache and tissue swelling and the score level of headache, tissue swelling and excessive sweating decreased significantly. In group 1 the score level of fatigue and arthralgia also decreased significantly. In conclusion, this study proves that in patients with GH-secreting pituitary macroadenoma: (i) surgery followed by SRL induces a better clinical and biochemical status than SRL alone; (ii) SRL treatment before surgery ameliorates the clinical and biochemical outcome and reduces the prevalence of hypopituitarism due to surgery.