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With an increased cesarean delivery rate, the incidence of abnormal placentation is steadily rising, and it is estimated to be around 1.7 per 1000 pregnancies for cesarean scar pregnancy and 1 per 500 pregnancies for placenta accreta spectrum disorder. Current evidence considers cesarean scar pregnancy and placenta accreta spectrum as being the same condition, with different aspects, of the same spectrum, having higher risks with advancing gestation. We present 7 cases, diagnosed and managed in our hospital, at different gestational ages. Early diagnosis is essential for appropriate counseling and subsequent management, and an ultrasound examination is the reference standard for diagnosis. Screening for an abnormally implanted placenta in the first trimester of pregnancy might improve the perinatal outcome and reduce maternal morbidity and mortality.

Objective To examine the performance of screening for pre-eclampsia (PE) at 35-37 weeks' gestation by maternal factors and combinations of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFlt-1). Methods This was a prospective observational study in women with singleton pregnancy attending for an ultrasound scan at 35 + 0 to 36 + 6 weeks as part of routine pregnancy care. Bayes' theorem was used to combine the prior distribution of gestational age at delivery with PE, obtained from maternal characteristics and medical history, with various combinations of biomarker multiples of the median (MoM) values to derive the patient-specific risks of delivery with PE. The performance of such screening was estimated. Results The study population of 13 350 pregnancies included 272 (2.0%) that subsequently developed PE. In pregnancies that developed PE, the MoM values of MAP, UtA-PI and sFlt-1 were increased and PlGF MoM was decreased. At a risk cut-off of 1 in 20, the proportion of the population stratified into high risk was about 10% of the total, and the proportion of cases of PE contained within this high-risk group was 28% with screening by maternal factors alone; the detection rate increased to 53% with the addition of MAP, 67% with the addition of MAP and PlGF and 70% with the addition of MAP, PlGF and sFlt-1. The performance of screening was not improved by the addition of UtA-PI. The performance of screening depended on the racial origin of the women; in screening by a combination of maternal factors, MAP, PlGF and sFlt-1 and use of the risk cut-off of 1 in 20, the detection rate and screen-positive rate were 66% and 9.5%, respectively, for Caucasian women and 88% and 18% for those of Afro-Caribbean racial origin. Conclusion Screening by maternal factors and biomarkers at 35-37 weeks' gestation can identify a high proportion of pregnancies that develop late PE. The performance of screening depends on the racial origin of the women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Objectives To assess the performance of first-trimester ultrasound (US) in identifying major fetal structural abnormalities in an unselected population. Methods We conducted a retrospective analysis of all pregnancies that underwent the 11- to 14-week scan in the Fetal Medicine Department of Filantropia Hospital in Bucharest, which were prospectively examined within our screening program. The purpose of the first-trimester US was to evaluate the risk for chromosomal abnormalities and to conduct fetal anatomic examination using a detailed protocol. Results Our population consisted of 7480 pregnant patients (7576 fetuses). The follow-up was completed for 6045 patients (6114 fetuses). The prevalence of major structural anomalies was 1.89%. In the first trimester, we identified 79% of all major structural anomalies. The highest detection rates were achieved for abdominal wall defects (100%), major central nervous system anomalies (88%), cardiac defects (74%), and skeletal anomalies (71%). The nuchal translucency was increased in 35% of the cases with structural anomalies, and 95% of these were diagnosed in the first trimester. Seventy percent of the patients who presented with structural anomalies and a normal nuchal translucency were diagnosed in the first trimester. Conclusions Our results emphasize the importance of performing a detailed US examination at 11 to 14 weeks' gestation in identification of fetal structural defects.

Objective To compare the degree of impaired placentation in pregnancies which develop preeclampsia (PE) in women with and without chronic hypertension (CH). Methods The data for this study were derived from prospective screening for adverse pregnancy outcomes in women with singleton pregnancies attending for their first routine hospital visit at 11+0-13+6 weeks’ gestation. This visit included recording of maternal characteristics and medical history and measurements of mean arterial pressure (MAP), uterine artery pulsatility index (UTPI), serum placental growth factor (PLGF) and serum pregnancy associated plasma protein-A (PAPP-A). The measured biomarkers were converted to multiples of the median (MoM) after adjustment for pregnancy characteristics and MoM values in women with CH that developed PE (n = 283) were compared to those of women without CH that developed PE (n = 2,236). Results In both groups with and without CH the measurements of MAP and UTPI were increased, whereas those of PLGF and PAPP-A were decreased and the deviation from normal in all biomarkers decreased with advancing gestational age at delivery with PE. There was no significant difference between those with and without CH in the slope of the regression line of Log10 MoM biomarker values with gestational age at delivery with PE for any of the biomarkers. However, there was a significant difference in the intercepts and coefficients of biomarkers in the two groups; in the CH group, compared to those without CH, the MAP MoM was higher (p

Objective To examine the effect of chronic hypertension (CH), with and without superimposed preeclampsia (PE), on the incidence of small for gestational age (SGA) neonates, and explore possible mechanisms for such association. Methods The data for the study were derived from prospective screening for adverse pregnancy outcomes in women with singleton pregnancies attending for their first routine hospital visit at 11-13 weeks’ gestation, which included recording of maternal characteristics and medical history and measurement of mean arterial pressure (MAP). Birth weight z-score, adjusted for gestational age and for maternal and pregnancy characteristics, and incidence of SGA were compared between those with and without CH in the total population and in the subgroups with and without PE. Regression analysis was used to examine the relationship between MAP and birth weight z-score and incidence of SGA and PE in those with and without CH. Results The study population constituted 74,226 pregnancies, including 1,052 (1.4%) with CH and 73,174 without CH. Preeclampsia developed in 233 (22.1%) cases of the group with CH and in 1,662 (2.3%) of those without CH. In the group that developed PE, there was no significant difference between those with CH and those without CH in either the median birth weight z-score or the incidence of SGA. In the group without PE, the incidence of SGA was twice as high in those with than in those without CH. There was a significant association between log10 MAP multiple of the median and incidence of SGA and PE which was more marked in those with CH than in those without CH. Conclusion CH is associated with increased risk of SGA and PE and this is related to MAP at 11-13 weeks’ gestation.

Objective To examine the association between chronic hypertension (CH) and a wide range of adverse pregnancy outcomes after adjustment for confounding factors in obstetric history and maternal characteristics. Methods This was a prospective screening study for adverse pregnancy outcomes in women with singleton pregnancy attending their first routine hospital visit at 11 + 0 to 13 + 6 weeks' gestation. Data on maternal characteristics, medical and obstetric history and pregnancy outcome were collected. Regression analysis was performed to examine the association between CH and adverse pregnancy outcomes, including late miscarriage, stillbirth, pre-eclampsia (PE), gestational diabetes mellitus (GDM), spontaneous and iatrogenic preterm birth (PTB), small-for-gestational-age (SGA) neonate, large-for-gestational-age (LGA) neonate and elective and emergency Cesarean section (CS). Results The study population of 109 932 pregnancies included 1417 (1.3%) women with CH. After adjusting for potential confounding variables from maternal characteristics, medical and obstetric history, CH was associated with increased risk of stillbirth (odds ratio (OR), 2.38 (95% CI, 1.51–3.75)), PE (OR, 5.76 (95% CI, 4.93–6.73)), SGA (OR, 2.06 (95% CI, 1.79–2.39)), GDM (OR, 1.61 (95% CI, 1.27–2.05)), iatrogenic PTB < 37 weeks (OR, 3.73 (95% CI, 3.07–4.53)) and elective CS (OR, 1.79 (95% CI, 1.52–2.11)), decreased risk of LGA (OR, 0.65 (95% CI, 0.53–0.78)) and had no significant effect on late miscarriage, spontaneous PTB or emergency CS. Conclusion CH should be combined with other maternal characteristics and medical and obstetric history when calculating an individualized adjusted risk for adverse pregnancy complications. CH increases the risk of stillbirth, PE, SGA, GDM, iatrogenic PTB and elective CS and reduces the risk for LGA. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.