Outcome In High Risk Pregnancies Research Articles

The Relationship between Modified Biophysical Profile, Standard Biophysical Profile, and Neonatal Outcomes of High-risk Pregnancies

Introduction: High-risk pregnancies can result in many complications for the fetus. In these pregnancies, different tests such as non-stress test (NST), biophysical profile (BPP), oxytocin contraction stress test (OCT), and Doppler sonography can be used to evaluate fetal health. As standard BBP requires more time and expertise, in this study, we evaluated the relationship between standard BPP, modified BPP, and neonatal outcomes. Therefore, in case there was a significant relationship, we could use modified BPP as a replacement for standard BPP. Methods:Overall, 106 high-risk pregnant women in their third trimester, who were admitted to the gynecology ward of Imam Reza Hospital, were included in this study. Unless the subjects had any problems leading to emergent termination of pregnancy, standard BPP and modified BPP were concurrently performed to evaluate fetal health; these tests were repeated once or twice a week. In case of delivery, the last BPP scores (both standard and modified) were compared with the neonatal outcomes. Results: In the evaluation of the last standard BPP scores, 83.1% and 16.9% of the patients obtained normal and abnormal scores, respectively; on the other hand, 73.6% and 26.4% of the patients obtained normal and abnormal scores in the last modified BPP, respectively. There was a significant relationship between neonatal outcomes and standard BPP results (P=0.05). Also, the relationship between standard BPP and modified BPP was significant (P=0.003). However, there was not a significant relationship between modified BPP and neonatal outcomes. Conclusion: As the results indicated, modified BPP score had a significant relationship with standard BPP score, and standard BPP score had a significant correlation with neonatal outcomes. Therefore, the modified test can replace the difficult and time-consuming standard method. In addition, if the modified test showed any abnormalities, standard BPP or other fetal health evaluation methods should be applied.

Uterine artery Doppler in high-risk pregnancies at 23-24 gestational weeks is of value in predicting adverse outcome of pregnancy and selecting cases for more intense surveillance.

To assess the role of the placental arterial Doppler examination at 23-24 gestational weeks for predicting adverse perinatal outcome in high-risk pregnancies. Retrospective register study. Skåne University Hospital in Malmö. Six hundred and forty-five women with high-risk pregnancies, without fetal malformations or chromosomal abnormalities. Placental (uterine and umbilical artery) Doppler ultrasound examination at 23-24 gestational weeks. Adverse perinatal outcomes including preeclampsia, small-for-gestational age newborns (smaller than 3rd percentile or smaller than the 10th percentile), preterm delivery (<34 weeks or <37 weeks of gestation at delivery), cesarean section, admission to the neonatal intensive care unit and intra-uterine fetal death. Abnormal uterine artery Doppler values were detected in 45% of this high-risk group but abnormal umbilical artery Doppler indices were only seen in 3.7%. Adverse perinatal outcome increased significantly with increasing placental vascular impedance (p < 0.0001). There were seven cases of intrauterine fetal death and in five the uterine artery Doppler values at 23-24 weeks were abnormal. A strong correlation between abnormal uterine artery Doppler and preeclampsia was present, but not with other forms of hypertensive disorder. Placental Doppler screening at 23-24 weeks can be used in detecting pregnancies at risk of adverse outcome and in selecting cases for more intense surveillance. A surveillance plan is proposed based on Doppler screening at 23-24 weeks of gestation.

Ultrasonographic Assessment Predicts Adverse Perinatal Outcomes

Background: Objective:The aim of this work was to evaluate accuracy of the ultrasonographic assessment at the first or the second trimester of gestation as a predictor of adverse outcome in high risk pregnancies. Patients and methods:A cross sectional study was conducted on 85 consecutive high risk pregnancies attending the Antenatal Clinic and Medical Genetics Center of Ain Shams University. Nuchal translucency thickness was obtained for all cases recruited during 1st trimester. Nuchal fold thickness was obtained for all cases recruited during 2nd trimester.We prospectively evaluated the outcome of each pregnancy. Results:The mean age of participants, mean marriage duration, and gestational age were 32.5 ± 6 years, 7.1±3.3 years and 14.5±2.1weeks respectively.Increased NT thickness and NF thickness were present in5%, and 8.89% respectively.Down syndrome was found in 1.2% of current pregnancy outcome, while, cystic hygroma was found in 1.2%, cystic hygroma with hydrops was found in 1.2%, skeletal dysplasia and renal agenesis was found in1.2% missed abortion was found in 3.53%.There is a highly significant difference between normal outcome pregnancy and abnormal outcome pregnancy regarding mean NF thickness while no significant differences regarding NT thickness. Conclusion:The findings of our prospective study demonstrate the feasibility of using NF thickness to screen for aneuploidies, adverse perinatal outcome in high risk pregnancies.

Reply: Admission cardiotocography: practice based on evidence or assumptions and untested theories?

I thank Pelle Lindqvist for his interest in my commentary 1. The commentary 2 evaluated admission cardiotocography (CTG) from the perspective of clinical epidemiology – this is a part of evidence-based medicine. Lindqvist refers to his own experience, assumptions and untested theories indicating that admission CTG in all women improves outcomes in high-risk pregnancies. It is well known that it is difficult to draw conclusions from experiences on serious outcomes with very low frequencies. The subjective risk estimation is usually much higher than the objective (or epidemiological) risk estimation 3. When there is disagreement about which procedures or treatments are best, it is important to have academic discussions about the topic and to review the research literature carefully. Today the evidence is interpreted differently, as the test is recommended for all women in Finland and Sweden, but only for high-risk women in Denmark, Iceland and Norway. In Great Britain, where the traditions for making evidence-based guidelines are stronger than in the Nordic countries, the guidelines for intrapartum care among healthy women do not recommend admission CTG in low-risk women 4. In my view, the current evidence does not support routine use in low-risk women. It is possible that future research will provide other results but until then we should base our practice on evidence, not assumptions. As to the specific points in Pelle Lindqvist′s letter: The correct definition is of course that the admission CTG was introduced as a screening for fetal distress in labor, as defined by Ingemarsson et al. in 1986 5. Pelle Lindqvist states that admission CTG has never been used to predict later outcome. This is incorrect, and he is obviously not aware of the history on how and why the test was introduced 5. He also states that the commentary does not address perinatal mortality and serious morbidity. This, again, must rely on a misunderstanding. These important issues are addressed, as is the risk of type II errors because of insufficient sample size. The comment about skills in interpreting CTG-tracings was already discussed in a previous author reply 6. Pelle Lindqvist seems to imply that the labor admission test plays an important role in detecting cases of intrauterine fetal deaths (IUFD) upon admission to the hospital. I strongly disagree. If the midwife suspects IUFD after auscultation, the woman should have an ultrasound examination to verify the diagnosis, not a CTG.

Delay in intervention increases neonatal morbidity in births monitored with cardiotocography and ST‐waveform analysis

To assess the effect of the time interval from indication of hypoxia to delivery on neonatal outcome in high-risk pregnancies monitored with cardiotocography (CTG) and ST-waveform analysis. Prospective observational study. University hospital, Norway, 2004-08. Singleton high-risk births with a gestational age above 35(+6) weeks, monitored with CTG and ST-waveform analysis. Logistic regression analysis and Kaplan-Meier survival plots. Neonatal morbidity in relation to the rapidity of intervention. Of 6010 deliveries monitored with ST-waveform analysis, 1131 (19%) had an indication to intervene for fetal distress according to clinical guidelines. Those fetuses were at increased risk of an adverse neonatal outcome, and if delivered later than 20 min after the indication of hypoxia their risk increased further; i.e. transfer to the neonatal intensive care unit (NICU) from an odds ratio of 1.6 (95% confidence interval 1.2-2.2) to an odds ratio of 3.3 (95% confidence interval 2.5-4.3). The indication-to-delivery interval was longer for neonates with a 5-min Apgar score of <7, transfer to NICU and neonatal encephalopathy than for those without adverse outcome. In deliveries monitored with CTG and ST-waveform analysis, the risk of an adverse neonatal outcome was dependent on the time between indication of hypoxia and delivery. Nonadherence to the specific clinical guidelines increased the risk of neonatal morbidity.

A clinical study of role of colour Doppler imaging in pregnancies at risk.

Aim : To determine the role of colour Doppler sonography in evaluation of fetal outcome in high risk pregnancies and in normal patients. Methods : Study carried out in 23 high risk cases and 10 normal antenatal cases in their third trimester. Studies of various arteries performed using colour Doppler ulatrasound {ESOATE BIOMEDICAL 3 AU TRIPLEX DOPPLER MACHCINE} with 3.5 MHz curvilinear transducer. The umbilical artery and fetal middle cerebral artery studied. The required measurements taken in form of peak systolic velocity and end diastolic velocity and calculation of Systolic/Diastolic(S/D) ratio and Resistive Index(RI) sone and results compared with fetal outcome. Results : The mean weight of the baby 2.13(0.62)kg. 6 babies had respiratory distress and 7 babies had APGAR score at 5’≤7. 9 babies stayed in NICU>24 hours. We had 1 intrauterine death Umbilical artery S/D ratio >3 for the prediction of IUGR had a sensitivity of 69.2% and specificity of 60%, and for the prediction of adverse perinatal outcome had a sensitivity of 76.5% and specificity 100%. RI ratio <1 for the prediction of IUGR had a sensitivity of 46.15% and specificity of 70% and for the prediction of adverse perinatal outcome has a sensitivity of 47.4% and specificity of 100 %. Conclusion : Doppler can be considered as one of the important non invasive technique to assess fetomaternal and uteroplacental circulation. Due to it feasibility and safety it can be used in antepartum surveillance in high risk cases to know pregnancy outcome and also formulate plan of management for optimum fetal and maternal outcome. Key words : colour Doppler, Doppler indices , high risk pregnancy

Abnormal ductus venosus pulsatility index in the absence of concurrent umbilical vein pulsations does not indicate worsening fetal condition

Recordings of blood flow velocity waveforms in the ductus venosus (DV) and umbilical vein (UV) are routinely used in order to predict fetal condition in high-risk pregnancies. The aim of this study was to investigate the relationship between pathological blood flow in the two vessels and perinatal outcome. High-risk pregnancies (n = 11 863) admitted from 1993 to 2011 for blood-flow examination, including recordings of DV pulsatility index for veins (DV-PIV) and UV pulsations, were included. The results were related to perinatal outcome, using the last Doppler examination prior to delivery in the analysis. Abnormal DV-PIV was observed in 3.9% of cases, intra-abdominal UV pulsations in 1.3% and pulsations in the cord in 0.7%. As expected, the rate of UV pulsations increased with increasing DV-PIV Z-score. Fetuses with a pathological DV-PIV, but without UV pulsations, showed fewer signs of compromise. This was also true for cases with a DV-PIV ≥ 4 SDs above the mean (53.7% had steady flow in the UV). In contrast, the occurrence of UV pulsations seemed to be an indicator of fetal compromise, regardless of level of DV-PIV. Abnormal fetal venous blood velocity is related to adverse outcome in high-risk pregnancies. However, abnormal DV-PIV is not a reliable indicator of fetal compromise unless UV pulsations are concurrently present, and should not be regarded an indication for emergency delivery.

OP002. Impact of the NO-donor pentaerythrithyltetranitrate on perinatal outcome in high-risk pregnancies: A prospective randomized double blinded pilot study

To evaluate the effectiveness of the oral NO-donor PETN in secondary prevention of intrauterine growth restriction (IUGR), preterm birth and preeclampsia in high risk pregnancies. 111 women presenting with abnormal placental perfusion (bilateral notch or mean RI>0.7) at 19-24weeks of gestation were included in a prospective, randomized, placebo-controlled, double-blinded study. Primary endpoint was IUGR and/or perinatal death, secondary endpoints were preterm birth, preeclampsia and placental abruption. 54 women received PETN and 57 placebo. PETN significantly decreased the risk of IUGR and/or perinatal death (adjusted RR 0.623 [95% - CI: 0.395-0.983]). Preterm birth before 32weeks was reduced (adjusted RR 0.359 [95% - CI 0.123-1.054]) and no placental abruption occurred in the PETN, but 5 in the placebo group. There was no reduction of preeclampsia. Significant reduction of adverse pregnancy outcome might be possible in pregnancies exhibiting abnormal placentation using PETN.

Prenatal Ultrasound Screening for Fetal Anomalies and Outcomes in High-Risk Pregnancies due to Maternal HIV Infection: A Retrospective Study

Objective. To assess the prevalence of prenatal screening and of adverse outcome in high-risk pregnancies due to maternal HIV infection. Study Design. The prevalence of prenatal screening in 330 pregnancies of HIV-positive women attending the department for prenatal screening and/or during labour between January 1, 2002 and December 31, 2012, was recorded. Screening results were compared with the postnatal outcome and maternal morbidity, and mother-to-child transmission (MTCT) was evaluated. Results. One hundred of 330 women (30.5%) had an early anomaly scan, 252 (74.5%) had a detailed scan at 20–22 weeks, 18 (5.5%) had a detailed scan prior to birth, and three (0.9%) had an amniocentesis. In seven cases (2.12%), a fetal anomaly was detected prenatally and confirmed postnatally, while in eight (2.42%) an anomaly was only detected postnatally, even though a prenatal scan was performed. There were no anomalies in the unscreened group. MTCT occurred in three cases (0.9%) and seven fetal and neonatal deaths (2.1%) were reported. Conclusion. The overall prevalence of prenatal ultrasound screening in our cohort is 74.5%, but often the opportunity for prenatal ultrasonography in the first trimester is missed. In general, the aim should be to offer prenatal ultrasonography in the first trimester in all pregnancies. This allows early reassurance or if fetal disease is suspected, further steps can be taken.

Effect of vaginally administered DHA fatty acids on pregnancy outcome in high risk pregnancies for preterm delivery: a double blinded randomised controlled trial

to verify whether vaginally intake of docosahexaenoic acid (DHA), an n-3 long chain polyunsaturated fatty acid, would improve length of gestation and newborn birth weight in high risk pregnancies for preterm delivery. this study was a randomized, double-blind, controlled, clinical trial, including women at high risk for preterm delivery. Of 74 eligible women, 31 refused to participate and 34 were enrolled and randomized with equal chance of selection, 22 were assigned to treatment group and 21 were assigned to the control group, and received placebo. One gram of DHA was administered vaginally once a day starting from 21 (1 week of gestation until 37 weeks + 0 day). The primary endpoint was to determine the length of the pregnancy and secondary endpoint the newborn weight. gestational age at delivery was 38.6 (SD, 1.05) weeks in the docosahexaenoic acid group and 37.6 (SD, 0.84) weeks in the placebo group (P =0.007). For women who completed the treatment and delivered at term there was a statistically difference of the weights in the two groups [3082.1 (SD, 293) gr cases vs 2699.3 (SD, 150) gr controls P <0.0001]. in high risk patients for preterm delivery, the vaginal administration of a DHA increases length of gestation and newborn birth weight.

Umbilical artery doppler flow patterns in high-risk pregnancy and foetal outcome in Mulago hospital

Objective: To demonstrate the flow patterns and factors associated with adverse foetal outcome in high-risk pregnancy at Mulago Hospital using Doppler ultrasound of the foetal umbilical artery. Design: Cross-sectional descriptive study. Setting: Mulago National Referral Hospital, Kampala Uganda. Study Subjects: One hundred and ninety-two patients in a 4-month period (December 2008-April 2009). Results: Maternal age was 16 to 41 years. Twenty-one foetuses had abnormal flow patterns (12 had reduced end-diastolic flow, 8 had AEDF and 1 had RF). Prematurity was associated with abnormal flow patterns. 11 out of 12 foetuses with reduced end-diastolic flow survived. Of the foetuses with AEDF, 3 survived but were admitted to the neonatal special care unit while 5 died. One foetus had RF and was a stillbirth. Eighteen foetuses were delivered after an obstetric intervention. Conclusions: 1) The prevalence of abnormal flow patterns is 10.9%. 2) Abnormal flow patterns, low biophysical profile score, premature delivery, low birth weight and low Apgar score are related to adverse foetal outcome. 3) A low biophysical profile score is related to AEDF/RF. 4) Foetuses of low parity mothers are more likely to have abnormal flow patterns. Recommendation: Umbilical artery Doppler Biophysical profile scores should be done in high-risk pregnancy.

Advanced Glycation End Products, Measured as Skin Autofluorescence, During Normal Pregnancy and Pregnancy Complicated by Diabetes Mellitus

Advanced glycation end products (AGEs) accumulate with age and in diabetes mellitus (DM). AGEs can be measured by the AGE Reader (DiagnOptics Technologies BV, Groningen, The Netherlands) using skin autofluorescence (SAF). SAF is related to chronic diabetes complications. In a previous study we reported that SAF is comparable in patients with gestational DM (GDM) and controls at 27 weeks of gestation. In the current study we investigated SAF at multiple time points during pregnancy in pregnancies complicated by DM (type 1 or type 2) or GDM and in controls. Furthermore, the relation between SAF levels and adverse pregnancy outcomes was investigated. In this single-center prospective observational study SAF was measured during pregnancy from 26 gestational weeks onward in 79 GDM patients, 21 patients with preexistent DM (type 1 or type 2), and 55 women without diabetes. Adverse pregnancy outcomes were recorded. SAF decreased slightly but significantly (β = -0.018) during normal pregnancy but not in pregnancies complicated with hyperglycemia. At the end of pregnancy SAF was higher in patients with preexistent DM (1.91 arbitrary [AU] units) compared with patients with GDM (1.71 AU) or normal pregnancy (1.66 AU) but did not differ between the latter two groups. SAF was not related to adverse pregnancy outcomes. The decrease in SAF during normal pregnancy could be the result of physiological changes. Because SAF was not related to adverse pregnancy outcomes, it is unlikely that the AGE Reader will be of use in daily clinical practice for GDM patients as a marker for identifying high-risk pregnancy outcomes.

1160 Effect of Cervical Colonization on Neonatal Outcome in High Risk Pregnancies: Results From a Tertiary Maternity Center in Turkey

Backgraund and aimTo evaluate and compare the morbidity and mortality of neonates born to pregnant women with positive and negative cervical cultures.MethodsThe demographic and clinical features of mothers included in...

Do color Doppler studies predict perinatal outcome in high risk pregnancies?

Do color Doppler studies predict perinatal outcome in high risk pregnancies?

New score by color Doppler ultrasound indicating placental vascular resistance and pregnancy outcome in high-risk pregnancy

Aim of the workTo evaluate the role of the new placental score (PLS) by combining the Doppler umbilical artery score (blood flow classes, BFC) and the uterine artery score (UAS) to predict the pregnancy outcome in high risk pregnancy. Patients and methodsForty pregnant ladies with high risk pregnancy were included in the study. The UAS and the BFC were combined to form a placental score (PLS) as an expression of general placental vascular resistance PLS=BFC+UAS, with figures in the range 0–7. Serial examinations were performed for each patient, in the 3d trimester. The results of last examination were related to the three perinatal outcome variables; premature birth, small for gestational age (SGA), and delivery by cesarean section (CS). ResultsThe relation between placental score and pregnancy outcome revealed – score (0) in 62.5% of patients, which was significant for CS (52%) followed by SGA+CS (28%) – score (I) in 20% of patients, was significant for CS (50%) and SGA (37.5%) – score (II) in 12.5% of patients, was mainly significant for preterm delivery+SGA (80%) – score (III) in 5% of patients, was highly significant for CS+preterm delivery (100%). ConclusionThe new PLS showed a better relationship to adverse perinatal outcome than the BFC and the UAS. The PLS can simplify evaluation of uteroplacental and fetoplacental Doppler velocimetry.

Evaluation of the safety and reliability of preimplantation genetic diagnosis

Preimplantation genetic diagnosis (PGD) refers to a procedure to genetically analyze embryos prior to implantation, in order to prevent the occurrence of specific inherited disorders before conception and improve the outcome of high-risk pregnancy with genetic disorders. In recent years, with the advance of molecular biology techniques, more and more genetic diseases have been elucidated, and PGD has been gradually expanding its scope and applications. New technologies, such as microarray comparative genomic hybridization (array CGH), are developed to improve the accuracy of diagnosis. However, the safety of this procedure has aroused great attention. In this article, authors will review the safety of zona opening procedures, different biopsy procedures at different stages, and removal of one or two cells from cleavage-stage embryos. The reliability of genetic analysis technologies will be discussed as well.

Mid-trimester uterine artery Doppler ultrasound as a predictor of adverse obstetric outcome in high-risk pregnancy

Objective The aim of this study was to assess uterine artery Doppler ultrasonography efficiency in prediction of adverse pregnancy outcome in high-risk pregnancies. Materials and Methods We selected 70 pregnant women who were high risk for development of preeclampsia, abruption, low birth weight (LBW), and preterm delivery during their pregnancy, and Doppler ultrasonography was performed for them in 18–24 gestational weeks for evaluation of uterine artery notching. Absence of diastolic flow in uterine artery waves was defined as notching. The women were divided into two groups: with notching (Group A) and without notching (Group B), then they were compared for complications such as preeclampsia, abruption, LBW, and preterm delivery. Results In 70 high-risk pregnant women, 27 women (39.2%) were in Group A and the others were in Group B. The birth weight in Groups A and B was 2,897.5 ± 757.15 and 3,248.39 ± 374.27, respectively. In our study, 15 patients were delivered before 37 gestational weeks (preterm labor). Preeclampsia, abruption, and LBW were significantly higher in the group with positive notching, but preterm delivery did not show any statistical difference between the two groups. Conclusion According to the results, uterine artery Doppler ultrasonography had high negative predictive value for prediction of preeclampsia, abruption, and LBW. Therefore, absence of uterine artery notching in mid-trimester evaluation of high-risk pregnant women may predict better pregnancy outcome. We recommend Doppler ultrasonography for all high-risk pregnant women in second trimester for prediction of pregnancy outcome.

Value of Third Trimester Uterine Artery Doppler in High-risk Pregnancies for Prediction of Adverse Perinatal Outcome

ABSTRACT Objective To determine the usefulness of uterine artery Doppler in evaluation of third trimester high-risk pregnancies in prediction of adverse perinatal outcome. Methods In this prospective study uterine artery Doppler parameters such as PI and early diastolic notch were recorded in a group of 60 high-risk pregnancies mainly consisting of pre-eclampsia and small for gestational age. Uterine artery score (UAS) was calculated from the Doppler parameters and a score ≥ 2 was considered abnormal. Perinatal outcome was then correlated to this score and compared with umbilical artery Doppler. Results Abnormal UAS was noted in 72% of the study group while umbilical artery Doppler was abnormal in only 35%. All the five perinatal deaths and high-rate of perinatal morbidity was observed when both uterine and umbilical artery Dopplers were abnormal. Perinatal morbidity parameters such as birth weight &lt; 2 kg, gestational age &lt; 34 weeks and NICU admission was significantly high in 23 women who had abnormal UAS with normal umbilical artery Doppler. In pregnancies beyond 34 weeks abnormal uterine artery Doppler was a better predictor of adverse outcome than umbilical artery Doppler. Conclusion Abnormal uterine artery Doppler is a reliable predictor of adverse perinatal outcome in high-risk pregnancies with preeclampsia and fetal growth restriction. Normal uterine artery Doppler in third trimester is reassuring. Thus inclusion of uterine artery Doppler along with umbilical artery Doppler in high-risk pregnancy in third trimester will improve fetal surveillance.

The ways of amniotic fluid sampling and its influence on lamellar body count

Even though artificial surfactant is now available, respiratory distress syndrome still remains a serious problem in neonatology. Prenatal analysis of the amniotic fluid can provide data giving insight into the fetal lung maturity, which enables planning of the further outcome of high-risk pregnancies. Surfactant prevents atelectasis by forming a layer rich in phospholipids between the air and liquid phase in alveoli thus leading to increased surface tension in them, which is a precondition for a good lung function after birth. Lamellar bodies are a form of stored surfactant, and their count in the amniotic fluid can be determined simply by a standard hematology analyzer. The method of determining lamellar body count has found an important place in prenatal diagnostics and is recommended as an initial method of a "cascade" procedure of testing fetal lung maturity. However, considering the importance of procedure of sample collection, storage and centrifugation, which can significantly affect the results obtained for the lung maturity, the amniotic fluid samples must be absolutely free of contamination with blood, meconium, mucus, bacteria and leucocytes.

P79 Value of third trimester uterine artery Doppler for prediction of adverse perinatal outcome in high risk pregnancies

International Journal of Gynecology & ObstetricsVolume 107, Issue S2 p. S433-S434 Poster presentations P79 Value of third trimester uterine artery Doppler for prediction of adverse perinatal outcome in high risk pregnancies L. Rai, L. RaiSearch for more papers by this authorL. Shivananda, L. ShivanandaSearch for more papers by this author L. Rai, L. RaiSearch for more papers by this authorL. Shivananda, L. ShivanandaSearch for more papers by this author First published: 20 November 2009 https://doi.org/10.1016/S0020-7292(09)61570-8AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume107, IssueS2Abstracts of XIX FIGO World Congress of Gynecology and ObstetricsOctober 2009Pages S433-S434 RelatedInformation