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Objective: To study whether knowledge of cervical length (CL) is useful in reducing the length of hospital stay in women admitted because of threatened preterm labor. Methods: We performed a single-center, parallel, randomized trial at the Hospital Clínic of Barcelona. Inclusion criteria were single pregnancy, gestational age (GA) between 24+0 and 35+6 weeks, Bishop score 25 mm, early discharge within 12-24 h from randomization was recommended. Length of hospital stay was the main outcome. Results: After randomization, 149 patients had complete follow-up (control group, n = 74; study group, n = 75). The mean (SD) length of stay was significantly shorter - 3.0 (2.2) vs. 4.0 (2.0) days (p = 0.004) - in the study group, with a higher proportion of women remaining hospitalized ≤3 days (relative risk [95% confidence interval] 0.43 [0.26-0.70]), with no differences in GA at delivery or preterm birth rate. Conclusions: Knowledge of CL in women admitted because of threatened preterm labor is useful in reducing length of stay, with no impact on GA at delivery or preterm birth rate.

The menstrual cycle is a finely tuned biological process comprising a precisely orchestrated sequence of events: follicular growth, selection and ovulation, extensive endometrial changes, corpus luteum (CL) growth and maturation, and luteolysis. Differences in the length of the menstrual cycle (MCL) have been associated with variable female fecundity. However, the reason for these differences is so far unknown. The donor-recipient model, separating uterine from ovarian factors, allows clarifying the origin of MCL-associated fecundity variations.We analyzed retrospectively 2015 oocyte donation cycles, resulting in 3427 embryo transfers (ET) and pregnancy follow-up.Surprisingly, we found that oocyte donors MCL of 34-35 days were strongly associated with significantly higher biochemical, clinical and ongoing pregnancy rates in woman who received the embryos, compared to the reference group of MCL of 27-29 days. Moreover, donors with longer MCL presented higher ovarian response to stimulation and lower amount of hormonal stimulation needed to achieve multifollicular growth. Conversely, MCL of25 days were associated with a poorer ovarian response to stimulation, less cumulus oocyte complexes (COCs) and less mature oocytes (MII) retrieved; however, the quality of oocytes in these women is not associated to their ovarian response, as evidenced by the pregnancy rates obtained when transferred into an adequately prepared endometrium.We conclude that oocyte quality, rather than natural endometrial preparation, is the main reason for the reported higher fecundity of women with longer MCL. This result is further confirmed by our data on bleeding length in the donor pool. Response to ovarian stimulation is the definitive test of ovarian reserve; moreover, since different MCLs result from varying length of the follicular phase, longer MCL should be associated with a higher number of follicular recruitment events. We hypothesize that MCL is associated with - and a marker of - ovarian reserve in healthy reproductive age women.

The risk of transmission of human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C virus (HCV) during invasive procedures may not be negligible, although it has been poorly assessed. The risk of hepatitis B transmission during amniocentesis seems to be low, but it may be increased in women with a positive HBeAg. HCV transmission risk cannot be established because evidence is lacking. No information exists about other invasive procedures in such infections. An increased risk of vertical transmission following an invasive procedure was suggested in HIV infection, but amniocentesis seems to be safe when performed under highly active antiretroviral treatment, with a low viral load and when avoiding placental passage. International guidelines do not clearly define policies to screen for maternal blood-borne virus infection during invasive procedures. Nevertheless, serological status should be assessed in all cases and parents should be aware of the existing evidence for transmission risk. Transplacental amniocentesis should always be avoided.

Congenital cytomegalovirus (CMV) infection occurs in 0.6–0.7% of all newborns and is the most prevalent infection-related cause of congenital neurological handicap. Vertical transmission occurs in around 30% of cases, but the fetus is not always affected. Symptomatic newborns at birth have a much higher risk of suffering severe neurological sequelae. Detection of specific IgG and IgM and IgG avidity seem to be the most reliable tests to identify a primary infection but interpretation in a clinical context may be difficult. If a seroconversion is documented or a fetal infection is suspected by ultrasound markers, an amniocentesis should be performed to confirm a vertical transmission. In the absence of a confirmed fetal infection with fetal structural anomalies, a pregnancy termination should be discouraged. Fetal prognosis is mainly correlated to the presence of brain damage. Despite promising results with the use of antiviral drugs and CMV hyperimmune globulin (HIG), results have to be interpreted with caution. Pregnant women should not be systematically tested for CMV during pregnancy. Managing CMV screening should be restricted to pregnancies where a primary infection is suspected or among women at high risk. The magnitude of congenital CMV disease and the value of interventions to prevent its transmission or to decrease the sequelae need to be established before implementing public health interventions. In this paper, aspects of CMV infection in the pregnant woman and her infant are reviewed.

In this retrospective, matched study we evaluated the outcome of 31 oocyte donation (OD) cycles performed in 29 Turner syndrome (TS) patients involving the elective transfer of a single, fresh cleavage-stage (day 2 to 3) embryo. Due to the fact that ongoing pregnancy rate was statistically significantly lower (3.2% versus 22.5%) in TS patients when compared with matched, non-TS recipients, other strategies (such as single blastocyst transfer) should be evaluated that could enable better outcomes and at the same time avoid potential complications related to multiple pregnancies in this particularly high obstetric-risk group.

Aim: To construct a predictive model for respiratory distress syndrome (RDS) from gestational age (GA) at delivery and TDx-FLM II value. Methods: Pregnant women who underwent an amniocentesis in which TDx-FLM II was determined were included in the study. A model for the occurrence of RDS was constructed by means of a logistic regression procedure from TDx-FLM II values and GA at delivery. Results: The mean value of TDx-FLM II was 47.11 mg/g. The mean GA at delivery was 33.4 weeks. The incidence of RDS was 7.8% (18/231). The optimal cutoff of predicted risk for respiratory distress was found to be 8.8%, resulting in a sensitivity and specificity of 89 and 83%, respectively. Conclusions: The adjustment of the TDx-FLM II value for GA at delivery results in a significant improvement in the predictive capacity of the test for the occurrence of RDS. The use of GA-specific cutoff values may simplify clinical decisions.

Objective To analyze prognostic factors that are associated with a discordant outcome in egg recipients sharing oocytes from the same donor. Design Matched case-control single-center study. Setting Private infertility clinic. Patient(s) Four hundred forty-four recipients (222 pairs) sharing oocytes from the same donor and showing a discordant outcome. Intervention(s) Controlled ovarian hyperstimulation of egg donors, oocyte donation, intracytoplasmic sperm injection, and ET in egg recipients. Main Outcome Measure(s) Recipient age, obstetric (gravidity, parity) and gynecologic variables (previous uterine surgery, uterine fibroids, uterine malformations, endometriosis, history of tubal infertility), previous oocyte donation cycles, duration of E 2 replacement, received cumulus-oocyte complexes, mature (MII) oocytes, fertilized oocytes, transferred embryos, mean embryo score, transfer difficulty, and semen parameters. Result(s) No significant differences were found in the above-mentioned prognostic factors between the study and control groups. Conclusion(s) Recipient- and cycle-related prognostic factors investigated in our study were not associated with a discordant outcome in recipient pairs sharing oocytes from the same donor. Other possible prognostic factors involving oocyte donor heterogeneity, embryo aneuploidy rates, male factor infertility, and endometrial receptivity should be further investigated.

INTRODUCTION: Information is scarce regarding the outcome of oocyte donation (OD) in patients with a history of cancer treatment. Therefore, we conducted a matched controlled analysis on the outcome of OD in these recipients. METHODS: Between January 2000 and November 2005, 33 patients with a history of chemotherapy and/or radiotherapy had an OD cycle. Matching was performed to the chronologically closest patient without a history of cancer therapy by number of days of hormonal stimulation before embryo replacement, number of replaced embryos, day of embryo transfer and origin of sperm. RESULTS: The primary diseases of the patients were Hodgkin’s lymphoma (n 5 12), non-Hodgkin’s lymphoma (n 5 3), leukaemia (n 5 7), ovarian cancer (n 5 6), Ewing’s sarcoma (n 5 2), breast cancer (n 5 1), sympathoblastoma (n 5 1) and histiocytosis X (n 5 1). Twentythree patients had undergone chemotherapy and radiotherapy, nine patients chemotherapy only and one radiotherapy only. The mean age of the recipients was 33.1 years [95% confidence interval (CI) 30.9–35.3] and 39.6 (95% CI 37.1–42.1) in the study and control groups, respectively. The average number of received oocytes and transferred embryos, was similar in both groups. Nineteen (57.6%) versus 13 (39.4%) pregnancies resulting in an ongoing pregnancy (i.e. viable at 12 weeks) in 15 (45.4%) versus 9 cycles (27.3%) (NS) were obtained in study and control groups, respectively. Implantation rate in study and control groups was 35.8 versus 17.9%, respectively (P 5 0.02). CONCLUSIONS: The results suggest that patients with a history of cancer treatment have a pregnancy rate after OD similar to that in the general population of oocyte recipients.

Objective: Fetal growth restriction is associated with adverse perinatal outcome but is often not recognised antenatally, and low birthweight centiles based on population norms are used as a proxy instead. This study compared the association between neonatal morbidity and fetal growth status at birth as determined by customised birthweight centiles and currently used centiles based on population standards. Design: Retrospective cohort study. Setting: Referral hospital, Barcelona, Spain. Patients: A cohort of 13 661 non-malformed singleton deliveries. Interventions: Both population-based and customised standards for birth weight were applied to the study cohort. Customised weight centiles were calculated by adjusting for maternal height, booking weight, parity, ethnic origin, gestational age at delivery and fetal sex. Main outcome measures: Newborn morbidity and perinatal death. Results: The association between smallness for gestational age (SGA) and perinatal morbidity was stronger when birthweight limits were customised, and resulted in an additional 4.1% (n = 565) neonates being classified as SGA. Compared with non-SGA neonates, this newly identified group had an increased risk of perinatal mortality (OR 3.2; 95% CI 1.6 to 6.2), neurological morbidity (OR 3.2; 95% CI 1.7 to 6.1) and non-neurological morbidity (OR 8; 95% CI 4.8 to 13.6). Conclusion: Customised standards improve the prediction of adverse neonatal outcome. The association between SGA and adverse outcome is independent of the gestational age at delivery.

The objective of the study was to assess the fertility of non-infertile couples seeking pregnancy in whom the woman was HIV infected. Therefore, a cross-sectional study was conducted between January 1998 and March 2005. A standardized fertility assessment was performed in all the included couples. A total of 130 women and 121 men were evaluated. Their median age was 34 years (range 22-43). Only 7.2% of the women were severely immunocompromised. The majority of women had regular cycles. Only one woman had an active sexually transmitted disease at the time of evaluation. A tubal occlusion on hysterosalpingogram was present in 27.8% of the women with no proven fertility. In 50.5% of the women, hepatitis C virus co-infection was present. One-third of the male partners (38/121) was infected with HIV. Abnormal semen parameters were observed in 83.4% of HIV-infected and 41.7% of HIV-uninfected partners (OR = 7; 95% CI = 2.1-23). It is concluded that the great majority of the HIV-infected women seeking pregnancy had a good infection status. Because in many of the couples, the women presented unexplained tubal occlusions and the men presented semen alterations, a hysterosalpingography and semen analysis should be part of the preconceptional investigations.

Objective To assess the amniopatch procedure when premature rupture of membranes occurs after first-trimester chorionic villus sampling (CVS). Study Design From May 2001 to June 2004, the amniopatch procedure was offered in cases of premature rupture of membranes after CVS when severe oligohydramnios was present (largest vertical pocket < 2 cm) and persistent (more than 1 week). Results The amniopatch was placed in five pregnancies at 12–18 weeks of gestation, resulting in amniotic fluid restoration in all but one pregnancy. In three pregnancies, fetal demise was observed at 1, 2 and 36 days after the procedure. The last procedure resulted in a healthy newborn. Conclusion Although the amniopatch restored normal amniotic fluid levels in all cases, 4 of the 5 cases resulted in fetal demise. Copyright © 2007 John Wiley & Sons, Ltd.

Objectives To compare the efficacy of nifedipine and ritodrine in prolonging pregnancy beyond 48 h, 1 week and 36.0 weeks and to evaluate maternal side effects and adverse perinatal outcome. Study design Non-blinded, randomized controlled trial. Eighty patients with singleton pregnancies admitted for preterm labor with intact membranes between 22 and 35 weeks of gestation were included in the study. Preterm labor was defined as the persistence of at least two symptomatic uterine contractions within a 10 min period during 60 min after admission and despite bed rest. Results Forty women received oral nifedipine and forty intravenous ritodrine. Two patients, one from each group, were excluded because of loss to follow-up after discharge. Therefore, 39 women in the nifedipine and the ritodrine groups, respectively, were evaluable for the final analysis. Baseline characteristics were comparable in both groups. The percentage of initial response, the speed of onset of action and the rate of successful treatment within 48 h were significantly better in the ritodrine group. However, prolongation of pregnancy beyond 7 days and 36 weeks of pregnancy was similar with a significantly lower rate of side effects in the nifedipine group. Conclusions In this small trial, ritodrine provided more effective tocolysis within the first 48 h than nifedipine at the doses used in this study, although with a significantly higher rate of side effects.

Objective This study was undertaken to describe a new prenatal diagnosis program among human immunodeficiency virus (HIV)-infected women, and the perinatal outcome of this program's application over a more than 2-year period. Study design From June 2000 to December 2003, all HIV-infected women who were booked into the antenatal clinic before 20 weeks were offered a screening for chromosomal anomalies, with midtrimester amniocentesis in the tests that were positive. Results A total of 116 pregnancies (including 3 sets of twins) were seen: 96 women were offered and accepted screening for chromosomal anomalies. Thirteen pregnancies had a positive screening test and amniocentesis was performed in 10 at median 16.5 gestational weeks: a trisomy 21 and a monosomy X were diagnosed. No vertical transmissions were documented by age 6 months in the 6 liveborn infants who underwent amniocentesis. Conclusion A program of prenatal diagnosis for chromosomal anomalies appears to be effective when applied to HIV-infected women, although safety remains to be proven.

Resumen Objetivo Evaluar la eficacia y seguridad del intento de version externa a termino. Material y metodos Entre enero de 2001 y marzo de 2004 se han recogido los resultados perinatales de las gestantes remitidas a la unidad de bienestar fetal para version externa, procedentes del dispensario de obstetricia. Los criterios de inclusion para el intento de version externa fueron: a) presentacion no cefalica; b) edad gestacional entre las 36 y 38 semanas; c) indice de liquido amniotico ≥ 8 cm; d) indice cerebroplacentario superior al percentil 5; e) patron cardiotocografico reactivo, y f) ausencia de contraindicaciones para el parto vaginal. Como grupo control se ha incluido a las gestantes remitidas para intento de version que en el momento de la inclusion tenian una presentacion cefalica. Resultados Se remitio a 246 gestantes, de las que un 72% (178/246) cumplia los criterios de inclusion y eran elegibles, de las cuales 5 no aceptaron el procedimiento, finalmente se incluyeron 173 casos. De los casos incluidos, un 56% (97/173) fueron versionadas a cefalica con exito, mientras que en un 44% (76/173) no se consiguio la version. La tasa de cesarea en las 173 gestantes incluidas fue del 42% (73/173): un 8,2% (8/97) en las versionadas y un 85,5% (65/76) en las que no se consiguio versionar. En el grupo control la tasa de cesarea fue del 11,5% (6/52). No se observaron diferencias significativas en la puntuacion de Apgar al minuto (8,5 frente a 8,7), a los 5 min (9,8 frente a 9,9) ni en el pH arterial al nacimiento (7,24 frente a 7,21) entre las gestantes aceptadas para intento de version y el grupo control de versiones espontaneas. Conclusiones El intento de version externa a termino parece ser una tecnica eficaz y segura.

Resumen Objetivo Describir los resultados perinatales de las gestaciones con rotura prematura de membranes (RPM) antes de la semana 24 de gestacion. Pacientes y metodos Se incluyo a 50 pacientes consecutivas con RPM antes de las 24 semanas de gestacion. Despues de 1 semana de ingreso, se ofrecio la realizacion de amniopatch a las pacientes con columna maxima de liquido amniotico (Cmax) Resultados La edad gestacional (EG) media ± desviacion estandar (DE) en el momento de la amniorrexis fue de 18,2 ± 3,6 semanas. En 13 (26%) ocasiones se realizo un amniopatch. De los 50 casos, 15 pacientes optaron finalmente por una interrupcion legal del embarazo (ILE) y en 35 casos se adopto finalmente una conducta expectante. De los 35 casos que decidieron continuar la gestacion, 12 (34,3%) pacientes presentaron un fallecimiento intrautero o un parto previo a la viabilidad (antes de la semana 24); en 4 (11,4%) casos hubo una muerte anteparto despues de la semana 24 y 4 (11,4%) presentaron una muerte posparto. El lapso de tiempo entre la RPM y el parto mostro una relacion inversa y significativa con la EG de la amniorrexis. Presentaron hipoplasia pulmonar 4 (11,4%) neonatos y en 8 (22,9%) casos hubo una corioamnionitis clinica. Un neonato (2,9%) presento una luxacion congenita de rodilla. Conclusiones Las gestaciones complicadas con RPM antes de las 24 semanas de gestacion presentan un 42,9% de supervivencia con una mortalidad neonatal del 57,1%. Sin embargo, para las gestaciones que superan las 24 semanas de gestacion, la supervivencia mejora notablemente y en nuestra serie se situa en un 65,2%.

Resumen El citomegalovirus (CMV) produce la infeccion congenita mas frecuente (alrededor del 1% de las gestaciones) con una significativa afeccion y secuelas fetales. En ausencia de cribado serologico sistematico, el diagnostico de infeccion fetal suele hacerse a partir de una ecografia habitual, que revela anomalias ecograficas indicativas de tal afeccion. En el caso que se presenta las anomalies aparecieron de forma progresiva, inicialmente una hiperecogenicidad intestinal con oligoamnios en la semana 17 y, posteriormente, ventriculomegalia, hepatomegalia y ascitis en la semana 21, cuando se realizo el diagnostico de la infeccion mediante estudio de la reaccion en cadena de la polimerasa (PCR) en el liquido amniotico.

Resumen Objetivo El objetivo del presente estudio es construir unas curvas de normalidad de la altura uterina (AU) con criterios metodologicos estrictos y evaluar la eficacia diagnostica de su uso en la practica clinica. Sujetos y metodos Entre julio de 2003 y enero de 2004, se seleccionaron de manera aleatoria 16 gestantes para cada semana de edad gestacional (EG) entre las 24 y 42 semanas (un total de 304 gestaciones), en las que se midio la AU de forma estandarizada. Se modelo la media de la medida de la AU para la EG y se construyeron los intervalos de normalidad. Para estudiar el valor diagnostico de la medida de la AU se diseno un estudio retrospectivo de casos y controles. Se considero caso a todos los fetos nacidos en nuestro centro en el ano 2002, con un peso neonatal inferior al percentil 10 para su EG. Como control se eligio el parto inmediatamente posterior a cada caso con un peso neonatal dentro de los limites de normalidad. Mediante un analisis de curvas ROC se selecciono el percentil de corte que optimizaba la sensibilidad y especificidad para la deteccion de peso neonatal inferior al percentil 10. Resultados El modelo matematico seleccionado para ajustar la relacion entre la EG y la AU fue lineal (8,96 + 0,68 EG), con un coeficiente de determinacion (R 2 ) de 0,67, es decir, el modelo explica un 67% de la variabilidad de la AU. Para el estudio de casos y controles se identificaron 135 gestaciones con peso neonatal inferior al percentil 10 de normalidad. El analisis mediante curvas ROC de la variable estandarizada AU para la deteccion de un peso neonatal inferior al percentil 10 mostro como el punto de corte que optimizaba la sensibilidad y la especificidad fue el percentil 10 (el 29 y el 96%, respectivamente). Conclusion El uso clinico de curvas de normalidad de la AU de la poblacion propia puede mejorar la deteccion prenatal de fetos pequenos para su EG y podria permitir mejorar los resultados perinatales.

Objective To compare the reliability of Doppler blood flow measurements of the fetal aortic isthmus (AoI) according to whether the sampling plane is obtained from the traditional longitudinal aortic arch (LAA) view or the more recently described three vessels and trachea (3VT) view of the fetal upper mediastinum. Methods Doppler blood flow measurements of pulsatility index (PI), resistance index (RI), peak systolic (PSV), end-diastolic (EDV) and time-averaged maximum (TAMXV) velocities were performed in the AoI of 40 fetuses between 24 and 36 weeks of gestation. All measurements were sampled in two different sonographic planes of the AoI: the LAA view, at a few millimeters beyond the origin of the left subclavian artery, and the 3VT view, just before the V-shaped junction of the aortic and ductal arches. All scans were performed by the same observer. The reliability of Doppler blood flow measurements was assessed by calculating intraclass correlation coefficients (ICCs) and limits of agreement between the two different sonographic sites evaluating the AoI. Results Mean values of PI, RI, PSV, EDV and TAMXV were similar in the LAA and 3VT views. The PI and vascular velocities were reliably measured from both sonographic sites. ICCs for variability of measurements were 0.78, 0.63, 0.63, 0.60 and 0.55 for PI, RI, PSV, EDV and TAMXV, respectively. Limits of agreement revealed minimal disagreement between the two sites of evaluation of the AoI for all measurements. Conclusions On the basis of our observations, Doppler blood flow measurements across the fetal AoI can be reliably obtained from both the 3VT and the traditional LAA sonographic views. Since the transverse upper thoracic 3VT plane is achievable in most fetal positions, Doppler study of the AoI appears to be easier than expected. Copyright © 2005 ISUOG. Published by John Wiley & Sons, Ltd.

Resumen Objetivo Evaluar el impacto que tiene en la estancia hospitalaria la utilizacion de la longitud cervical ecografica en pacientes ingresadas por amenaza de parto pretermino. Material y metodos Estudio prospectivo longitudinal que incluyo una muestra de pacientes ingresadas por amenaza de parto pretermino en 2 unidades de hospitalizacion. En la unidad 1 las pacientes fueron tratadas segun el protocolo habitual, basado en el indice de Bishop y la constatacion de la presencia de dinamica uterina en la monitorizacion. En la unidad 2 se modifico el protocolo de actuacion en funcion de la longitud cervical ecografica, optandose por el alta precoz en las pacientes con una longitud ecografica ≥ 25 mm. Se analizaron las caracteristicas de ambos grupos, la duracion media del ingreso y la tasa de parto antes de 7 dias, 34 y 37 semanas de gestacion en ambas unidades. Resultados Se incluyo en el estudio a un total de 138 pacientes. La tasa de parto antes de 7 dias, 34 y 37 semanas fue similar en las 2 unidades, asi como la incidencia de reingresos. Sin embargo, la estancia media hospitalaria se redujo significativamente en la unidad 2 (6,14 frente a 3,86 dias; p Conclusiones La introduccion de la longitud cervical ecografica en el manejo clinico de pacientes ingresadas por amenaza de parto pretermino puede hacer disminuir la estancia media hospitalaria sin aumentar la tasa de partos prematuros ni los reingresos hospitalarios.

Objective: To compare the efficacy of a combined regimen of misoprostol with vaginal misoprostol for early 2nd-trimester pregnancy termination. Methods: This is a prospective study that includes 79 pregnant women who requested legal termination of 2nd-trimester pregnancy between 13 and 22 weeks. Two regimens of misoprostol were used. Group 1: 400 µg of oral plus 400 µg vaginal misoprostol every 8 h (combined regimen) and group 2: 400 µg of vaginal misoprostol every 3 h up to a maximum of five doses (vaginal regimen). Results: The induction-to-abortion interval was significantly longer in group 1 (25.5 ± 24.45 h) than in group 2 (15 ± 7.14 h) (p = 0.016). The abortion rate within 24 h in group 1 was of 56.8 vs. 85.7% in group 2 (p = 0.006). The hazard rate for vaginal delivery within 24 h was found to be 2.277-fold greater in the group with the combined therapy once controlled for plausible confounders. Conclusions: Our study suggests that oral misoprostol combined with vaginal misoprostol does not reduce the induction-to-abortion interval compared to an exclusively vaginal route when used for early 2nd-trimester pregnancy termination.

Objective To evaluate the impact of ultrasound cervical length measurement on duration of hospital stay in patients admitted for threatened preterm labor. Study design This was a prospective, comparative study in 294 patients with threatened preterm labor in three hospitalization units (Units A, B and C). In the first phase of the study (observational), cervical length was measured by transvaginal ultrasound, but managing physicians were blinded to the results. In the second phase (interventional), physicians from Unit A remained blinded to cervical length information, but Units B and C incorporated these data into their clinical management protocols. Early discharge was contemplated if the cervix measured 25 mm or more on admission (Unit B) or no changes were observed over 48 h (Unit C). Duration of hospital stay and delivery rates within 7 days and before 37 weeks' gestation were recorded. Results Hospital stay was significantly reduced in Units B and C in the interventional phase, while no changes were observed in Unit A. Delivery rates within 7 days and before 37 weeks' gestation were similar in the three units during the two stages of the study. Conclusion Routine use of ultrasound cervical length assessment in patients admitted with threatened preterm labor may reduce the duration of hospital stay without increasing the rate of preterm births. These data should be confirmed by means of an appropriately designed randomized clinical trial. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Objective To construct normal ranges for umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI) and cerebroplacental ratio (CPR) in prolonged pregnancies according to strict methodological criteria using polynomial regression analysis. Methods This was a retrospective, cross-sectional observational study involving 140 women, 10 women for each gestational day between 287 and 300 days of gestation. Fetal Doppler parameters were assessed to construct normal reference ranges for UA PI and MCA PI. CPR was calculated as a ratio of MCA PI/UA PI. Results Mathematical modeling of the data demonstrated that the optimal fit was a linear polynomial one. Mean, 5th and 95th centiles were calculated for UA, MCA and CPR and centile curves from the regression analysis were constructed. Conclusions Reference ranges for UA PI, MCA PI and CPR in prolonged pregnancies have been constructed. MCA PI shows a wider range than previously reported in the literature. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Objectives To assess the value of middle cerebral artery Doppler indices obtained from different sampling sites in predicting umbilical cord gases at delivery in prolonged pregnancies. Methods This was a prospective study of consecutive pregnant women referred for prolonged-pregnancy surveillance. The predictive value of distal and proximal middle cerebral artery Doppler indices for cord blood gases was evaluated in women who delivered within 48 h of their last antenatal test using stepwise multiple regression. Results There was a significant linear correlation between proximal and distal middle cerebral artery pulsatility indices (R = 0.777; P < 0.0001), the mean values being 1.49 (SD, 0.45) and 1.56 (SD, 0.47), respectively. There was also a linear correlation between proximal and distal cerebroplacental ratios (R = 0.68; P < 0.0001), the mean values being 1.85 (SD, 1.96) and 1.92 (SD, 1.89), respectively. The stepwise multiple regression analysis for umbilical artery pH showed that once the distal middle cerebral artery pulsatility index was introduced into the model, the addition of any variable did not result in a significant improvement of the predictive capacity. The model showed a coefficient of determination (R2) of 0.079. There was a significant correlation between umbilical artery pO2 and both proximal middle cerebral artery pulsatility index (positive) and the occurrence of elective Cesarean section (negative). This model accounted for 21% of the variance (R2 = 0.21). No other variables added any significant prediction for pO2. Conclusions In post-term pregnancies the proximal middle cerebral artery pulsatility index significantly predicts umbilical artery pO2 at delivery but does not predict pH. There is a weak association between distal middle cerebral artery pulsatility index and pH but, as this only explains 8% of the variance, it is of little clinical value. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Objective To compare Doppler evaluation of the ductus venosus and contraction stress test (CST) in the prediction of adverse perinatal outcome in growth-restricted fetuses with evidence of hemodynamic redistribution and a non-reactive non-stress test (NST). Methods Data were collected from all singleton pregnancies seen in our Fetal Surveillance Unit who underwent antenatal monitoring for fetal growth restriction, non-reactive NST and arterial redistribution beyond 26 weeks of pregnancy. Patients were divided into four groups based on their CST and ductus venosus waveform results. Perinatal outcome was evaluated by means of four variables: the need for admission to the neonatal intensive care unit (NICU), need for neonatal intubation, an umbilical artery pH < 7.10 and significant neonatal morbidity. Outcome was compared among fetuses delivered within 3 days of their antenatal test. Logistic regression analysis was used to analyze the relation between predictive and outcome variables. Results Sixty-eight women met the inclusion criteria for the study. The positive predictive value of the CST was 45% for admission to the NICU, 13% for significant neonatal morbidity, 26% for need of neonatal intubation and 29% for umbilical artery pH < 7.10. The positive predictive values of abnormal ductus venosus waveform (ADVW) were 81.5%, 26%, 48% and 55%. Groups with ADVW showed significantly poorer neonatal outcome. No significant differences were observed when CST results were compared. Logistic regression analysis showed that both gestational age at delivery and ADVW significantly predict the occurrence of adverse perinatal outcome. Conclusion In growth-restricted fetuses with hemodynamic redistribution and a non-reassuring NST, Doppler assessment of the ductus venosus correlates with adverse perinatal outcome. In this clinical situation there is no benefit of CST in terms of prediction. Copyright © 2003 ISUOG. Published by John Wiley & Sons, Ltd.

Study question Is the drug used for final oocyte maturation a factor in determining the prevalence of empty follicle syndrome (EFS)? Summary answer The drug used for final oocyte maturation is not a factor in determining the prevalence of EFS among women unaffected by infertility. What is known already Despite satisfactory follicular stimulation and adequate follicular development, cases of EFS, i.e. failure to recover any cumulus oocyte complex, have been reported both with hCG and GnRH agonist triggering. No standard management protocol has been proposed so far. Study design, size, duration Retrospective analysis of oocyte donation cycles performed between August 2006 and April 2013 in a large private fertility centre. Participants/materials, setting, methods The analysis included 12 483 oocyte donation cycles of which 74 were EFS cycles. All cycles were triggered with either hCG or GnRH agonists. Main results and the role of chance There were no differences in the gonadotropic stimulation, pituitary suppression and triggering drug between cycles where oocytes were recovered successfully and EFS cycles. The total prevalence of EFS was 0.59%. Given the rarity of the syndrome, caution is advised when interpreting the analysis. Limitations, reasons for caution The main limitation of this study is its retrospective nature. Although this is the largest analysis of EFS in donors reported so far, its statistical power is limited because the syndrome has a low incidence. In some cycles of EFS from 2006 to 2007 there is a lack of hormone data. Wider implications of the findings Our findings may be generalized to oocyte donors and IVF patients younger than 35 years old, with cycles undergoing final maturation triggering with either hCG or GnRH agonists. The generalization cannot be extended to patients with an ovarian factor as the cause of their reproductive pathology. The theoretical aetiology of a temporary hypothalamic-pituitary hyposensitivity can explain the cycles where a rescue protocol with hCG has been successful. Study funding/competing interests This work was supported in part by funding from Fundacio EUGIN. The authors have no conflicts to declare. Trial registration number NA.

Objective To evaluate the effect of physician training in empathic skills on patients' satisfaction just after their first consultation in a private fertility clinic setting. Design Prospective study. Setting Private fertility clinic. Patient(s) Thirteen physicians were evaluated by 2,146 patients. Intervention(s) The empathic training of physicians was centered on emotional intelligence, communication elements, social styles and empathy, and practical workshops. After their first consultation with the physician, patients answered a self-rating questionnaire comprising five scales: information provided, dynamic of the visit, time dedicated, patient-physician interaction, and expertise. Main Outcome Measure(s) Patients' satisfaction scores after the empathic training of physicians. Result(s) For all five scales, the empathic training resulted in a significant change of the global scoring distribution with a shift toward higher scores. The intervention also resulted in a lower likelihood of low scoring (in the lower quartile) for all the items. Conclusion(s) Training in empathic skills of physicians resulted in higher patient satisfaction levels on the perceived information quality, communication skills, and time dedicated at first consultation for fertility treatment.

Objective To compare pregnancy and implantation rates with transvaginal (TV) versus transabdominal (TA) ultrasound-guided embryo transfer (ET). Design Randomized, clinical trial registered at clinicaltrials.gov (NCT 01137461). Setting Private, infertility clinic. Patient(s) Three-hundred thirty randomized recipients of donor oocytes. Intervention(s) Embryo transfer using TV (with empty bladder, using the Kitazato ET Long catheter) versus TA ultrasound guidance (with full bladder, using the echogenic Sure View Wallace catheter). Main Outcome Measure(s) Overall pregnancy, clinical pregnancy, implantation, and ongoing pregnancy rates. Duration and difficulty of ET. Patient-reported uterine cramping and discomfort, as evaluated by questionnaire. Result(s) No statistically significant differences were observed in clinical pregnancy 50.9% versus 49.4% (95% confidence interval of the difference: −9.2 to +12.2%), implantation 34.5% versus 31.4% (95% CI of the difference: −4 to +10.3%) between the TV and TA ultrasound-guided groups. Transfer difficulty (6% versus 4.2%) and uterine cramping (27.2% versus 18.3%) were not statistically significantly different between treatment groups. Total duration (154 ± 119 versus 85 ± 76 seconds) was statistically significantly higher in the TV ultrasound group. Light to moderate-severe discomfort related to bladder distension was reported by 63% of the patients in the TA ultrasound group. Conclusion(s) Transvaginal ultrasound-guided ET yielded similar success rates compared with the TA ultrasound-guided procedure without requiring the assistance of a sonographer. It was associated with increased patient comfort due to the absence of bladder distension.

BACKGROUND: Race and ethnicity are one of the newly investigated patient-related prognostic factors that might affect the outcome of assisted reproduction techniques. To our knowledge no data currently are available on the effect of race on oocyte donation outcome. MATERIALS: A retrospective, matched cohort study was performed in a private infertility centre evaluating 1012 Black, South-East Asian and Caucasian recipients undergoing their first oocyte donation cycles. RESULTS: A significantly lower ongoing pregnancy rate (24.6 versus 36.8%, OR: 0.56 95% CI: 0.40-0.77, P = 0.01) was observed among Black recipients compared with their matched Caucasian counterparts. The prevalence of uterine fibroids (49.6 versus 17.1%, P < 0.0001) and previous history of tubal infertility (53.2 versus 16.5%, P < 0.0001) was significantly higher among Black women. Multiple logistic regression analysis showed that, after adjusting for confounding variables, Black race was an independent risk factor for not achieving an ongoing pregnancy (for ongoing pregnancy, adjusted OR: 0.62 95% CI: 0.43-0.89, P = 0.009). Ongoing pregnancy rate (37.2 versus 37.2%, OR: 1.0 95% CI: 0.49-2.04, P = 1.0) was not significantly different between South-East Asian and matched Caucasian patients. CONCLUSIONS: Black race was an independent risk factor for not achieving an ongoing pregnancy after oocyte donation. Although yellow race does not seem to adversely affect oocyte donation, larger studies are still warranted to draw more solid conclusions. Race should be considered as an independent prognostic factor in oocyte donation.

This study was conducted to explore the effect of gestational age (GA) on the induction-to-abortion interval of mifepristone-misoprostol midtrimester termination of pregnancy (TOP) regimen.This study involved a consecutive series of 270 pregnancies between 12.0 and 22.6 weeks that have undergone legal TOP from April 2006 to June 2009. All women received a single oral dose of 200 mg mifepristone and, 36-48 h later, a course of misoprostol (an initial vaginal dose of 800 mcg plus four oral doses of 400 mcg at 3-hourly intervals). Treatment was considered to be a failure if abortion did not occur within 24 h. The impact of GA, parity and maternal age on the induction-to-abortion interval was assessed by means of Cox regression.Overall, the mean GA at TOP was 18.0 weeks. The mean induction-to-abortion interval was 9.8 h (SD=8.2 h; range=1-50 h), and 246 women (91%) aborted successfully within 24 h. GA at TOP and parity were the only two variables independently associated with the induction-to-abortion interval. The mean induction-to-abortion interval was increased by about 50% in patients undergoing TOP between 20.0 and 22.6 weeks (12.9 h, SD=8.9), as compared with those at 16.0-19.6 weeks (7.8 h, SD=5.9) and 12.0-15.6 weeks (8.2 h, SD=8.3) (p.001). The effect of parity on the induction-to-abortion interval was more modest, with a 20% increase in induction-to-abortion interval in nulliparous (10.1 h, SD=9.1), as compared with women with a previous live birth (8.1 h, SD=6.7).The mean induction-to-abortion interval increases by 4 h after 20 weeks GA. This information may be relevant for counseling and planning of the procedure.

In this prospective, follow-up study of 102 high-risk oocyte donors in their luteal phase, we found a complete absence of ovarian hyperstimulation syndrome (no signs of hemoconcentration or ascites) after the donors were triggered with a gonadotropin releasing-hormone (GnRH) agonist. Due to its powerful preventive effect, the GnRH antagonist protocol combined with a GnRH agonist trigger should preferentially be used in egg donors; in conjunction with an effective luteal support or embryo cryopreservation, the protocol could also be applied to high-risk in vitro fertilization patients.

To compare donor and recipient outcome after inducing the final oocyte maturation with hCG or GnRH agonist in GnRH-antagonist treated oocyte donation (OD) cycles.Two-hundred fifty-seven oocyte donors were enrolled to participate in a clinical trial in a private fertility centre. After stimulation with 225 IU rFSH and Cetrorelix 0.25 mg/day, 212 oocyte donors were randomised with sealed envelopes for triggering with recombinant hCG (Ovitrelle 250 microgr, n = 106) or a GnRH agonist (triptorelin 0.2 mg, n = 106).The number of retrieved COCs (12 +/- 6.3 vs 11.4 +/- 6.4), mature oocytes (8 +/- 4.6 vs 7.5 +/- 4.1), the proportion of mature oocytes (67.2 +/- 20.4% vs 67.1 +/- 20.9%) and fertilisation rates (67.8 +/- 23.5% vs 71.1 +/- 22.1%) were comparable. Clinical, ongoing pregnancy and live birth rates were not statistically different in the corresponding recipient groups. Nine cases of mild and one case of severe OHSS occurred in hCG group, whereas no cases were detected in GnRH agonist group.The findings of our RCT suggest that donor and recipient outcome are comparable in OD cycles triggered with hCG or a GnRH agonist. Furthermore, the risk of OHSS seems to be reduced considerably, therefore the combination of a GnRH antagonist protocol with GnRH agonist triggering constitutes a safe treatment option for egg-donors.

We report a case of a twin pregnancy at term obtained after five multiple embryo transfers in a patient who presented diethylstilbestrol (DES)-associated cervical and uterine structural abnormalities, a septate uterus and bilateral tuberculous salpingitis. The suitability of in-vitro fertilization/embryo transfer in DES-exposed women is discussed.

A retrospective study was conducted in a private infertility centre to evaluate the rate of complications in a large oocyte donation programme. A total of 4052 oocyte retrievals were performed between January 2001 and October 2007. Altogether, 1238 cycles (30.6%) were stimulated with the use of gonadotrophin-releasing hormone (GnRH) agonists and in 2814 cycles (69.4%) the GnRH antagonist protocol was used. The GnRH antagonist treated cycles were triggered with human chorionic gonadotrophin (HCG) or a GnRH agonist in 1295 and 1519 cycles, respectively. Complications related to oocyte retrieval occurred in 17 patients (0.42%) (intra-abdominal bleeding: n = 14, severe pain: n = 2, ovarian torsion: n = 1). Fourteen of these were hospitalized (0.35%) and six donors (0.15%) required surgical intervention. Pelvic infections, injury to pelvic structures or anaesthesiological complications were not observed in this series. Moderate/severe ovarian hyperstimulation syndrome (OHSS) occurred in 22 donors; 11 required hospital admission and 11 were managed on an outpatient basis. All cases were related to HCG triggering (0.87%). Serious complications related to oocyte retrieval occurred at a low rate in healthy young donors. The risk of OHSS can be substantially reduced by specific stimulation protocols, which include GnRH agonist triggering. Prospective oocyte donors should be adequately counselled about the risks related to egg donation.

BACKGROUND: The aim of this study was to describe the experience of pregnant and non-pregnant HIV-infected women regarding fertility and childbearing, with a view to inform policies and practices to improve reproductive outcome. METHODS: A cross-sectional survey collected information on socio-demographic and basic reproductive characteristics of HIV-infected women in Europe. A total of 403 women participated; 121 were pregnant. RESULTS: The median age was 29 years and 84% (228) of women were born in Europe. Overall 68% (275 of 403) had been pregnant at some time. At the time of the survey, 59% (n 5 160) of women had no HIV symptoms; severe symptoms were more frequent among non-pregnant than pregnant respondents (36% (65 of 181) versus 5% (4 of 88)). Of the women, 80% reported being in a long-standing relationship; 39% (74 of 190) reported that they became infected by their current partner and, overall, heterosexual infection was reported as the mode of acquisition in 55% (190 of 344). Maternal well-being, no previous live birth and having an uninfected partner were strongly associated with the likelihood of being pregnant. To assess the problems relating to fertility, pregnant and nonpregnant women were considered separately. Overall, 46% of pregnant women reported not using condoms to protect against infection during pregnancy. Of the 60 pregnant women who planned their pregnancies, 10 reported the need for assistance in conceiving: five monitored their ovulation period and five became pregnant through in vitro fertilization. Of 34 non-pregnant women currently trying for a baby, 15 (44%) had done so for more than 18 months. Overall 25 (27%) of 94 women who planned to become pregnant needed reproductive care. CONCLUSIONS: Our results suggest that these days knowledge of HIV infection neither influences the desire for children nor the decisions regarding pregnancy in HIV-infected women living in Europe.

Pregnant women are at increased risk for malaria infection. Although important advances have been made in the last years, the mechanisms that explain the increased susceptibility are not yet fully understood. Malaria infection in pregnancy is associated with maternal and fetal morbidity and mortality. The severity of the disease depends on the level of pre-pregnancy acquired immunity against malaria, and the consequences of infection are more severe in non-immune women. In highly endemic areas, the frequency and severity of the infection is higher in primigravida and decreases with increasing parity. In non-immune women, the risk is similar across the parity and malaria may be an important direct cause of maternal mortality. Malaria infection during pregnancy has important negative effects on infant's health, causing intrauterine growth retardation and prematurity or directly through congenital infection. In this paper, we review the pathology, diagnosis, and current recommendations for treatment and prevention of malaria in the pregnant woman and her infant.

To evaluate the characteristics and association with perinatal outcome of the aortic isthmus (AoI) circulation as assessed by Doppler imaging in preterm growth-restricted fetuses with placental insufficiency.This was a prospective cross-sectional study. Fifty-one fetuses with intrauterine growth restriction (IUGR) and either an umbilical artery (UA) pulsatility index (PI)95(th) centile or a cerebroplacental ratio5(th) centile were examined at 24-36 weeks' gestation. AoI impedance indices (PI and resistance index) and absolute velocities (peak systolic (PSV), end-diastolic and time-averaged maximum (TAMXV) velocities), were measured in all cases and compared with reference ranges by gestational age. Furthermore, fetuses were stratified into two groups according to the direction of the diastolic blood flow in the AoI: those with antegrade flow (n = 41) and those with retrograde flow (n = 10). Clinical surveillance was based on gestational age and Doppler assessment of the UA, middle cerebral artery and ductus venosus (DV). Adverse perinatal outcome was defined as stillbirth, neonatal death and severe morbidity (respiratory distress syndrome, bronchopulmonary dysplasia, Grade III/IV intraventricular hemorrhage, necrotizing enterocolitis and a neonatal intensive care unit stay14 days).Adverse perinatal outcome was significantly associated with an increased AoI-PI (area under the curve 0.77; 95% CI, 0.63-0.92; P0.005). A significant correlation (P0.001) was found between retrograde blood flow in the AoI and adverse perinatal outcome, the overall perinatal mortality being higher in the retrograde group (70% vs. 4.8%, P0.001). In 4/5 (80%) fetuses the reversal of flow in the AoI preceded that in the DV by 24-48 h. AoI-PSV and AoI-TAMXV were5(th) centile in 40/51 (78%) and 48/51 (94%) cases, respectively, whereas AoI-PI was95(th) centile in 21/51 (41%) cases.Retrograde flow in the AoI in growth-restricted fetuses correlates strongly with adverse perinatal outcome. Absolute velocities in the AoI are decreased in growth-restricted fetuses. The data suggest a potential role for Doppler imaging of the AoI in the clinical surveillance of fetuses with severe IUGR, which should be confirmed in larger prospective studies.

Objective To compare pregnancy rates and the incidence of ovarian hyperstimulation syndrome (OHSS) in donor stimulation cycles where final maturation of oocytes was induced with recombinant hCG or GnRH agonist. Design Retrospective, cohort study. Setting Private infertility clinic. Patient(s) A total of 1171 egg donors performing 2077 stimulation cycles. Intervention(s) Controlled ovarian hyperstimulation of egg donors with GnRH antagonist protocol triggered with recombinant hCG (rhCG; 250 μg) or GnRH agonist (triptorelin 0.2 mg) based on the physician's decision. Main Outcome Measure(s) Proportion of mature and fertilized oocytes per donor cycle; clinical, ongoing pregnancy and implantation rate in recipients; and incidence of moderate/severe OHSS in oocyte donors. Result(s) The proportion of mature oocytes was comparable, whereas the difference in the fertilization rate reached statistical significance (65% vs. 69%). No significant differences were observed in the implantation rate or clinical and ongoing pregnancy rates per ET. The incidence of moderate/severe OHSS was 1.26% (13/1031; 95% confidence interval [CI], 0.74–2.15) and 0% (0/1046; 95% CI, 0.00–0.37) in the rhCG and GnRH agonist groups, respectively. Conclusion(s) Recipient outcome was not significantly different when using oocytes from GnRH antagonist–treated donor cycles triggered with hCG or GnRH agonist. However, GnRH agonist triggering was associated with a lower incidence of moderate/severe OHSS in egg donors.

Objective To evaluate acceptance, feasibility and difficulties in the application of a policy of vaginal delivery in selected cases in HIV-infected women. Study design HIV-infected women delivering March 2002 to December 2004 and enrolled in a prospective observational study in a University hospital tertiary care center were included. A vaginal delivery was not considered if labor before 36 weeks of pregnancy, preterm premature rupture of membranes, on non-highly active antiretroviral therapy (HAART) or viral load >1000 copies/mL. Main outcome measures were mode of delivery, prematurity, acceptance of vaginal delivery and mother-to-child transmission of HIV infection. Results The study included 91 pregnancies, with a total of 95 fetuses. Eighty percent (n = 73) of women knew their HIV infection status before becoming pregnant and 57 (63%) were on HAART at conception. Median gestational age at delivery was 37 weeks (range 22–41). Twelve women delivered a live-born before 36 weeks, all with a caesarean section. Among 74 women who reached 36 weeks gestation, 47 (64%) met the pre-established criteria for vaginal delivery, of whom 21 (45%) delivered vaginally. The most common reason for not having a vaginal delivery was the woman's request for a caesarean section. No cases of HIV vertical transmission occurred (0/90, 95% CI 0–4.02%). Conclusion Recommending vaginal delivery among HIV-infected women in selected cases was well accepted, particularly once the policy became established. Nevertheless, a high proportion of HIV-infected women will continue to require caesarean section delivery.

Objective To determine whether the optimal cut-off value to predict low risk of preterm delivery in women admitted for preterm labor should be adjusted for gestational age. Methods A cohort of 333 women with singleton pregnancies admitted with preterm labor and intact membranes between 24 and < 36 weeks' gestation was studied. The women were categorized according to prematurity into one of two groups: those admitted at < 32 weeks (Group 1, very preterm) and those admitted at ≥ 32 weeks (Group 2, preterm). Transvaginal ultrasound was performed 24–48 h after admission and cervical length measured. The predictive value of different cut-off points was explored. Outcome variables were spontaneous preterm delivery within 7 days of admission and delivery at < 34 weeks. Results The mean ( ± SD) gestational ages at admission and delivery were 31.9 ( ± 2.6) and 37.5 ( ± 2.2) weeks, respectively, and the mean ( ± SD) cervical length was 30.4 ( ± 8.9) mm. The rates of spontaneous delivery within 7 days and at < 34 weeks were 6.3 and 7.0%, respectively. The cut-off value of 15-mm cervical length showed a sensitivity, negative predictive value and false positive rate for delivery within 7 days of 0, 96.5 and 2.7% in the very preterm group, and 35.3, 94.6 and 4% in the preterm group, respectively. For a cut-off point of 25 mm, these values were 75, 99 and 14.3%, and 70.6, 96.8 and 24.5%. Conclusions The predictive value of different cut-off points of cervical length is similar at different gestational ages. However, the higher false positive rate after 32 weeks' gestation might justify the adoption of gestational-age related cut-off values in clinical protocols. In women admitted at < 32 weeks' gestation, a cut-off point of 25 mm may be used to predict a low risk of preterm delivery, whereas in women admitted at 32 weeks or later, 15 mm might be more appropriate. Copyright © 2007 ISUOG. Published by John Wiley & Sons, Ltd.

Objective To evaluate pregnancy outcome and the role of the amount of amniotic fluid (AF) in the prognosis of extremely preterm ( Study design Women with EPPROM and on-going pregnancy after 1 week of expectant management were included. Exclusion criteria: fetal anomalies, termination of pregnancy and spontaneous recovery of AF within the first week. The effect of the large vertical pocket (LVP) on pregnancy outcome was assessed by a Cox regression model which included three covariates: LVP measurements from rupture to 24 weeks, gestational age at rupture of membranes and sealing procedure. Results Thirty-seven women were included in the study. The overall survival rate after the neonatal period was 40.5% (15/37) which increased to 62.5% (15/24) in neonates born alive after 24 weeks of gestation. Mean and S.D. of gestational age at rupture of membranes were 19.0 (±3.8) weeks. From rupture to 24 weeks, the pooled mean and standard deviation of LVP were 20.5 (±15.4) mm. Multivariate analysis showed that the likelihood for neonate survival increased by 2.7 (95% CI 1.45–4.65) for each 5 mm of LVP during the follow-up from rupture to 24 weeks. After controlling for AF amount, neither the gestational age at rupture nor the sealing procedure showed any significant effect on pregnancy outcome. Conclusion Although the prognosis of EPPROM is poor overall, survival improves as the amount of AF before 24 weeks increases.

Objective To analyze the association between maternal smoking and fetal growth restriction, defined as a failure to achieve the growth potential, and to define subgroups of higher susceptibility for this association. Study design A definition of growth restriction by customized birthweight standards applied to 13,661 non-malformed singleton deliveries. Customization was performed by maternal ethnic origin, height, booking weight, parity, gestational age at delivery and fetal gender. The adjusted risk of smoking for customized smallness-for-gestational age and the identification of subgroups with higher susceptibility were assessed by logistic regression. Results Overall, the adjusted odds ratio of smoking (all levels of exposure grouped) for the occurrence of growth restriction was 1.9 (95% confidence interval: 1.69–2.13). Smoking was etiologically responsible for 13.9% (95% confidence interval: 11.2–16.5) of the cases of growth restriction occurring in the population. Smoking resulted in an increasingly greater risk of growth restriction with progressive levels of cigarette consumption. The risk of smoking for fetal growth restriction was significantly greater in older women and those with a previous history of spontaneous preterm delivery. Conclusions Smoking is associated with a higher risk for growth restriction. In addition, older pregnant women and those with a previous history of preterm delivery have an increased susceptibility.

Objective To describe sequential changes in uterine artery waveform between the first and second trimesters of gestation and to analyze their association with the subsequent risk of hypertensive disorders and fetal growth restriction (IUGR). Methods Sequential uterine artery Doppler recordings were obtained in a final cohort of 870 singleton pregnancies over two gestational age intervals: 11–14 weeks and 19–22 weeks. The left and right uterine arteries were examined by color and pulsed Doppler and the mean pulsatility index (PI) as well as the presence of a bilateral protodiastolic notch were recorded during both intervals. Pregnancies were followed for occurrence of hypertensive disorders and IUGR. Results Mean uterine artery PI showed a significant linear decrease within each of the two intervals considered, while the prevalence of a bilateral notch showed decreasing values only throughout 11–14 weeks of gestation. Sixty-four (7.3%) pregnancies developed a hypertensive disorder and/or IUGR, including three (0.34%) cases of gestational hypertension, 24 cases of pre-eclampsia (2.75%) and 37 (4.25%) of IUGR. Compared with pregnancies with a normal outcome, complicated pregnancies showed a significantly higher prevalence of a bilateral notch and a higher mean PI in each of the two intervals studied. Compared with normal pregnancies, complicated pregnancies had a significantly higher persistence of a bilateral notch (30% vs. 8%), a higher proportion of women with an abnormal first-trimester uterine artery PI shifting to normal in the second trimester (14% vs. 4%) and a higher incidence of a normal first-trimester mean PI that shifted to abnormal in the second trimester (13% vs. 4%). Persistence of an abnormal mean PI from the first to the second trimester identified the group with the greatest risk for adverse perinatal outcome (OR, 10.7; 95% CI, 3.7–30.9). In addition, women in whom the uterine artery mean PI shifted from abnormal to normal between the two trimesters and women in whom the reverse shift occurred showed a similar intermediate risk (OR, 5; 95% CI, 2.1–10.6), comparable to that in women with persistence of a bilateral notch (OR, 5.6; 95% CI, 2.9–10.7). Conclusions The sequence of changes in uterine flow between the first and second trimesters correlates with the subsequent development of hypertensive disorders and IUGR. Women with a persistent abnormal mean PI represent the group with the greatest risk for adverse perinatal outcome. Copyright © 2006 ISUOG. Published by John Wiley & Sons, Ltd.