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Objectives: Invasive prenatal procedures including amniocentesis, chorionic villus sampling (CVS) can be prenatally indicated for diagnostic purposes. Chronic viral infections with Human Immunodeficiency Virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV) are not uncommon in women of reproductive age. The aim of this narrative literature review is to provide guidance on the best clinical practice in antenatal invasive testing and fetal surveillance in pregnancies with HIV, HCV, HBV and treponema pallidum infected women. Material and methods: A review of the literature was conducted in the database of PubMed to select full-length articles published in peer-reviewed journals between 1990 and 2020. The keywords along with respective combinations included in the search strategy were invasive testing, prenatal diagnosis, amniocentesis, chorionic villus sampling, cordocentesis, fetoscopy, chronic viral infections, hepatitis B, hepatitis C, HIV, treponema pallidum, syphilis, vertical transmission, MTCT. Results : For patients with hepatitis B infection, it is important to assess the HBeAg status and HBV DNA levels and for those patients with high viral load, antiviral therapy (Tenofovir) for a few weeks may be needed to reduce the viral load prior to the invasive procedure. In women positive for HCV, the viral load and HIV status should be assessed to establish the risk of vertical transmission; while for patients with HIV, highly active antiretroviral therapy administration and low viral load are predictive for reduced vertical transmission even after performing an invasive procedure. In all cases invasive procedure should be replaced by non-invasive prenatal testing if this is a feasible alternative and when invasive testing is indeed required, transplacental passage should be avoided.

Hypertensive disorders such as gestational hypertension, preeclampsia, eclampsia and HELLP syndrome are one of the most common pregnancy-associated entities that imply substantial maternal-fetal mortality and morbidity. When hypertensive disorders are associated with a multiple pregnancy, the outset is established sooner, with a rapid evolution and a more severe development. Although, the pathophysiology of hypertensive disorders is not fully understood, there are several risk factors that could be identified. A multiple pregnancy implies additional risks due to specific features: larger or multiple placentas, failure of the uteroplacental unit to uphold the natural development of multiple fetuses or elevated risk of abnormal placental site. Hypertensive disorders include complications that are common for both single and multiple pregnancies, complications such as kidney failure, liver dysfunction, neurological or hematological malfunction, among others. Maternal features, including mean arterial blood pressure, uterine artery pulsatility index and blood levels of PAPP-A and/or PlGF could be determined at an early age and used as screening methods.

Cervical excisional procedures stand as an important risk factor for preterm birth (PTB) in subsequent pregnancies in various articles in the medical literature. We performed an evidence-based review of the obstetrical outcomes succeeding excisional procedures for cervical dysplasia as follows: we reviewed 16 studies published between 2015 and 2020 that assessed whether there is an association between excisional cervical procedures and unfavorable obstetrical outcomes. Nevertheless, there are several other aspects of the problem, taken into account as possibly responsible for increasing the risk of PTB, as the grade of the dysplasia, the effect of depth/length/volume of the excised cone specimen, prophylactic procedures for the prevention of PTB, age, interval conization-pregnancy. The majority of the authors suggested an association between excisional procedures and preterm birth or other obstetrical events. However, some of them did not find statistically significant data in order to strongly affirm a correlation between conization and PTB, or, on the contrary, disproved the given hypothesis. There is no consensus regarding cervical excisions as being an individual risk factor for PTB, therefore more studies need to be conducted in order to come to a strong, universal conclusion.

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal (GI) disorders and, despite the fact that it is a benign condition, it may seriously affect the quality of life of women during pregnancy. The most commonly symptoms seen of GERD are heartburn and reguritation and the cause is probably an association between the decreased pressure in lower esophageal sphincter (LES), influenced by the high concentrations of estrogen and progesterone, and the increased intra-abdominal pressure. Contrary to non-pregnant patients, the management of GERD during pregnancy is based on a step-up algorithm, beginning with lifestyle modifications and dietary changes. If symptoms persist, or in case of complicated reflux disease, antacids or sucralfate are considered the first-line therapy, followed by the histamine-2-receptor antagonists and proton pump inhibitors. The purpose of this article is to make a review of the medical literature concerning the symptoms, pathophysiology, diagnosis, and management of GERD in pregnancy. For this purpose, a scientific research in databases such as Medline, PubMed, Elsevier, The Lancet was conducted.

One of the greatest problems that patients and medical system confront worldwide nowadays is cancer. Even if there is a great focus on treatment improvement, it is equally or even more important to find cancer prevention pathways. If we concentrate on gynecological malignancies, we have as example cervical cancer which can now be prevented through vaccination, but less is known about prevention methods for endometrial and ovarian cancer. In 1992, Alice S. Whittemore first described the protective role of combined oral contraceptives (COC) use against ovarian cancer. After that, many other studies tried to find out how combined oral contraceptive use influence the risk of gynecological cancers. According to all researches, it is now known that COC are associated with risk reduction in ovarian and endometrial cancers. It was observed that their risk reduction depends on different factors such as length of use, the period of life when they were used, or some other associated risk factors. Moreover, it seems that they offer protection only against some histological types of endometrial and ovarian cancer. This review relates the most important findings regarding COC use and their risk reduction effect on ovarian and endometrial cancer in the recent studies. Even if some certain conclusions were made, such as time-dependent effect, more studies need to be conducted in order to have certain future recommendations.

Background. Urinary tract infections (UTI) are the most common infections during pregnancy. The feto-maternal complications linked to this pathology can be severe if untreated and the treatment has been a subject of interest hence the multiple drugs contraindications in pregnancy, the restraint panel of antibiotics that can be used and the antimicrobial resistance that is constantly increasing. The purpose of this article is to review the latest data from literature and guidelines regarding the best management of the urinary tract infections in pregnancy. Methods. It was undertaken a systematic electronic search for articles, reviews and guidelines using Cochrane Date Base, PubMed and the international protocols in use recommended by the Obstetrics and Gynecology societies (ACOG - American College of Obstetricians and Gynecologists, CNGOF – Collège National des Gynécologues et Obstétriciens Français, RCOG – Royal College of Obstetricians and Gynecologists). Results and conclusions. Special consideration should be given to urinary tract infections developed during pregnancy because they are related to serious fetal and maternal complications. Routine screening is recommended and the antibiotic therapy properly individualized. Emotional impact on the future mothers is particularly important and non-pharmacologic prophylaxis should always be discussed at the begging of pregnancy. Future research should be focused on finding the actual mechanism of pathogenesis that link UTI and the complications they associate.

Medullary thyroid carcinoma (MTC) is a rare neuroendocrine tumor of the parafollicular cells of the thyroid gland. The tumor occurs, either sporadically or in a hereditary form, as a component of the type 2 multiple endocrine neoplasia (MEN) syndromes, MEN2A and MEN2B, both with an autosomal dominant transmission. Due to its higher aggressiveness and urgency to treat, it poses a challenge when diagnosed during pregnancy. We performed a literature review searching medical databases as UpToDate and PubMed for relevant information about diagnosis, impact, treatment, and outcome of medullary thyroid carcinoma during pregnancy. Diagnosis of MTC is established by clinical and ultrasound evaluation, followed by a fine needle aspiration biopsy. Further analyses decide whether it is a sporadic or a hereditary disease. Surgery offers the curative solution, but careful postoperative follow-up is needed for the best outcome. The decision for surgery is taken considering the DNA mutation of RET oncogene and pregnancy status. A premature planned delivery is associated with potential complications for the newborn, but it is recommended when maternal status worsens. Conclusions. Complete resection of the thyroid tumor and any local and regional metastases is the only curative solution. Timing of the intervention is extremely important to decrease fetal outcomes. Close follow-up during the postoperative period, by both biochemical and imaging methods, is needed.

Obesity is defined as a body mass index (BMI) greater than 30 kg/m² and it is a major healthcare issue, with an increasing number of people being obese worldwide, including reproductive-aged women. Due to the great impact it has on morbidity and mortality, finding solutions to combat this century’s health menace became an issue and a necessity. Bariatric surgery is nowadays the treatment of choice for severe obesity due to the major weight loss following the procedure and improvements in several health outcomes. But as with all surgical procedures, it can also lead to complications, such as intestinal occlusions, with severe consequences, especially during pregnancy. Moreover, bariatric surgery can favor fetal growth restriction, depending on the type of procedure applied. There are two main types of bariatric surgery, purely restrictive procedures (sleeve gastrectomy, gastric banding) and malabsorptive or mixed procedures (biliopancreatic diversion, gastric bypass). Mixed procedures have been the first choice for many years because of the greater weight loss compared to gastric banding, but they can lead to nutritional deficiencies, with a potential impact on fetal development, causing an increased incidence of small-for-gestational-age fetuses (SGA). Main nutritional deficiencies include iron, vitamin B12, folate, and calcium. On the other hand, pregnant women who underwent bariatric surgery have lower risks of GDM (gestational diabetes mellitus), gestational hypertension and fetal macrosomia.

Intrahepatic cholestasis of pregnancy is the most common liver disease during pregnancy. The main features are maternal pruritus, in the absence of a rash, and raised serum bile acids. Intrahepatic cholestasis of pregnancy is associated with an increased risk of adverse perinatal outcomes, including preterm birth, meconium-stained amniotic fluid, fetal asphyxia with neonatal unit admission or even stillbirth. The main treatment option is ursodeoxycholic acid. We review the etiology, diagnosis, adverse pregnancy outcomes, focusing especially on management of this intriguing condition.

Breast cancer is an extremely important public health issue for doctors. Health professionals draw attention to the importance of early detection of the disease, so that treatment becomes effective. The experience of the disease can be extremely shocking and devastating for women. Studies show that women diagnosed with breast cancer experienced prolonged emotional difficulties during the year following diagnosis. This article proposes a review of some important methods and techniques used in the psychotherapy of breast cancer patients, such as: art therapy, cognitive-behavioral stress management, mindfulness-based stress reduction, acceptance and commitment therapy, compassion focused therapy and experiential psychotherapy. This paper is a review based on information from the literature. The analysis was limited to articles and guides in English published between January 1 and June 1 2021, on PubMed, ScienceDirect and Google Scholar, using the following keywords: breast cancer, women, depression, distress, anxiety, mental health, psychotherapy, interventions, treatment. In this review we discuss the characteristics of breast cancer pathology, the psycho-emotional effects and the interventions needed to optimize quality of life. The psychotherapeutic approaches presented draw attention to the fact that psychological interventions are part of the complementary procedures to the treatment in the pathology of breast cancer and can improve the quality of life of pacients.

Pneumonia is a common disease worldwide and the coexistence with pregnancy increase its morbidity and mortality. Physiologic changes in pregnancy can augment susceptibility to pulmonary diseases and change their clinical course. This review article attempts to make an assessment of current information on the risks, maternal and fetal effects, etiology, clinical features and management of pneumonia in pregnancy. A systematic literature electronic search for journal articles and guidelines regarding pneumonia and respiratory disease in pregnancy was undertaken. Pathogens, clinical course and treatment of pneumonia in pregnancy is similar to the non-pregnant circumstances, with particular consideration on obstetric and fetal outcomes and drug safety during pregnancy. Prompt diagnosis and treatment reduce potential complications. Vaccination may reduce severity of pneumonia in high-risk pregnant patients.

Malignant melanoma is one of the most frequent cancers diagnosed during pregnancy. Any pigmented skin lesions that change the color should be examined by an experienced dermatologist and if suspected, should be biopsied. Recent studies showed that malignant melanoma in pregnancy has not a worse outcome compared with non-pregnant state. Diagnosis of melanoma does not require an early delivery excepted pregnant patients with poor prognosis that need more aggressive treatment. Diagnosis and treatment need to be established in specialized centers with a multidisciplinary team. Pregnancy monitoring should be performed by team consisting of an obstetrician, a neonatologist and a specialist in fetal medicine.

Pregnancy affects women's sleep in many ways. Physical and emotional difficulties, especially towards the end of pregnancy, can lead to sleep disorders. Several studies suggest associations between sleep quality and high blood pressure, diabetes and depression. Sleep deprivation affect both mother and fetus. Sleep disorders are associated with low birth weight, intrauterine growth restriction, premature birth and cesarean births. This paper is a review based on information from the literature. The analysis was limited to articles and guidelines in English published between January 1, 2000 and May 1, 2020 on PubMed, ScienceDirect and Google Scholar using the following keywords: sleep, pregnancy, depression, anxiety, mental health, sleep disorders, pregnant women, interventions, treatment. In this review, we discuss the characteristics of prenatal maternal sleep, hormonal changes during pregnancy and their effects on sleep, the effects of changing sleep patterns on the pregnant woman, and the interventions needed to optimize sleep quality. According to the literature, sleep disorders are significant risk factors for mood disorders. Knowing sleep changes and their effects is useful for informing mothers. Consideration of non-pharmacological treatments and interventions such as cognitive-behavioral therapy, mindfulness therapy and relaxation exercises can be effective in optimizing the quality of sleep in pregnant women.

Nowadays, women diagnosed with multiple sclerosis and belonging to the reproductive age group have high pregnancy rates, thus increasing the need of a careful pregnancy management in order to avoid maternal and fetal complications. The challenge of the chosen subject consists in identifying the available treatment that can be used during pregnancy time, emphasizing the need of a rigorous care during the preconceptional and postpartum period. The aim of the current review is to describe the management of a pregnant woman diagnosed with multiple sclerosis, in regards of treatment, anesthesia, mode of delivery and management and prevention of relapses during the postpartum period.

Pregnancy is a particular period of time for a woman, so that it is important to accurately determine the impact of adjacent pathologies on the natural evolution of the nine months of pregnancy. Although there is still much to debate on the association between periodontal disease and pregnancy, the conclusion seems to remain the same: untreated periodontal pathology in pregnancy could have adverse consequences such as premature birth or low birth weight fetuses. Periodontopathies are introduced as risk factors, the novelty of the subject being the association between untreated periodontal pathology and the evolution of pregnancy. The affected periodontal tissue has the potential of releasing microorganisms that could colonize the placenta, ultimately having adverse consequences on the evolution of pregnancy, consequences such as premature birth or inadequate birth weight. The purpose of this review is to assess the association between periodontal disease and the negative consequences on pregnancy. Using databases such as PubMed, more than 1,500 articles were screened, including systematic reviews, case-control studies and prospective cohort studies assessing the association between periodontitis and pregnancy. Only 54 from the abovementioned papers were included in the final review.

Diabetes mellitus is a metabolic disease with life-threatening morbidity and with epidemic spread. This metabolic disorder affects an increasing number of pregnant women. General practitioners and obstetricians need to know how some occult maternal metabolic disorders could be revealed by pregnancy and how pregnancy could influence the fetal health and the long-term progression of maternal disease. Pregnancy is considered a stress test for life and diabetes mellitus is a good example to illustrate this correlation.

Objectives: Over the last few years, the impact of infertility on the psychological well-being of couples has been well recognised. Men and women with infertility experience stress, anxiety and depression and their relationship might be under pressure. Material and methods: We conducted a non-experimental correlational descriptive study where transversal analysis using questionnaires and quantitative data was performed for 76 couples with diagnosed infertility under the care of various reproductive medicine clinics in Romania between 2018 to 2019. Participants were asked to fill, via internet or in person, a set of tests including data on socio-demographic and infertility characteristics along with five psychological tests: The Fertility Problem Inventory (FPI), State-Trait Anxiety Inventory, Beck’s Depression Inventory (BDI), Dyadic Adjustment Scale and Interpersonal Support Evaluation List-12. The aim of the study was to explore how couples with infertility respond and adapt to this diagnosis and to assess the relationship between emotional disorders, marital adjustment and social support. Results: Mean age of females was 34.2 and of males 36.7 and 38.2% of the couples were experiencing infertility for > 6 years. Women had worse scores on infertility-related distress (FPI) (t = –4.35, p = 0.01), on the BDI depression scale (t = –5.43, p = 0.01) and on anxiety scales (t = –5.48, p = 0.01). Participants with a longer duration of infertility scored significantly higher on infertility-related distress than those with more recent difficulties. Marital adjustment scores correlated negatively with emotional disorders. Both appraisal social support and belonging support moderated the relationship between state-anxiety and marital adjustment. Conclusions: Infertility carries a significant psychological burden for the couple and the longer its duration, the higher the distress level. Women seem to be more vulnerable to its psychological consequences. Marital adjustment correlates negatively with the degree of emotional disorders. In couples with high levels of social support, the relationship between state-anxiety and marital adjustment was negatively correlated.

Infections acquired during pregnancy add up to the overall perinatal rate of mortality and morbidity. Because it has the potential to be screened in all pregnant women, infection with cytomegalovirus continues to raise awareness among obstetricians and healthcare providers, given the perinatal complications involved, but also because not all parturient women are equally informed about the impact of the disease. A significant possibility of vertical transmission is attainable if primary infection is acquired in pregnancy, especially in the first trimester, when the risk of developing a congenital neonatal disease is higher. Even so, there are many more steps to be taken into consideration in order to fully understand the consequences of the infection, given the fact that the leading consequence of the congenital disease is the sensorineural hearing loss in the neonates, thus raising an important question: why a generalized serological screening in early pregnancy for CMV is just not justifiable?

Although there has been various pandemics throughout the history of humankind, modern age was thought to be ready to face such a challenge by implementing an advanced health care system. However, epidemic outbreaks are ubiquitous, and they have a substantial potential to evolve into pandemics, hence this being the actual context of SARS-CoV-2 pandemics from 2019. The difficulty of the addressed subject consists in the fact that the majority of pharmacological clinical studies omited pregnant patients. Acknowledging the physiological changes, pregnant women represent an unique group of patients as pregnancy could embody a particular substrate for this contemporary type of infection.

Superior vena cava (SVC) agenesis or total congenital absence of superior vena cava is a very rare vascular anomaly, mainly asymptomatic throughout neonatal period. We present a case of bilateral total congenital absence of superior vena cava and thoracic duct obstruction in a newborn which were detected during the anomaly scan at 22 weeks gestation as unilateral pleural effusion. Transthoracic echocardiography and angiography computed tomography in the postnatal period clearly established the diagnosis of congenital anomaly of the great veins. The pleural lymphatic effusion has resolved after drainage and medical treatment in 14 days.

Thrombophilias are a group of coagulation disorders associated with a predisposition to thrombotic events. They could be inherited (genetic) or acquired. The most encountered inherited thrombophilias are factor V Leiden (FVL), prothrombin gene mutation (G20210A) (PGM), protein S deficiency, protein C deficiency and antithrombin (AT) deficiency. Based upon the risk of thrombosis, there are two types of inherited thrombophilias, high risk and low risk. The high risk inherited thrombophilia includes antithrombin III deficiency, factor V Leiden homozygotes, prothrombin gene mutation and compound heterozygotes FVL and PGM. The low risk thrombophilia includes factor V Leiden heterozygote, PGM heterozygote, protein C deficiency and protein S deficiency. The incidence of all thromboembolic events is estimated to approximately 1-2 per 1000 pregnancies and about an equal number are identified antepartum and in the puerperium. Screening for thrombophilia in pregnancy is not universally recommended because of the low incidence of the condition and because it is not cost-effective. Some adverse pregnancy outcomes could be associated with some types of thrombophilia, but this association is weak and there is no reason to initiate extensive investigations or therapeutic measures. Both obstetricians and hematologists and women need to be correctly informed and avoid emotional decisions and unnecessary invasive treatments.

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.

Low back pain is a common complaint during pregnancy, affecting approximately half of pregnant women. However, true disc herniation is extremely rare, and the majority of patients heal without surgery. The purpose of this study was to provide an overview of conservative management strategies and delivery modes for pregnant patients suffering from lumbar disc herniation without severe neurologic deficits that would require emergency surgery. We performed a narrative review of the literature using the PubMed database. Thirty-one articles were originally retrieved, out of which 7 met the inclusion criteria, compiling a total of 10 cases of parturient patients with lumbar disc hernia treated conservatively until childbirth. The preferred delivery mode was a Cesarean section, which was performed in 6 out of 10 cases. Two patients developed the cauda equina syndrome, one during a failed induction and the other patient 4 weeks after vacuum extraction. However, the second patient failed to improve after surgery. No patients developed cauda equina syndrome during or after the Cesarean section. Based on limited data, the Cesarean section seems to be preferred compared to vaginal delivery to avoid worsening symptoms and progression to the cauda equina syndrome.

Pregnancy-associated breast cancer is one of the leading pregnancy-related types of cancer with an increasing incidence. It represents a special situation which requires careful attention for the medical team in fulfilling the goals of the treatment: the cure of the disease and the well-being of the pregnancy. The decisions regarding the most appropriate therapeutic methods should be made by a multidisciplinary team after offering counseling to the patient. The diagnosis of breast cancer during pregnancy or breastfeeding is a challenging situation considering the physiological changes. The first line of treatment is considered to be surgery indicated in any trimester of pregnancy, with mastectomy being often used. Chemotherapy can be offered, except for the first trimester, taking into account the risk of malformations. Radiotherapy, hormonal and biological treatment are contraindicated during pregnancy. The fetus must be evaluated regularly during treatment and the decision of delivery should be made on obstetrical and oncological indications.

Toxoplasmosis is the most common cause of congenital infection, causing long term ocular and neurological lesions with relapses during childhood and adolescence. The risk of congenital infection is highest after primary maternal infection with advancing maternal gestation. Only a few european countries recommend a routine prenatal screening although therapeutic options are the same. Primary prevention measures regarding food hygiene and secondary prevention through serological testing are the most important ways to prevent and detect toxoplasmosis during pregnancy. Counselling is challenging since there is a need for reference centers of diagnosis. In Romania there is a routine clinical practice to offer screening through the TORCH panel in the first trimester of pregnancy. This review summarizes the current methods of diagnosis and management of toxoplasmosis in pregnancy.

Background. Oral anti-diabetics in the treatment of gestational diabetes mellitus have had different approaches among time in medical guidelines. The interest in this pregnancy-associated disease is due to the dramatic increase of rates of gestational diabetes but also to the significantly higher short-term and longterm implications for mother and off-spring. This article aims to review the literature and guidelines on current recommendations regarding oral therapy in gestational diabetes mellitus. Methods. A systematic literature electronic search for reviews and guidelines was undertaken using Pub Med and the official websites of Diabetes and Obstetrics and Gynecology associations. Conclusions. Whereas oral anti-diabetics are an attractive alternative approach to insulin, in the last guidelines published by the societies of Obstetrics and Gynecology and Diabetes a new trend is noticeable subtracting oral anti-diabetics as the first option because of the lack in high-quality data on long-term safety, higher rate of treatment failure and pharmacokinetics.

To describe the incidence and the characteristics of pregnancies complicated by hypertensive disorders of pregnancy (HDP) in one of the largest maternity hospitals in Romania.A retrospective cohort study including all deliveries at ≥24 weeks' gestation was performed.The incidence of preeclampsia was 1.2%, of gestational hypertension 2.2% and of chronic hypertension 0.4%. Pregnancies with HDP had higher rates of stillbirth, birthweight10Incidence of HDP in our population was relatively low, and was associated with early gestational age and adverse perinatal outcomes.

Myasthenia gravis (MG) is an autoimmune disorder defined by weakness and rapid fatigue of skeletal muscles due to deterioration of neuromuscular junction by autoantibodies targeting either acetylcholine receptors (AchRs) or oth-er molecules such as muscle specific kinase receptors (MuSK). It affects predominantly women in the third decade of life and the effects of pregnancy on the evolution of the disease is variable, usually the aggravation of symptoms occurs during the first trimester or first month postpartum. The aim of this review is to discuss the clinical management of MG in pregnancy and to highlight the implications of MG on pregnancy and vice-versa, as well as reviewing the available treatment by using documentary analysis.The findings of this review show a variable clinical course of the disease with remission, worsening or preserving the status quo. MG does not influence the course of pregnancy to a large degree and by careful antenatal care and a multidisciplinary team approach a normal pregnancy and delivery can be achieved.

Borderline ovarian tumors represent a heterogeneous group of tumors with a specific noninvasive histology, a low malignant potential, and an uncertain outcome. They have a low incidence, occurring at younger age and diagnosed in early stages, and are associated with infertility, and they have a better prognosis when compared with epithelial ovarian cancer. We retrospectively evaluated all the patients with the diagnosis of borderline ovarian tumors who underwent surgical treatment between January 1, 2013, and December 31, 2016, in Filantropia Clinical Hospital. In the study, were included 50 patients with borderline ovarian tumors with an average age of 52. Thirty-four patients (68%) were postmenopausal and 16 (32%) were premenopausal. We found 44 unilateral tumors (88%) and 6 bilateral (12%), and the size varied between 3 and 40 cm. Regarding the histopathological examination, we found 34 patients with borderline ovarian tumors of serous type (68%), 12 of mucinous type (24%), and 4 (8%) other types. We had 2 cases of extraovarian extension, one to peritoneal surface and one to the appendix. Surgical treatment was radical in 38 cases and conservative in 12 cases. The management of borderline ovarian tumors should first consider the oncologic safety but will be well balanced with less radical treatment in selected cases. The various clinical and histological aspects of BOT should guide the surgeon and the oncologist to take the best decisions for the patient in order to be as radical as it is necessary.

Graves’ disease (GD) is one of the most common autoimmune conditions in women of reproductive age. The disorder is characterized by the presence of pathogenic immunoglobulins that bind the TSH receptors (TRAbs) and stimulate the production of thyroid hormones leading to hyperthyroidism (the occurrence of inhibiting or neutral antibodies being rare). Affected individuals can be treated by radioiodine therapy, surgical removal of the gland or by antithyroid drugs (ATDs). Thyroid stimulating immunoglobulins may persist for years after medical treatment, radioiodine therapy or surgical removal of the gland in those affected by GD and during pregnancy can cross the placenta and can act on the fetal thyroid gland resulting in the development of fetal and neonatal hyperthyroidism and sometimes to goiter. Antithyroid drugs used during pregnancy can also cross the placenta and may be teratogenic and act on the fetal thyroid gland, leading to fetal and neonatal hypothyroidism and goiter. This chapter will discuss specific aspects of GD during pregnancy and postpartum focusing on fetal and neonatal consequences related to this disorder.

Wharton’s jelly is a specialized connective tissue surrounding and protecting umbilical cord vessels. In its absence, the vessels are exposed to the risk of compression or rupture. Because the condition is very rare and there are no available antepartum investigation methods for diagnosis, these cases are usually discovered after delivery, frequently after in utero fetal demise. We report the fortunate case of a 29-year-old nulliparous woman, with an uncomplicated pregnancy, admitted at 39 weeks in labor where a persistently abnormal cardiotocographic trace led to delivery by cesarean section of a healthy 3500 g newborn. After delivery, a Wharton’s jelly anomaly was identified at the abdominal umbilical insertion (umbilical cord vessels, approximately 1 cm in length, were completely uncovered by Wharton’s jelly), which required surgical thread elective ligation. In the presence of a persistently abnormal CTG trace, in a pregnancy with no clinical settings suggestive of either chronic or acute fetal hypoxemia, the absence of Wharton’s jelly should be taken into consideration in the differential diagnosis.

Background and objectives: Rosai–Dorfman disease (RDD) is a type of histiocytosis that usually appears in young adults or children as bilateral cervical lymphadenopathy, but extranodal involvement in not uncommon. Although the pathogenesis is not entirely elucidated, recent studies showed a possible neoplastic process. Materials and methods: Our manuscript presents a rare case of Rosai–Dorfman disease of the breast, the management of this rare case, and a literature review. There are few cases reported of RDD of the breast (around 90 globally reported cases); the data is poor, and the management not yet standardized for these cases. The case reported here shows the importance of correct breast investigation, breast imaging, and ultrasound-guided biopsy that provided an accurate diagnosis and guided further management. Results: Although RDD of the breast was rarely presented as bilateral disease in other case reports, our case showed bilateral breast disease with the suspicion of breast cancer on imaging. Pathology and immunohistochemistry were of critical importance and showed a specific pattern for histiocytosis. A multidisciplinary approach was taken into consideration for these cases in order to establish the approach. Some patients underwent surgery, but watchful waiting and close follow-up were the preferred approach. Conclusions: RDD of the breast is a rare form of histiocytosis, with fewer than 100 globally published cases. Although the management of this disease is not established yet by guidelines, a follow-up approach should be enough for these patients, and surgery might be overtreatment. Mortality from RDD is very low due to comorbidities. A multidisciplinary team decision is important, and abstinence might significantly benefit these patients.

Background and Objectives: Myelomeningocele is the most severe form of spina bifida, a congenital neural tube defect arising from an incomplete neural tube closure during early development with damage worsening with advancing gestational age. The Management of Myelomeningocele Study (MOMS) Trial proved that surgery performed before 26 weeks of gestation significantly improved the prognosis, significantly changing treatment paradigms. This article aims to provide a review of the changes and updates in spina bifida repair over the 10-year period following the MOMS Trial. Material and methods: We performed a systematic review in the PubMed and Cochrane databases as well as a hand-search of high-impact journals using the reference list of all identified articles, searching for randomized controlled trials and observational studies. Results: We identified 27 articles published between 2011 and 2021 that fulfilled the inclusion criteria and review them in the present study. Conclusions: With growing experience and with the improvement of prenatal open and fetoscopic techniques, the outcome of SB-associated conditions could be improved and the risks to both the mother and the fetus reduced. A continuous follow-up of the treated infants and further randomized trials are essential to study the complications and advantages or disadvantages of any given treatment strategy.

Congenital heart disease (CHD) is the most common birth defect, with a reported prevalence of 5–12 per 1000 live births. Very recently, the American Institute of Ultrasound in Medicine published a guideline recommending the use of the four-chamber and the three-vessel and trachea views to screen for CHD in the first trimester of pregnancy. Our aim is to present abnormal image patterns that are seen in the four-chamber, three-vessel, and trachea views of the fetal heart in the first trimester and to describe their association with specific CHD types. We used a total of 29 cases of CHD from the archives of Filantropia Hospital and the Maternal and Child Health Institute (INSMC) fetal medicine units. We selected cases with a clear and well-documented diagnosis of the CHD type. We identified a series of repeating color doppler flow patterns seen in the four-chamber, three-vessel, and trachea views of the studied cases. Our observations could be developed into a diagnosis algorithm to orientate the examiner to the most likely type of CHD in individual cases.

Background: The COVID-19 pandemic has meant significant precautions and changes in delivering healthcare services. The aim of the study was to explore the lifestyle changes of pregnant women during the COVID-19 pandemic in Romania, the changes in prenatal care and delivery during the pandemic and the psychological impact on women and to determine how healthcare providers can help them to overcome this period. Methods: A cross-sectional survey was conducted anonymously and distributed among pregnancy-related groups from Romania, recruiting 559 study participants, between May and October 2020. A total of 559 pregnant women completed an online 26-item questionnaire but we only validated 557 responses for study. The survey included basic demographic questions, pregnancy-related questions, questions regarding the pregnant women’s lifestyle changes during the pandemic and their perception of the COVID-19 pandemic and questions which evaluated the impact of the pandemic on prenatal care and delivery in Romania. Results: The pandemic restrictions affected women’s routine activities regarding professional, familial and social life. Therefore, for pregnant women who were emotionally vulnerable, these restrictions had a great impact on their mental health. The majority of the study participants (78.8%, N = 439) were emotionally affected by the pandemic. The fear related to the possibility of having their pregnancy affected by the virus was dominant in the group (45.8%). A high number of women (69.5%) felt safe when they accessed health services, but private hospitals were considered safer (53.1%) compared to public hospitals (14.4%). The majority of participants (53.7%) used to have prenatal care in a private healthcare system. During the pandemic, preventive measures were associated with low confidence in the healthcare system. Of the total group of participants, 123 women (22.1%) gave birth during the pandemic. Of these, a majority of the study participants considered that it was very difficult for them to cope without their partner during the hospitalization and labor period. Conclusions: The main anxiety of pregnant women were related to threats to their lives and their baby’s health because of the uncertainty caused by pandemic. It is important to know that the restrictions and the changes in maternity care had a negative impact on them. This conclusion must be taken into account when preventive measures will be decided for helping them to get through such a period. Additionally, psychological support will be essential for improving the mental health of pregnant women and for preventing a negative outcome of the pregnancy. These feelings must be taken into account when preventive measures will be established during pandemic and a psychological support will be essential for improving their mental health for preventing negative outcome of pregnancy.

Heterotopic pregnancy is the condition where both intrauterine and ectopic pregnancy are present. It rarely occurs after natural conception, but is more common with assisted reproductive techniques, when more than one embryo is transferred. Quadruplet heterotopic pregnancy is exceedingly rare. Methods: A literature review was conducted aiming to highlight the diagnosis difficulties and the management options in heterotopic quadruplet pregnancies. Results: Nine relevant studies were identified by researching PubMed up to 2021 for “heterotopic quadruplet pregnancy”, “quadruplet intrauterine and ectopic pregnancy”, “synchronous intrauterine and ectopic pregnancy”. Conclusions: In this paper, we present a case of heterotopic quadruplet pregnancy and address the difficulty in diagnosing this condition and make formal recommendations.

Meningiomas are common primary tumors of the central nervous system. The incidence at the age of fertility is low, although there are some hormonal mechanisms involved. Growth in size was observed during the luteal phase of the menstrual cycle, which could lead to developing new symptoms during pregnancy or worsening of the already existing ones. Visual impairment is the chief complaint, followed by headache, nausea, vomiting, and seizures. Diagnosis is based on neurological examination, ophthalmoscopy, imaging techniques like gadolinium-enhanced magnetic resonance imaging (MRI), and contrast-enhanced computed tomography (CT) scans, bearing in mind the patient’s irradiation and prejudice on the fetus together with the histopathological examination. The objective of the review is to determine the influence of meningioma on pregnancy and vice-versa and provide a strategy of follow-up for maternal-fetal specialists and not only. We performed a systematic review by searching relevant information in PubMed and Wiley databases using keywords as meningioma, pregnancy, progesterone receptors. The results showed that besides a similar incidence of meningioma in pregnant and non-pregnant women, symptoms might flare during pregnancy due to water retention, engorgement of vessels, and the presence of sex hormone receptors on tumor cells. Meningioma may impact the route of pregnancy with adverse effects on the fetus. Thus, fetal monitoring by biophysical profile and cardiotocography (CTG) is needed. The preferred treatment option is surgery, but gestational age and the woman’s status must be taken into consideration.

Monochorionic monoamniotic pregnancy are considered high risk gestations and the fetal outcome is at times unpredictable. Correct diagnosis and counselling are extremely important, especially regarding the risk of unexpected fetal demise. We present the rare case of a monochorionic monoamniotic twin pregnancy with early identification of cord entanglement and the characteristic ultrasound findings in the first trimester of pregnancy.

Cornelia de Lange syndrome (CDLS) is caused by pathogenic variants in genes which are structural or regulatory components of the cohesin complex. The classical Cornelia de Lange (CDLS) phenotype is characterized by distinctive facial features, growth retardation, upper limb reduction defects, hirsutism, and developmental delay. Non-classical phenotypes make this condition heterogeneous. Although CDLS is a heterogeneous clinical and genetic condition, clear diagnostic criteria have been described by specialist consensus. Many of these criteria refer to features that can be seen on prenatal ultrasound. The aim of this paper is twofold: to present the ultrasound findings in fetuses affected by CDLS syndrome; to discuss the recent advances and the limitations in the ultrasound and genetic prenatal diagnosis of CDLS. Our review aims to offer, apart from the data needed to understand the genetics and the prenatal presentation of the disease, a joint perspective of the two specialists involved in the prenatal management of this pathology: the fetal medicine specialist and the geneticist. To better illustrate the data presented, we also include a representative clinical case.

There is a growing consensus that the antioxidant and anti-inflammatory properties of melatonin are of great importance in preserving the body functions and homeostasis, with great impact in the peripartum period and adult life. Melatonin promotes adaptation through allostasis and stands out as an endogenous, dietary, and therapeutic molecule with important health benefits. The anti-inflammatory and antioxidant effects of melatonin are intertwined and are exerted throughout pregnancy and later during development and aging. Melatonin supplementation during pregnancy can reduce ischemia-induced oxidative damage in the fetal brain, increase offspring survival in inflammatory states, and reduce blood pressure in the adult offspring. In adulthood, disturbances in melatonin production negatively impact the progression of cardiovascular risk factors and promote cardiovascular and neurodegenerative diseases. The most studied cardiovascular effects of melatonin are linked to hypertension and myocardial ischemia/reperfusion injury, while the most promising ones are linked to regaining control of metabolic syndrome components. In addition, there might be an emerging role for melatonin as an adjuvant in treating coronavirus disease 2019 (COVID 19). The present review summarizes and comments on important data regarding the roles exerted by melatonin in homeostasis and oxidative stress and inflammation related pathologies.

The presence of maternal Anti-Ro/Anti-La antibodies causes a passively acquired autoimmunity that may be associated with serious fetal complications. The classic example is the autoimmune-mediated congenital heart block (CHB) which is due in most cases to the transplacental passage of Anti-Ro/Anti-La antibodies. The exact mechanisms through which these pathologic events arise are linked to disturbances in calcium channels function, impairment of calcium homeostasis and ultimately apoptosis, inflammation and fibrosis. CHB still represents a challenging diagnosis and a source of debate regarding the best management. As the third-degree block is usually irreversible, the best strategy is risk awareness and prevention. Although CHB is a rare occurrence, it affects one in 20,000 live births, with a high overall mortality rate (up to 20%, with 70% of in utero deaths). There is also concern over the lifelong consequences, as most babies need a pacemaker. This review aims to offer, apart from the data needed for a better understanding of the issue at hand, a broader perspective of the specialists directly involved in managing this pathology: the rheumatologist, the maternal–fetal specialist and the cardiologist. To better illustrate the theoretical facts presented, we also include a representative clinical case.

Background: Citicoline represents a dietary source of choline, an essential nutrient, and precursor of cell membrane components, highly required during development and post-injury recovery. Objectives: We previously showed that perinatal asphyxia (PA) induces hippocampal neuroinflammation and injury that are subject to epigenetic change by maternal diet. The present study investigates maternal citicoline-supplemented diet (CSD) impact on offspring hippocampal response to PA. Methods: Six-day-old Wistar rats from mothers with standard-diet or CSD were exposed to PA. The hippocampal inflammation and injury were assessed by interleukin-1 beta (IL-1b), tumor necrosis factor-alpha (TNFα), and S-100B protein (S-100B), 24–48 h post-asphyxia. The microRNAs species miR124, miR132, miR134, miR146, and miR15a were measured from the hippocampus 24 h post-asphyxia, to investigate its epigenetic response to PA and maternal diet. At maturity, the offspring’s behavior was analyzed using open field (OFT), T-maze (TMT), and forced swimming (FST) tests. Results: Our data show that the maternal CSD decreased IL-1b (p = 0.02), TNFα (p = 0.007), and S100B (p = 0.01) at 24 h postexposure, upregulated miR124 (p = 0.03), downregulated miR132 (p = 0.002) and miR134 (p = 0.001), shortened the immobility period in FST (p = 0.01), and increased the percentage of passed trials in TMT (p = 0.01) compared to standard-diet. Conclusions: Maternal CSD reduces hippocampal inflammation and S100B level, triggers epigenetic changes related to homeostatic synaptic plasticity, memory formation, and neuronal tolerance to asphyxia, decreases the depressive-like behavior, and improves the lucrative memory in offspring subjected to PA. Thus, citicoline could be valuable as a maternal dietary strategy in improving the brain response to PA.

Context Oxytocin has been investigated as a potential medication for psychiatric disorders. Objective and design This study prospectively investigates correlations between oxytocin and other neuropeptides plasma levels in patients with autism spectrum disorders (ASD) according to severity and treatment, as compared to controls. Subjects and methods Thirty-one children (6 neurotypical as control) participated in this study. The patients were classified into mildly and severely-affected, according to Autism Diagnostic Observation Schedule (ADOS) scores. Oxytocin, orexin A and B, α-MSH, β-endorphins, neurotensin and substance P were investigated using a quantitative multiplex assay or a competitive-ELISA method. Results Plasma oxytocin levels differed between the groups (F (2, 24) =6.48, p=0.006, η2=0.35, observed power=86%): patients with the mild ASD had higher values of plasma oxytocin than those with the severe form (average difference=74.56±20.74pg/mL, p=0.004). Conclusions These results show a negative correlation between plasma levels of oxytocin and the severity of ASD and support the involvement of oxytocinergic mechanisms in ASD.

Perinatal asphyxia (PA) is a burdening pathology with high short-term mortality and severe long-term consequences. Its incidence, reaching as high as 10 cases per 1000 live births in the less developed countries, prompts the need for better awareness and prevention of cases at risk, together with management by easily applicable protocols. PA acts first and foremost on the nervous tissue, but also on the heart, by hypoxia and subsequent ischemia-reperfusion injury. Myocardial development at birth is still incomplete and cannot adequately respond to this aggression. Cardiac dysfunction, including low ventricular output, bradycardia, and pulmonary hypertension, complicates the already compromised circulatory status of the newborn with PA. Multiorgan and especially cardiovascular failure seem to play a crucial role in the secondary phase of hypoxic-ischemic encephalopathy (HIE) and its high mortality rate. Hypothermia is an acceptable solution for HIE, but there is a fragile equilibrium between therapeutic gain and cardiovascular instability. A profound understanding of the underlying mechanisms of the nervous and cardiovascular systems and a close collaboration between the bench and bedside specialists in these domains is compulsory. More resources need to be directed toward the prevention of PA and the consecutive decrease of cardiovascular dysfunction. Not much can be done in case of an unexpected acute event that produces PA, where recognition and prompt delivery are the key factors for a positive clinical result. However, the situation is different for high-risk pregnancies or circumstances that make the fetus more vulnerable to asphyxia. Improving the outcome in these cases is possible through careful monitoring, identifying the high-risk pregnancies, and the implementation of novel prenatal strategies. Also, apart from adequately supporting the heart through the acute episode, there is a need for protocols for long-term cardiovascular follow-up. This will increase our recognition of any lasting myocardial damage and will enhance our perspective on the real impact of PA. The goal of this article is to review data on the cardiovascular consequences of PA, in the context of an immature cardiovascular system, discuss the potential contribution of cardiovascular impairment on short and long-term outcomes, and propose further directions of research in this field.

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.

Key Clinical Message In the presence of megacystis in the second half of pregnancy, with increased amniotic fluid, especially in a female fetus, the most likely diagnostic result is megacystis, microcolon, intestinal hypoperistalsis syndrome, MMIHS. In these cases, the diagnosis of MMIHS should be strongly considered instead of lower urinary tract obstruction.

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.

During gestation, the maternal body should increase its activity to fulfil the demands of the developing fetus as pregnancy progresses. Each maternal organ adapts in a unique manner and at a different time during pregnancy. In an organ or system that was already vulnerable before pregnancy, the burden of pregnancy can trigger overt clinical manifestations. After delivery, symptoms usually reside; however, in time, because of the age-related metabolic and pro-atherogenic changes, they reappear. Therefore, it is believed that pregnancy acts as a medical stress test for mothers. Pregnancy complications such as gestational hypertension, preeclampsia and gestational diabetes mellitus foreshadow cardiovascular disease and/or diabetes later in life. Affected women are encouraged to modify their lifestyle after birth by adjusting their diet and exercise habits. Blood pressure and plasmatic glucose level checking are recommended so that early therapeutic intervention can reduce long-term morbidity. Currently, the knowledge of the long-term consequences in women who have had pregnancy-related syndromes is still incomplete. A past obstetric history may, however, be useful in determining the risk of diseases later in life and allow timely intervention.

Fetal goitre is found in about 1 in 5,000 births, usually in association with maternal Graves’ disease, due to transplacental passage of high levels of thyroid stimulating antibodies or of anti-thyroid drugs. A goitre can cause complications attributable to its size and to the associated thyroid dysfunction. Fetal ultrasound examination allows easy recognition of the goitre but is not reliable in distinguishing between fetal hypo- and hyperthyroidism. Assessment of the maternal condition and, in some cases, cordocentesis provide adequate diagnosis of the fetal thyroid function. First-line treatment consists of adjusting the dose of maternal anti-thyroid drugs. Delivery is aimed at term. In cases with large goitres, caesarean-section is indicated.