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Publicly Available Published by De Gruyter September 7, 2019

2 – Oral Presentations

14th World Congress of Perinatal Medicine (WCPM)

September 11-14, 2019, Istanbul, Turkey

ICEC – Istanbul Lütfi Kırdar Convention and Exhibition Centre


Obstetrics – Fetal echocardiography and Congenital Heart Diseases


Fotaki A. 1, Velegrakis A. 2, Sifakis S. 3

Venizeleio General Hospital, Department of Pediatrics, Heraklion Crete-Greece 1

Venizeleio General Hospital, Department of Obstetrics and Gynecology, Heraklion Crete-Greece 2

Mitera Maternity Hospital, Heraklion Crete-Greece 3


Del 22q11.2 is the most commonly diagnosed deletion syndrome and is manifested clinically as Di George, velocardiofacial syndrome and conotruncal anomalies. Almost all types of congenital heart disease (CHD) have been diagnosed in patients carrying 22q11.2 deletion. Due to absence of typical extracardiac abnormalities and the fact that 85-91% of the deletion carriers suffer from CHD, echocardiography is the main diagnostic tool. Our present study aims to retrospectively review the echocardiographic findings of prenatally diagnosed patients with del22q11.2.


Retrospective review of the literature from 1995 until September 2017

We collected data regarding the prenatal echocardiographic diagnosis of del22q11.2, extracardiac findings and pregnancy outcome.


There are 39 studies included and 526 patients described in total. The majority was diagnosed with Tetralogy of Fallot (32,8%), followed by interrupted aortic arch (14,6%), common arterial trunk (14,3%), pulmonary valve abnormalities (9,1%), ventricular septal defect (6,5%), isolated right aortic arch (3,8%), coarctation of aorta (3.6%), double outlet right ventricle (1.7%), transposition of the great arteries (1.3%) and single cases of aortic stenosis, hypoplastic right heart, aberrant right subclavian artery, absent aortic valve, bilateral superior vena cava, double aortic arch, vascular ring and normal intracardiac anatomy. In 10% of cases the cardiac abnormality is not specified. The extracardiac abnormalities are reported in a small number of patients (5.8%) and include cleft lip/palate, thymus aplasia/hypoplasia, hydrops, intrauterine growth restriction, renal abnormalities, single umbilical artery, microcephaly, polyhydramnios, esophageal atresia, sacral meningomyelocele, ventriculomegaly and hygroma colli. The pregnancy outcome is reported in 35% of patients. The majority (62.7 %) decided for termination of pregnancy and 22.7% of fetuses is noted to have survived the neonatal period.


The prenatal echocardiographic diagnosis of certain cardiac abnormalities should raise the suspicion for del22q11.2. Detailed fetal anomaly scan and genetic testing should ensue. In case of positive results for this deletion extensive genetic counseling based on cardiac, extracardiac findings and their prognosis is mandatory.


Reyna P. 1, Ayala R. 1, Ibarrola E. 1

Abc Medical Center, Obstetrics and Gynecology, Mexico-Mexico 1

Case report on a multiparous 28 year old woman with single pregnancy diagnosed at 22 weeks of gestation with a fetus with atresia of the pulmonary valve through structural ultrasound, four chamber asymmetry due to small right chambers in comparison to the left and resulting in smaller size for the gestational age of the fetus. AV valves opening were found synchronic, rhythmic, pulmonary valve with a diameter of 1.8 mm with low flow index, the rest of the study is reported as normal.

During the first trimester nuchal translucency (NT) was performed as a marker of chromosomopathy reporting 1.99 mm, corresponding to 95th percentile (see figure 1) with a crown-rump length (CRL) of 48.8 mm, reverse wave of ductus venosus (DV) with pulsatility index of 2.74, the study was complemented with fetal DNA in maternal blood reporting no aneuploidies or microdeletions. The parents decided to keep the pregnancy with no interventions neither in uterus or neonatal period, the newborn died 10 days after birth. Congenital heart defects correspond to one third of all mayor congenital anomalies, with a prevalence of 4 –9 per 1000 live births, in which pulmonary atresia with intact ventricular septum corresponds to an estimated frequency of 0.083 per 1000 live births, currently there are traditional and advanced methods to identify these anomalies prior to birth, prenatal screening during second trimester identifies less than 40% of all cardiac malformations, but there are some markers during first trimester that include tricuspid regurgitation and abnormal ductus venosus blood flow. It has been determined that the combination of reduced or absent a-wave in DV flow with NT, correlated with increased risk of right heart defects as in this case.

Once the diagnosis is made it is important to perform detailed prenatal echocardiography, to establish the treatment of choice, outcome and possible complications of the fetus in uterus and after birth. Congenital heart defects that can benefit from fetal cardiac intervention are: severe aortic stenosis with evolving hypoplasic left heart syndrome, pulmonary atresia with intact ventricular septum with evolving hypoplasic right heart syndrome and hypoplasic left heart syndrome with intact or severely restrictive atrial septum. Even when pulmonary atresia with intact ventricular septum could benefit from fetal intracardiac intervention, they must go through a careful selection, choosing those that might have best long term outcome, including fetuses with an identifiable but atretic pulmonary valve (PV), a patent sub-valvar right ventricle outflow tract, and variable right heart hypoplasia. Even though there are new treatments for this congenital heart disease it is important to advice the parents that there is the need of further surgeries, compromising quality of life, hence emotional, economical, and psychological challenges must be met further ahead. Also, the proper selection of an experienced and advanced hospital is advised.


Kesrouani A. 1, Jaber L. 1, Daou L. 2, Mcheik C. 1

Saint Joseph University, Obstetrics and Gynecology, Beirut-Lebanon 1

Saint Joseph University, Cardiopediatrics, Beirut-Lebanon 2


The aim of this study is to determine the sonographic characteristics of cardiac rhabdomyomas in antenatally diagnosed cases and to characterize their evolution and postnatal management.


This is a retrospective descriptive study. It includes cases diagnosed prenatally in our University hospital between 2003 and 2018. Exclusion criteria were postnatal diagnosis, twins and cases with intra-uterine fetal demise. The information is collected from fetal and postnatal echocardiography as well as birth records and newborns’ records. In viable fetuses, postnatal echocardiography and patient outcome data are also obtained. This study was approved by our ethics committee.


Eight cases of rhabdomyoma diagnosed antenatally met the inclusion criteria. The mean gestational age at diagnosis of rhabdomyoma is 31w. The earliest diagnosis is at 26w while the latest is 35w + 5d. Five of eight patients were diagnosed after 32 weeks (62.5%). The mean age of the mother is 29.5 years. Gender of the babies is male in 6 / 8 (75%) and female in 2/8 (25%). Only one patient (fetus) has a familial Tuberous sclerosis (12.5%). Four fetuses have multiple rhabdomyomas (50%) and the remaining 4 have single rhabdomyomas (50%). A total of 17 tumors were found in the 8 patients. Seven are located in the interventricular septum (41%), 5 in the left ventricle (29.5%), 3 in the right ventricle (17.5%), one in the atrioventricular septum (5.8%) and the last at the level of the right atria (5.8%). At diagnosis the average size is 19.5 +/−8.8 mm. The smallest diameter is 4 mm and the largest is 48 mm. During follow-up, in all the 5 cases that had a control ultrasound there was a size increase with a mean of 1.68 mm +/−0.55. In two patients of eight (25%) there was a valvular insufficiency. No patient had an associated cardiac malformation. All patients delivered at term between 36 and 40 weeks of age (87.5%) including five cesareans (62.5%), and three vaginal deliveries (37.5%). One patient had a preterm birth at 33 weeks due to polyhydramnios (12.5%). One baby died (he had a mass effect and a hypokinesia of the 2 ventricles) and another required reanimation with intubation. Three patients required resuscitation at birth (37.5%). The first requires an urgent surgery but unfortunately died during the operation (12.5%), the second died despite resuscitation (12.5%) (he had a large heart mass with heart failure, abdominal ascites and cardiac effusion). The third improved after a three-day resuscitation (12.5%). So in total six babies survived (75%); three of them were later diagnosed with Tuberous sclerosis (50%), and two were lost to follow-up. Two of the four patients with a single tumor antenatally were found to have several tumors postnatally.


Cardiac rhabdomyomas are often asymptomatic, benign tumors that have multiple presentation. Neonatal death occurred however in 12% of the cases. Association with tuberous sclerosis syndrome could impact the long term neurological status.

Obstetrics – Diabetes and obesity during pregnancy


Yapar Eyi E. 1, Mollamahmutoglu L. 2, Esen M. 2

Zekai Tahir Burak Women’s Health Education & Research Hospital, Perinatology, Ankara-Turkey 1

Women Reproductive Health Department, Public Health Ministry Health of Turkey, Ankara-Turkey 2


To clarify the risk factors in thromboprophylaxis and to reinforce proper and safer guidelines for correct antemortem diagnosis of proven fatal pulmonary embolism (PE) during pregnancy, delivery and within 42 days after delivery


Design: Descriptive study

Setting: Analysis of maternal deaths due to PE verified by autopsies/embolectomies/computerized tomographic angiographies from the national registration system of maternal deaths in Turkey

Participants: 29 women who had necropsy computerized angiography or thrombectomy confirmation for fatal pulmonary embolism (PE) Main outcome measures: The risk factors and the prevention of death with current thromboprophylaxis protocols.


29 women had necropsy, computerized angiography or thrombectomy confirmation for PE in the first trimester (n=4), second trimester (n=3), third trimester (n=2), during labour (n=3), and in the puerperium (n= 17). All women had antenatal risk factors for PE. One, two, three and four or more risks were identified in three, five, three and 18 women, respectively, including age > 35 (n=13), gravida > 3 (n=12), body mass index(BMI) > 30 (n=10), acute infection(n=8), venous thromboembolism (VTE) in the current pregnancy (n=7), transfusion (n=6), obstetric hemorrhage (n=5), intrauterine growth restriction (n=4), autoimmune disease(n=4), preterm birth (n=4), high risk thrombophilia (n=3), preeclampsia (n=2), stillbirth (n=2), previous VTE (n=2), hysterectomy(n=2), diabetes (n=1), varicose veins (n=1), sepsis after fetal invasive procedures (n=1), smoking (n=2), epilepsy (n=2), corticosteroid administration>10 days (n=4), hypertension (n=1) and hyperthyroidism (n=1). 13 women were delivered by the abdominal route including six repeated cesarean deliveries (CD), six primary CD and one hysterotomy. There were five vaginal deliveries. Three postmortem CD and two hysterectomies were performed. Eight (25%) of the patients were already on thromboprophylaxis due to prior episode of venous thrombosis + high risk thrombophilia+ leg amputation + immobilization(n=1), cerebral sinus venous thrombosis+ autoimmune disease (n=1), deep venous thrombosis (DVT) of the leg (n=4), obesity (n=3), hypertension (n=3) and mesenteric vein thrombosis (n=1) and intestinal surgery (n=1) , gravida>3 and smoking cigarettes (n=1).


Reducing the risk of fatal PE requires clinical risk appraisal of every women during pregnancy and puerperium. Because 18 women had four or more risk factors, clinical evaluation and physical examination is mandatory. Clinical symptoms, especially pain and swelling in the legs, acute infection and pregnancy complications, warrant attention; however, heterogeneous characteristics of the women and the unpredictable and abrupt onset of the catastrophic events may present challenges. Thromboprophylaxis protocols may be subject to change in terms of indications, dosage, dosing intervals and duration to achieve both efficacy and safety during pregnancy and puerperium for reducing the risk of fatal PE. CD does not appear to be the sole factor for PE unless other risk factors are present.


Kim E. 1

National Health Insurance Service Ilsan Hospital, Obstetrics and Gynecology, Goyang-si Korea, South 1


In South Korea, about 45% of women giving birth are 35 years or older. Women who were age 35 or older at delivery are generally referred to Advanced Maternal Age (AMA), which is risk factors for various kinds of complication besides genetic changes in fetus. The aim of this study is to evaluate maternal and neonatal adverse outcomes following induced labor in AMA.


This was a retrospective observational study of singleton, vertex-presenting nulliparous women from 37 0/7 to 41 6/7 weeks of gestation who were delivered following induced labor. After induced labor, outcomes in women with AMA were compared with young aged mother.


A total of 314 nulliparous women were attempted induced labor (≥ 35 years n=73, 23.2%; < 35 years n=257, 81.8%) and among them, 257 (81.8%) delivered vaginally. There was no difference in gestational age and Bishop score between two groups. Rate of Cesarean delivery was significant higher in women with AMA (31.5% vs. 14.1%, p=0.001). Multivariable analysis showed that AMA was an independent predictor for Cesarean delivery (OR 2.98, 95% CI 1.56-5.71, p=0.001). Delivery time and the blood loss during the delivery were similar between the two groups (861±506 Vs. 843±529 min, 1.97±1.32 vs. 1.86±1.25 mg/dl, respectively, all p > 0.05). Regarding neonatal outcomes, there was no different between the two groups in NICU admission rate and Apgar score < 7 at 5 minute. There was no cesarean hysterectomy and perinatal death in this study.


Following induced labor, AMA was associated with a more than three-fold increased likelihood of birth by Cesarean in nulliparous women. We found, however, no evidence that induced labor in elderly primigravida increases adverse maternal and neonatal outcomes as compared with a young woman.


Rivera L. 1, Marcos J. 1

San Juan De Dios Hospital, Dept.of Obstetrics and Gynecology, Manila-Philippines 1


Gestational Diabetes Mellitus (GDM) is one of the most common diseases complicating pregnancy and is associated with both maternal and fetal complications. Women with GDM have a high risk of developing postpartum type II diabetes mellitus. Prevention of this progression is speculated to be influenced by lifestyle modifications including breastfeeding, diet, and exercise. The objective of this study was to determine if exclusive breastfeeding during the postpartum period can improve results of 75 gram OGTT done at 6-12 weeks postpartum.


We compared baseline and postpartum 75 gram OGTT results of 120 patients with GDM in a tertiary hospital. Comparison was done among four (4) subgroups: (a) those that did not breastfeed, (b) those who breastfed for 1-4 weeks, (c) those who breastfed for 5-8 weeks, and (d) those who breastfed for 9-12 weeks. Analysis of variance (ANOVA) was used to compare the means of the four subgroups versus their 75 grams OGTT results.


There was a significant difference in 75 gram OGTT results done at 24-28 weeks age of gestation and done 6-12 weeks postpartum, for values of fasting blood sugar, first hour, and second hour. There was also an observed higher decline in values as duration of exclusive breastfeeding increases.


This study showed that exclusive breastfeeding during the postpartum period is associated with improvement of results of 75 gram OGTT done at 6-12 weeks postpartum compared with those done at 24-28 weeks age of gestation. It was also observed that duration of breastfeeding is inversely correlated with 75 gram OGTT values.


Kim E. 1

National Health Insurance Service Ilsan Hospital, Obstetrics and Gynecology, Goyang-si Korea, South 1


Women who give birth at 35 years of age or older are generally referred to advanced maternal age (AMA), which is risk factors for various kinds of complication besides genetic changes in the fetus. The aim of this study is to evaluate the effect of maternal age on emergency Cesarean delivery (CD) rate and maternal and neonatal morbidity following induced labor.


This was a retrospective observational study of singleton, vertex-presenting nulliparous women from 37 0/7 to 41 6/7 weeks of gestation who were delivered following induced labor. After induced labor, outcomes in women with AMA were compared with women < 35 years.


A total of 314 nulliparous women were attempted induced labor (≥ 35 years n=73, 23.2%; < 35 years n=257, 81.8%) and among them, 257 (81.8%) delivered vaginally. The rate of CD was significantly higher in women with AMA (31.5% vs. 14.1%, p=0.001). Multivariable analysis showed that AMA was an independent predictor for CD (OR 2.98, 95% CI 1.56-5.71, p=0.001). The rate of instrumental deliveries and the blood loss during the delivery were similar between the two groups (13.7% vs. 7.9%, p=0.133, 1.97±1.32 vs. 1.86±1.25 mg/dl, p=0.605, respectively). Regarding neonatal outcomes, there was no difference between the two groups in NICU admission rate and Apgar score < 7 at 5 minutes. There was no cesarean hysterectomy and perinatal death in this study.


Following induced labor, AMA was associated with a more than three-fold increased likelihood of birth by Cesarean delivery in nulliparous women. We found, however, no evidence that induced labor in elderly primigravida increases adverse maternal and neonatal outcomes as compared with women < 35 years.


Bartha I. 1, De la Fuente M. 2, De la Calle M. 3, Martín-Boado E. 3, Martínez-Sánchez N. 3, Bartha J. 3

University Hospital De La Princesa, Allergy, Madrid-Spain 1

University Hospital Virgen De La Salud, Pediatrics, Madrid-Spain 2

University Hospital La Paz, Obstetrics and Gynecology, Madrid-Spain 3


To evaluate body mass index and the prevalence of obesity and overweight in women with asthma during pregnancy


In total 238 pregnant women with asthma were compared to a reference obstetric population of 5296 non-asthmatic pregnant women. Maternal weight, height and body mass index were compared. Groups of BMI were defined as follows: < 18.5 k/m2 Thin, 18.5 –25 normal weight, => 25 and < 30 k/m2 overweight and => 30 obese. Chi squared and Students t test were used for comparisons. Statistical significance was sset at 95% level (p < 0.05).


Pregnant women with asthma have increased weight and BMI values while height was similar to that of the general population. There was a significant difference in the categories of BMI (p = 0.01) according to the asthma status. The proportion of obesity was significantly higher in the group with asthma (16.8% Vs. 10.9%).


The presence of obesity and asthma during pregnancy are related. If both conditions are present is probably that may influence in having worse obstetric and perinatal outcome but further studies are needed to clarify this. Prevention of obesity may reduce the presence of asthma during pregnancy.


Bartha I. 1, Joumady I. 2, González-González N. 3, Bailén M. 2, Perdomo G. 2, Bartha J. 4

University Hospital De La Princesa, Allergy, Madrid-Spain 1

University Hospital Puerta Del Mar, Clinical Chemistry, Cadiz-Spain 2

University Hospital of The Canary Islands, Obstetrics and Gynecology, Tenerife-Spain 3

University Hospital La Paz, Obstetrics and Gynecology, Madrid-Spain 4


To evaluate the effect of maternal obesity and lipid profile on first trimester serum progesterone levels


Prospective cohort study on 734 pregnant women

First trimester maternal serum progesterone, cholesterol, HDL-c, LDL-c and triglycerides were measured between 9–11 weeks’ gestation. Free β-hCG, PAPP-A, age, BMI, smoking status, gestational age at delivery, fetal sex and birthweight were also recorded. Women were classified according to their BMI in underweight (n = 21), normal weight (n = 395), overweight (n = 221), obese (n = 64) and morbid obese (n = 33).


Gestational age at sampling was 10.0 4 ± 1.12 weeks. Serum progesterone levels decreased as maternal BMI increased (35,84 ± 12,00 ng/mL, 33,08 ±11,27 ng/mL, 28,04± 8,91 ng/mL, 24,37 ± 8,56 ng/mL and 19,87 ±11,00 mL for underweight, normal weight, overweight, obese and morbid obese groups respectively (p < 0.000001). There were statistical significant negative correlations between maternal progesterone and maternal BMI, triglycerides and cholesterol/HDL-c ratio, and positive correlations with gestational age at sampling, maternal age, cholesterol, HDL-c, CRL, free β-hCG and PAPP-A. Linear regression showed that the only independent variables were BMI (p < 0.0001), PAPP-A (p <0.0001), HDL-c (p < 0.0001), and free β-hCG (p <0.0001) (R2= 0,33; p< 0,0000001).


First trimester serum progesterone levels are lower in overweight pregnant women and markedly decreased in obese, especially in severe obese women. Maternal HDL-c is independently related to progesterone levels as a protecting factor. Benefits of progesterone supplementation in obese women need further evaluation.


Budak Timur B. 1, Timur H. 1, Tokmak A. 2, Işık H. 3, Yapar Eyi E. 2

Ordu University Education and Research Hospital, Obstetrics, Ordu-Turkey 1

Zekai Tahir Burak Education and Research Hospital, Obstetrics, Ankara-Turkey 2

Lokman Hekim Private Hospital, Obstetrics, Ankara-Turkey 3


This study aimed to investigate the influence of obesity on pregnancy complications and neonatal outcomes in diabetic and nondiabetic women.


This retrospective case control study was conducted on 1193 pregnant women and their neonates at a tertiary level maternity hospital between March 2007 and 2011. The pregnant women were classified into 2 groups according to the presence of diabetes mellitus. Six hundred and seven patients with gestational diabetes or pregestational diabetes formed the diabetic group (study group) and 586 patients were in the nondiabetic group (control group). Demographic characteristics, body mass index, gestational weight gain, obstetric history, smoking status, type of delivery, gestational ages, pregnancy complications, neonatal outcomes were recorded for each patient. Multivariable logistic regression analysis was performed to evaluate the effect of obesity and diabetes on the pregnancy complications and neonatal outcomes.


The mean age and pre-pregnancy body mass indices of women with diabetes mellitus were significantly higher than the control group’s (p < 0.001). Gestational weight gain and number of smokers were similar among the groups. Multiparity and obesity were more prevalent in the diabetic group compared to controls (both p < 0.001). Although gestational age at birth was earlier in the diabetic group, birth weights were higher in this group than in the control group (both p < 0.001). Cesarean delivery rates, the incidence of macrosomia, and neonatal intensive care unit admission rates were significantly higher in the diabetes group both with normal and increased body mass index (all p < 0.001). However, adverse pregnancy outcomes were comparable between the groups (p = 0.279). Multivariable logistic regression analysis showed that obesity is a significant risk factor for pregnancy complications (OR = 1.772 [95 % CI, 1.283 – 2.449], p = 0.001) but not for adverse neonatal outcomes (OR = 1.068 [95 % CI, 0.683 – 1.669], p = 0.773).


While obesity increases risk of developing a pregnancy complication, diabetes worsens neonatal outcomes.

(This article was published online in the journal Geburtshilfe Frauenheilkd in 2018)


Antsaklis P. 1, Asimakopoulos G. 1, Psaris A. 2, Theodora M. 1, Daskalakis G. 1, Anastasiou E.3

Alexandra Maternity Hospital, Fetal & Maternal Medicine, Athens-Greece 1

Alexandra Maternity Hospital, Obstetrics & Gynecology, Athens-Greece 2

Alexandra Maternity Hospital, Endocrinology, Athens-Greece 3


To evaluate in everyday clinical practice the effectiveness of a protocol regarding the management of pregnancies with GDM

The protocol is based on a combination of maternal glycemic levels and the measurements from serial fetal growth ultrasound (USS) examinations in order to decide whether we should initiate insulin treatment in women with gestational diabetes (GDM). Aim of this protocol to prevent fetal macrosomia.


84 women diagnosed with GDM were followed up1 week immediately after their diagnosis of GDM and subsequently every 2 weeks. All women underwent fetal USS at the time of GDM diagnosis and then at least every 4 weeks, until delivery. After 1 week of diet control, insulin was initiated with the following two criteria: (a) if glucose levels were persistently high – fasting glucose (FCG)>95mg/dl and 1 hour postprandial glucose (PPCG)>130mg/dl – and fetal abdominal circumference (FAC)>10th centile or (b) if FAC>70th centile with simultaneous implementation of glucose targets FCG<80mg/dl and/or 1h PPCG<120mg/dl.


Of the 84 GDM women, 49 (58.3%) were treated with diet only and 35 (41.7%) with diet and insulin. The number of fetuses with FAC>70th centile were 23 (26.7%) at the time of the first USS and 11 (13.3%) during the last USS, indicating a 50% reduction (p=0,021). There was no difference in the rate of caesarean sections between the diet and insulin groups. Mean gestational age of last USS was 36 weeks, with an accuracy of 96.7% when compared with neonatal birthweight (mean GA=38 weeks). Out of 84 neonates only 2 was >90th centile and 3 were <10th centile.


Serial fetal USS in GDM pregnancies provides very useful information for the decision making of initiating insulin treatment in pregnancies complicated by GDM, and appears to decrease the percentage of macrosomia, without further increasing at the same time, the number of small for gestational age fetuses.

Obstetrics – Maternal fetal Doppler: Fetal growth disorders


Cebe F. 1, Tola E. 1, Aslan Koşar P. 2, Oral B. 1

Suleyman Demirel University Faculty of Medicine, Department of Obstetrics and Gynecology, Isparta-Turkey 1

Suleyman Demirel University Faculty of Medicine, Department of Medical Biology and Genetics, Isparta-Turkey 2


Impairment in placental angiogenesis is blamed for the etiopathogenesis of intrauterine growth restriction (IUGR). DNA methylation of angiogenetic genes in placenta could act as mediators in IUGR pathogenesis. We aimed to assess the genes which affect placental angiogenesis could be aberrantly methylated in placental biopsies of pregnancies complicated by IUGR.


The methylation profiles of soluble fms-like tyrosine kinase-1 (sFLT-1), vascular endothelial growth factor (VEGF) and the placental growth factor (PIGF) were evaluated using Illumina MiSeq System in placental biopsies from term IUGR pregnancies without preeclampsia (n=18) and normally grown controls (n=17). DNA was isolated from samples of tissue collected from the fetal side of the placenta immediately after delivery. In the targeted regions, we have identified 30 CpG island (CpGi) within the sFLT-1, 24 CpGi within VEGF and 29 CpGi within PIGF genes.


IUGR fetuses had significanlty lower placental and fetal birth weight compared to controls. The promoter of sFLT-1 at three CpGi and VEGF at six CpGi were the regions with significant methylation differences between IUGR and control placentas. sFLT-1 was hypermethylated at 265 and 352 CpGi, however hypermethylation was lower in IUGR group compared to control group at this position. sFLT-1 was hypomethylated at 456 CpGi in IUGR group and hypermethylated at the same region in control group. VEGF had hypomethylated at 668, 703, and 710 CpGi in conrol and IUGR groups, however hypomethylation at these positions were significantly higher in control group compared to IUGR. 776, 845 and 863 CpGi of VEGF promoter were hypermethylated in IUGR group whereas hypomethylated in control group with a significant differences. Comparison of DNA methylation profiles of different CpGi of sFLT-1 and VEGF promoter between the groups are shown in Figure 1 and 2. The methylation profile of promoter for the PIGF didn’t differ between the groups. After adjustment for gestational age and the factors known to affect fetal birth weight, DNA methylation of VEGF 668 CpGi had significant negative association with fetal birth weight and was significantly associated with higher relative odds of IUGR birth.


Methylation changes in a specific region corresponding to the promoter of VEGF 668 CpGi in placenta could involve in IUGR and could be used to identify pregnancies complicated by IUGR Large sample-sized studies should be performed to assess the effect of DNA methylation on IUGR.


Kamyshanskiy Y. 1, Turdybekova Y. 2, Kopobaeva I. 2, Altaeva A. 2, Zhanabaeva S. 2

Karaganda Medical University, Department of Pathology, Karaganda-Kazakhstan 1

Karaganda Medical University, Department of Obstetrics, Gynecology and Perinatology, Karaganda-Kazakhstan 2


The growth of placenta and maturation of the placental distal villi are important factors determining function of the placenta at the end of pregnancy. [Benirschke K. 2006, Redline R.W., 2013]. Violation of these processes leads to placental respiratory dysfunction, fetal and neonatal mortality and morbidity. [Redline R.W. 2013, Roescher A.M. 2014]. The aim of the study was a comparative evaluation of structural distal villous phenotype and placental weight from pregnancies with normal (NPO) and adverse perinatal outcome (APO) with appropriate (AGA) and small fetus for gestational age (SGA).


112 placentas of the 37-42 gestational weeks associated with AGA (n-76) and SGA (n-36) fetuses were recruited in retrospective histopathological study. The study cohort was divided according to clinical data in regard to NPO (n-36) or APO (low 5-minute Apgar score with severe umbilical cord blood acidosis, intrauterine fetal death (IUFD), n-76) and subjected to examination of placental weight and structural distal villous phenotype. Excluded were placentas from pregnancies with premature placental abruption. Placental weight was submitted as low (<10percentile), normal (25-75percentile) and high (>90 percentile). Evaluation of number of immature villi was carried out in 100 peripheral villi of the representative placental histological section. Their ratio was calculated as percentage of immature distal villi.


Placentas from pregnancies with NPO predominantly were associated with normal weight in 18(64,3%) of 28 cases with AGA and in 5(62,5%) of 8 cases with SGA, respectively. In 27 (96,4%) placentas with AGA and in 7(87,8%) with SGA we found mature structural placental villous phenotype. Only in 8,7% of cases with AGA and in 2,8% with SGA was found low placental weight (<10percentile), while there were identified mature distal villous phenotype. Placentas from pregnancies with APO were predominantly associated with normal weight in 26 (54,2%) of 48 cases with AGA and low weight in 26(92,9%) of 28 cases with SGA. Structural villous phenotype in placentas with APO was characterized by diffuse persistence of immature villi (>50% per slide) in 44(91,7%) of cases with AGA and in 27(96,4%) of 28 cases with SGA. Among them, in 31(39,5%) cases were observed combination of severe distal villous immaturity with low placental weight, that was in 96,7% of cases associated with IUFD in pregnancies with AGA (43,3%) and SGA (56,7%), respectively.


We identified that abnormal deviation of placental growth and maturity capacity at term pregnancies associate with APO and fetal hypoxia independently from fetal weight at term. Constellation of low placental weight and severe distal villous immaturity (>50% immature villi per slide) is a morphological indicator of adverse antenatal fetal condition and intrauterine fetal growth restriction (IUGR). We hypothesized that heterogeneity of placental weight and degree of placental immaturity at term reflects different gestational age of fetal disease and stage of development of the placental adaptive capacity. Histopathological evaluation of placental weight in combination with distal villous phenotype may help to identify pathomechanisms of perinatal fetal asphyxia and to postnatal stratification of newborn from pregnancies with latent form of chronic respiratory placental insufficiency.


Sekkin Eser M. 1, Yapar Eyi E. 2

Dr.Zekai Tahir Burak Women’s Health and Education Hospital, Obstetrics and Gynaecology, Ankara-Turkey 1

Dr.Zekai Tahir Burak Women’s Health and Education Hospital, Perinatology, Ankara-Turkey2


Doppler measurements are widely used for both the diagnosis and the management of intrauterine growth restriction (IUGR). As umbilical cord connecting the placenta to the fetus is accessible, we evaluated the antenatal ultrasonographic morphometry of the umbilical cord, to find out whether these measurements can be correlated with postnatal umbilical cord histopathology and neonatal outcomes to be used as a clinical guide in pregnant women with IUGR.


A prospective case control study was carried out of 36 pregnant women with IUGR and 3395 women without IUGR who were admitted Zekai Tahir Burak Women’s Health Education&Research Hospital. Evaluation was made on a total of 114 pregnant women, 36 women with IUGR(31.6%), randomly selected 42(36.8%) pregnant women with a previous C/S and 36(31.6%) pregnant women without a previous C/S. Fetal biometry, morphometric measurements from the cross-section of the umbilical cord, helical index of the umbilical cord and umbilical artery Doppler evaluation were performed. Transverse diameter, circumference and area of the whole cord, both umbilical arteries and vein measurements and the presence of Wharton jelly were correlated with the histopathological evaluation of the standard umbilical cord samples. Statistical evaluations were performed with SPSS 17.0.


The results of a total of 103 pregnant women including 30 with IUGR, 34 without a previous C/S, and 39 women with a previous C/S were evaluated. Statistically significant differences were detected in terms of: umbilical cord coiling index, umbilical artery Doppler values, whole umbilical cord measurements: transverse cross-section, circumference, diameter and area, small artery measurements, the umbilical vein area, perimeter and diameter measurements (p<0.005) between women with IUGR and those without IUGR. The presence of Wharton’s jelly surrounding umbilical vessels was also significantly different (p<0.001). About the histopathological evaluation, thickness of the umbilical artery (p=0.002 and p<0.001), umbilical vein (p=0.024) and cell density of the arterial wall(p=0.033) were also different between IUGR and non IUGR groups and a negative correlation was found between those and adverse neonatal outcomes. Umbilical artery from the measured larger one showing no ultrasonographic morphometric difference demonstrated histopathologic difference (p=0.002), suggesting us the concept of the compensation by one of the umbilical arteries. There were also significant differences in terms of umbilical artery S/D, RI and transverse diameter of the whole umbilical cord(p<0.05 )in pregnant women with prior C/S and with no C/S. There was also significant difference in the presence of Wharton’s jelly for negative neonatal outcomes in multivariate regression (p=0.035). The Receiver Operating Curve evaluation showed that the presence of Wharton’s jelly of the umbilical vessels, might be of diagnostic value for predicting the adverse neonatal outcome (Area Under the Curve:0.75, 95%CI:0.63-0.86, p<0.001).


In pregnant women with IUGR, morphometric differences were detected in umbilical cord verified by histopathological findings and the containment of Wharton jelly besides Doppler indexes with the potential to be included among the tests for the fetal well-being.


Inamura T. 1, Shibata T. 1, Ueno T. 1, Yamada T. 1, Takeda T. 1, Tano S. 1, Uno K. 1, Suzuki T. 1, Izawa T. 1, Kishigammi Y. 1, Oguchi H. 1

Toyota Memorial Hospital, Obstetrics, Perinatal Medical Center, Toyota-Japan 1


Although elevation of middle cerebral arterial peak systolic velocity (MCA-PSV) is known as a sign of fetal anemia, little studies of other clinical values have been reported. The aim of this study is to investigate the benefit of measuring of MCA-PSV for early diagnosis of fetal abnormalities or the benefit in cases of fetal growth restriction (FGR).


This retrospective study included fetuses who were measured MCA-PSV from June 2008 to December 2016 and delivered at our hospital. We defined high MCA-PSV as the value exceeding 1.5 multiple of median (MoM) and diagnosed fetal abnormalities after birth. To investigate the benefit of measuring of MCA-PSV in cases of FGR, 248 fetuses who were diagnosed FGR at our hospital were enrolled. We calculated estimated fetal body weight (EFBW) using ultrasonographic measurements, and diagnosed FGR (EFBW < –1.5 SD). We assigned the case to high MCA-PSV group when we found high MCA-PSV at least one time. We compared the perinatal prognosis of high MCA-PSV group and normal MCA-PSV group. The primary outcome was the frequency of emergency Cesarean section (CS), and the secondary outcomes were as follows: gestational age at delivery, birth weight, Apgar score, pH and base excess (BE) of umbilical cord blood gas and the rate of NICU admission.


The numbers of high MCA-PSV group and normal MCA-PSV group were 18 cases (7.3%) and 230 cases (92.7%) respectively. The range of gestational week when we measured MCA-PSV was from 14 weeks to 42 weeks, and the average was 32.3 weeks. The frequency of CS was higher in high MCA-PSV group (61.1% vs. 29.1%, p=0.007). In high MCA-PSV group, gestational age at delivery was earlier (34.9 weeks vs. 37.0 weeks, p=0.007) and birth weight was also lower (1559 g vs. 2106 g, p<0.001). The median of Apgar scores at 1-minute were lower in high MCA-PSV group (5 vs. 8, p=0.002), and those at 5-minute were also lower in high MCA-PSV group (8.5 vs. 9, p<0.001). The rate of NICU admission was higher (88.5% vs. 60.1%, p=0.002) in high MCA-PSV group. pH (7.255 vs. 7.267, p=0.594) and BE (−3.95 vs. –3.50, p=0.73) of umbilical cord blood gas did not show significant difference.


High MCA-PSV indicated the possibility of early diagnosis of FGR. In cases of FGR, there was correlation between high MCA-PSV and perinatal short prognosis. Measuring MCA-PSV can be effective in assessing the fetal condition.


Theodora M. 1, Rizou D. 1, Barbarousi D. 2, Maritsa V. 1, Antsaklis P. 1, Sindos M. 1, Loutradis D. 1, Daskalakis G. 1

National and Kapodistrian University, Maternal Fetal Medicine Dpt, 1

Dpt Obstetric Gynecology, Athens-Greece 1 National and Kapodistrian University, Hematology Dpt, Athens-Greece 2

The occurrence of cancer and pregnancy is relatively rare, occurring in about one in 1000 pregnancies. The most common tumors diagnosed during pregnancy are breast and cervical cancer followed by melanoma, leukemia and lymphoma. The incidence of acute lymphoblastic leukemia (ALL) during pregnancy is low. Management of these cases are challenging for hematologists and obstetricians. A key point in management should be the optimal therapeutic treatment given to the patient with the least possible exposure and burden of the fetus.

We present a case with a 36 years old patient diagnosed with Acute Lymphoblastic Leukemia and 23 weeks. Patient was informed about the risks of the treatment protocols for the fetus and she decided to carry on with the pregnancy. Initially she was treated with corticosteroids regiment in order to control the disease for initiation of chemotherapy. At 29th week of pregnancy modified GMALL protocol was administrated and at 31 weeks she delivered due to fetal distress. Three months after delivery patient received allogenic bone marrow transplant. Twelve months after the transplantation she had lung metastasis. she Died 15 months after transplantation. Her baby is growing normally with no problems so far. The diagnosis of acute lymphoblastic leukemia (ALL) during pregnancy is easy but the treatment requires high-dose chemotherapy and can raise concerns for risks to both the mother and fetus. Special consideration to chemotherapy regimen and its doses and to fetal gestational age at the time of chemotherapy administration should be taken.


Theodora M. 1, Antsaklis P. 1, Michala L. 1, Lolos M. 1, Kalambalikis A. 1, Koutroumanis P. 1, Loutradis D. 1, Daskalakis G. 1

National and Kapodistrian University, Maternal Fetal Medicine Dpt., Dpt Obstetric Gynecology, Athens-Greece 1


Greece is a first point entry to Europe for immigrats and refugees for more the three decades. The continuing conflict in Syria resulted in an unprecedented influx of refugees Many women were pregnant but also many became pregnant during their stay at the so called hot spots.


We sought the clinical characteristics and pregnancy outcomes of these women delivering in Alexandra hospital and compared them with those of Greek population.


A retrospective cohort analysis of all pregnant women attending Alexandra University Hospital from September 2015 to December 2018 Demographic data were collected together with obstetric and neonatal outcomes.


Seven thousand nine hundred and eight one pregnant women deliveries were recorded in Alexandra University Hospital during between 9/2015-12/2018. Refugees accounted for 11% of this population. More than half of them were Syrian with the remaining from Afghanistan and Iraq. Compared to the native population they were younger and of higher parity. Most of them received inadequate antenatal care and one out of five have had no antenatal care at all. Barriers to access to health care, inability to communicate, religious and cultural differences were identified and all posed risks for their management. Our review showed high rates of preterm delivery, both late preterm and less than 34 weeks, a high rate of primary caesarean section, especially for fetal distress, and low Apgar scores for their neonates. Preeclampsia, fetal growth restriction, low birth rates and stillbirth were all higher compared to the native population.


Our review showed that refugees pregnant women are at high risk for pregnancy related complications and their management remains a challenge for all mainly due to administrative problems.


Özalp M. 1, Erdil G. 2, Ercin M. 3, Osmanağaoğlu M. 1

KTU, Perinatology, Trabzon-Turkey 1

Arakli Bayram Halil State Hospital, Obstetrics and Gynecology, Trabzon-Turkey 2

KTU, Pathology, Trabzon-Turkey 3


Impairment of feto-maternal unit may result intrauterine growth restriction (IUGR). Placental microvasculature epigenetic regulation is one of the critical factor for fetal growth restriction, however, the spectrum of epigenetic pathophysiological mechanisms leading to IUGR remains to be elucidated. Epigenetic changes including DNA methylation, histone modification, and post-transcriptional small non-coding microRNAs are reversible modifications in gene expression without altering the primary DNA sequence. In this study, the GSE25861 gene’s microarray data were downloaded from the “Gene Expression OmniBus” database to investigate the association of intrauterine growth retardation with epigenetic modifications.


Differences in gene expression level were generated by re-analyzing the mRNA transcripts of the placental micro-vascular endothelial cells obtained from preterm control placentas (n = 3) and placentas from pregnancies with severe IUGR (n = 6) with absent or reversed end-diastolic velocity in the umbilical artery. “Biobase”, “Limma” and “Geoquery” libraries were obtained with bioinformatics analysis in R software. Protein-protein interaction network was constructed from the STRING database for visualize protein-protein interaction of these differentially expressed genes. In comparing the expression profiles of transcripts, “log2 fold change > 1” and P ≤ 0.05 were considered statistically significant.


Statistically significant differences were found in genes related to DNA methylation and histone modifications (acetylation, methylation, phosphorylation, ubiquitination) by using the DAVID (Database for Annotation, Visualization and Integrated Discovery) functional annotation system.


Epigenetic modifications have a crucial role in IUGR pathogenesis and this interplay will need to be explored by further molecular pathology studies to fully comprehend.


Hasegawa J. 1, Furuya N. 1, Suzuki N. 1

St. Marianna University School of Medicine, Obstetrics and Gynecology, Kawasaki-Japan 1

Superb Micro-vascular Imaging (SMI; Canon Medical Systems, Tokyo) is a blood flow imaging technique that employs a unique algorithm to minimize motion artifacts by eliminating signals based on analysis of tissue movement. SMI effectively separates flow signals from overlaying tissue motion artefacts preserving even the subtlest low flow components with unmatched detail and definition. Both blood flow and tissue motion (clutter) produce ultrasonic Doppler signals. The strong clutter signals overlap the low velocity blood flow components. Conventional Doppler imaging applies a wall filter to remove clutter and motion artefact, resulting in a loss of low velocity components. SMI analyzes the characteristics of clutter motion and uses a new adaptive algorithm to identify and remove tissue motion and reveal the true blood flow. Therefore, compared to conventional blood flow imaging such as color and power Doppler imaging, SMI significantly reduces motion artifacts and can visualize low-velocity blood flow in small vessels. Therefore, we considered SMI technic was particularly valuable in placental assessment during pregnancy. In our research, comparing ultrasound findings using SMI with placental histological findings after delivery, it is demonstrated that histological findings including congestion of villous stem vessels, placental infarction, increase of terminal villous vessels, and avascular villi were distinguishable by this technique. In the present report, the clinical value and future potential of SMI in antenatal placental assessment will demonstrate. We believe this new blood flow imaging technique is acceptable not only for the purpose of perinatal clinical assessments but also pathophysiological clarifications of various placental abnormalities.


Khan N. 1, Ciobanu A. 1, Akolekar R. 2, Nicolaides K. 1

King’s College Hospital, Fetal Medicine, Kent-United Kingdom 1

Medway Nhs Trust, Fetal Medicine, Kent-United Kingdom 2


To evaluate and compare the performance of routine ultrasonographic estimated fetal weight (EFW) and fetal abdominal circumference (AC) at 31+0 – 33+6 and 35+0 – 36+6 weeks’ gestation in the prediction of large for gestational age (LGA) neonates born at ≥37 weeks’ gestation.


This was a retrospective study. First, data from 21,989 singleton pregnancies that had undergone routine ultrasound examination at 31+0 – 33+6 weeks’ gestation and 45,847 that had undergone routine ultrasound examination at 35+0 – 36+6 weeks were used to compare the predictive performance of EFW and AC for LGA neonates with birthweight >90th and >97th percentiles born at ≥37 weeks’ gestation. Second, data from 14,497 singleton pregnancies that had undergone routine ultrasound examination at 35+0 – 36+6 weeks’ gestation and had a previous scan at 30+0 – 34+6 weeks were used to determine, through multivariable logistic regression analysis, whether addition of growth velocity, defined by a difference in EFW and AC Z-scores between the early and late third trimester scans divided by the time interval between them, improved the performance of EFW at 35+0 – 36+6 weeks in the prediction of delivery of LGA neonates born at ≥37 weeks’ gestation. Third, in the database of the 45,847 pregnancies that had undergone routine ultrasound examination at 35+0 – 36+6 weeks’ gestation the screen positive and detection rate of LGA neonates born at ≥37 weeks’ gestation and at ≤10 days from the initial scan were calculated for different EFW percentile cut-offs between the 50th and 90th percentile.


First, the areas under the receiver operating characteristic curves (AUROC) of screening for LGA neonates were significantly higher with EFW Z-score than AC Z-score and at 35+0 – 36+6 than at 31+0 – 33+6 weeks’ gestation (p<0.001). In screening by EFW >90th percentile at 35+0 – 36+6 weeks’ gestation the predictive performance for LGA neonates born at ≥37 weeks’ gestation was modest (65% and 46% for neonates with birthweight >97th and >90th percentiles, respectively, at screen positive rate of 10%), but the performance was better for prediction of LGA neonates born at ≤10 days from the scan (84% and 71% for neonates with birthweight >97th and >90th percentiles, respectively, at screen positive rate of 11%). Screening by EFW >70th percentile at 35+0 – 36+6 weeks’ gestation predicted 91% and 82% of LGA neonates with birthweight >97th and >90th percentiles born at ≥37 weeks’ gestation, at screen positive rate of 32%, and the respective values of screening by EFW >85th percentile for prediction of LGA neonates born at ≤10 days from the scan were 88%, 81% and 15%.


On the basis of these results it was proposed that routine fetal biometry at 36 weeks’ gestation is a screening rather than diagnostic test for fetal macrosomia and that EFW >70th percentile should be used to identify pregnancies in need for another scan at 38 weeks and in the latter those with EFW >85th percentile should be considered for iatrogenic delivery during the 38th week.


Antsaklis P. 1, Mariana T. 1, Eleytherios A. 2, Michael S. 1, George D. 1

University of Athens, Alexandra Maternity Hospital, Athens-Greece 1

Naval Hospital of Athens, Naval Hospial of Athens, Athens-Greece 2


To assess whether low PAPP-A (Pregnancy associated plasma protein-A) at 11-13+6 weeks of pregnancy is related to bad obstetrical outcome and more specifically small for gestational age newborns and stillbirths.


A retrospective study, from 2 university hospitals (Athens University-Greece and Craiova University-Romania), which included all women who attended for the first trimester screening for chromosomal abnormalities (Nuchal Translucency, free-βhCG and PAPP-A). The study included all women with singleton pregnancies. In total there were 9533 women, while complete data and pregnancy outcome were available in 4012 women. Low PAPP-A (<0,3MoM) was found in 215 women, while complete data and pregnancy outcome was available in 103 of these pregnancies.


From the 9533 pregnancies we identified 215(2.2%) with low PAPP-A (0,3MoM). Complete data and outcome of the pregnancy was available for 103 of these pregnancies. From the 103 pregnancies with low PAPP-A we excluded 11 cases who underwent termination of pregnancy for abnormal karyotype. From the remaining 92 pregnancies there were 8 cases of small for gestational age and 2 cases of intrauterine fetal death. There were also 3 cases of preterm delivery and 4 cases of late miscarriage (after 16 weeks).


Low PAPP-A (< 0,3MoM) during the first trimester of pregnancy seems to be related with an increased risk of adverse obstetrical outcome and more specifically with small for gestational age fetuses and stillbirth. Pregnancies with low PAPP-A values, even when the risk for chromosomal abnormalities is low should be managed as high-risk pregnancies.

Obstetrics – Hypertension in Pregnancy


Rivera L. 1, Holgado P. 2

University of Santo Tomas Hospital, Obstetrics and Gynecology, Metro Manila-Philippines 1

University of Santo Tomas Hospital, Obstetrics and Gynecology, Metro Manila-Philippines 2

A contraction stress test (CST) is an antenatal surveillance done in pregnancies at risk for the consequences of uteroplacental pathology like hypertension and diabetes. It evaluates fetal heart rate response to induced uterine contractions hence determining fetal reserve prior onset of labor. Acupuncture is used in obstetrics and gynecology as an effective tool in initiating uterine contractions.


This study aims to compare contractions produced by acupuncture technique from that of the conventional technique using oxytocin to determine if acupuncture can be an alternative method in establishing uterine contractions in CST.


This is a randomized controlled trial employed in fifty-four (54) term high risk pregnancies who were randomized into two groups: 27 patients in the acupuncture group and 27 patients in the oxytocin (control group). Acupuncture needles were applied bilaterally at two loci, Sanyinjiao (spleen 6) and Hegu (Large Intestine 4), to produce the desirable contractions that are interpretable for a CST.


Subjects who received acupuncture had greater intensity (p=0.551) and significant longer duration (p=0.001) of uterine contractions than the oxytocin group. However, there was a significant shorter interval of uterine contractions after oxytocin treatment (p=0.013) than acupuncture. Furthermore, subjects who were in the acupuncture group obtained initial uterine contractions (5.29 versus 10.62 minutes; p=0.000) and achieved desirable uterine contractions (14 versus 30.89 minutes; p=0.001) faster than oxytocin. There is shorter waiting time for disappearance of the contractions in the acupuncture group than in oxytocin group (36.70 versus 57.74; p=0.000). One subject in the acupuncture group experienced minor bleeding at the needling site and 2 subjects complained of pain from needling. During the conduct of the study, it revealed that subjects in the acupuncture group spent less than in the oxytocin group due to use of lesser materials than that of the conventional method.


Application of acupuncture in Spleen 6 (Sanyinjiao SP6) and Large Intestine 4 (Hegu LI4) is effective in initiating and inducing uterine contractions. Acupuncture technique when compared to the conventional method using oxytocin, produces stronger and longer contractions. Furthermore, this study showed that contraction stress test can be completed in a shorter time thru acupuncture technique as it shows shorter mean time to achieve initial and adequate contractions thru this technique. Contractions also disappear in a much shorter time in acupuncture technique than in oxytocin group hence ideal for outpatient setting. The adverse effects seen in this study were mild and transient. Cost to perform a contraction stress test using the acupuncture technique is significantly lower than that of the conventional method using oxytocin. Acupuncture should be considered as an alternative technique for contraction stress test as this is, simple, practical, cheap, and safe for the women and her infants.


Spyroulis C. 1, Gandhi H. 1

East Surrey Hospital, O&G, Redhill-United Kingdom 1

We are presenting a case of stroke in a primiparous woman with no history of BP, cardiac or hyper coagulability problems. She smoked 10cigarettes/day. Her BMI was 23 and Asian Black in ethnicity. She developed gestational diabetes which was well controlled with metformin 500mg BD. She was on Aspirin 75mg from 12 weeks. Induction of labour was planned at 37w due to diabetes. She was admitted at 36 weeks due to slurred speech and weakness of the left hand. Medical registrar advised CT Head which was normal. Due to persistent symptoms, MRI of the head was performed, which showed small lesions in the front-parietal cortex, suggestive of stroke. She was commenced on Aspirin 300mg OD. During her stay she had MRV, heart ECHO, Doppler of lower limbs and CT angio-head which were normal. She delivered by an uncomplicated Elective CS at 36 weeks and 3 days. MRI performed a week later was normal. She made a good recovery. She was discharged on Aspirin with a further appointment with the stroke team.

Stroke in pregnancy is a recognised complication which contributes to >12% of maternal deaths. Incidence is between 4.3-210/100000. Stroke in young age (15-35) is more common in women and associated with poorer outcomes in terms of disability and dependency. Some risk factors for stroke are: a)age >35, b)black ethnicity, c)hypertension, d)heart disease, e)lupus, f)sickle cell disease.

Exposure to CT scan can be teratogenic. There is strong evidence that the teratogenic levels of the CT are 5000mrad. A single CT head is equal to 50mrad, 10mrad for CT cerebral angiography and chest X-ray is 1mrad. The risk for the baby to develop cancer is 1/17000 per 100mrad of foetal exposure. Use of iodinated agents carries risk of hypothyroidism in the newborn. There are no adverse effects to the foetus from MRI, but the long term consequences, are unknown. Prior to use of Galodinium, due to its long half-life, a thorough risk-benefit assessment should be made as it is associated with stillbirths and neonatal deaths.

In conclusion, stroke is one of the causes of indirect maternal deaths since pregnancy itself is hyper coagulated period. Literature shows that CT and MRI of the head are safe to use in pregnancy.


Bektaş O. 1

Mersin University Medical Faculty Obstetrics and Gynecology Mersin-Turkey 1


The pathogenesis of preeclampsia is still poorly understood. Recent research has shown that the incidence varies according to conception and birth season. A cross-sectional study was conducted to determine whether there was a relationship between the birth season and the prevalence of preeclampsia in the province of Mersin.


We retrospectively analyzed hospital discharge records of 451 hypertensive pregnant women who delivered in our hospital between 2010-2018. Spring (March, April, May), summer (June, July, August) and autumn (September, October, November), winter (December, January, February), was discussed. Monthly map was taken according to the last date and date of delivery.


Among 451 hypertensive diseases, mild preeclampsia was the most common among women (42.1%). According to the season of birth, hypertensive pregnancy was the most common in winter (27.5%). According to the last menstrual period, hypertensive disease was higher in the pregnant women who were pregnant in spring (29.2%). The prevalence rate in January and July was higher than the other months (10.2%, 10%) and the prevalence in May was lower than in any month (4.2%).


The prevalence of hypertensive pregnancies was higher in the summer and winter months and it was lower for spring between Mersin women. It is observed that temperature and humidity changes may affect preeclampsia in different seasons. More extensive cohort studies are needed to validate this data.


Bektaş K. 1

Mersin University Medical Faculty, Obstetrics and Gynecology, Mersin-Turkey 1


Abnormal changes in immune mediated inflammation contribute to the pathogenesis of preeclampsia (PE). In this study, our aim was to evaluate systemic inflammatory indexes [neutrophil / lymphocyte (NLR), platelet / lymphocyte (TLR), monocyte / lymphocyte (MLR), platelet / neutrophil (PNR)] as indicators of disease, and to evaluate early diagnosis and severity of PE. to investigate as a theoretical basis.


In this retrospective case-controlled study, clinical records of 548 pregnant women were screened. 28 patients had eclamptic seizures, 50 patients had hellp syndrome, 20 patients had superimposed preeclampsia and 19 patients had chronic hypertension were taken off study due to these disease. 122 healthy healthy control group and 309 preeclampsia (PE) patient (190 mild, 119 severe PE) Hemoglobin (Hb), hematocrit (Hct), platelet count, mean platelet volume (MPV), platelet / MPV ratio (P/M), leukocyte, neutrophil, monocyte, lymphocyte count, alt, ast, urea, creatinine values and systemic inflammatory response markers (NLR), (TLO), (MLO), (TNO) rates were recorded.


No significant difference was found between mild and severe preeclampsia groups, but MPV, neutrophil, lymphocyte and monocyte counts, NLO, TLO, MLO and TNO values were significantly different when compared to control group. The ROC curve analysis showed that NLR had better diagnostic accuracy in separating PE from controls [NLR area under curve (AUC) = 0.548. ,When NLR taken as >3.49, 51.5% sensitivity, 50.8% specificity, 71.9% positive predictive value, 71.4% negative predictive value is obtained.


Secondary analysis of complete blood count parameters effectively evaluates systemic inflammation and immune status. Compared to absolute cell numbers, NLR and PLR provide more effective indicators for clinical evaluation, disease severity assessment and prognosis of PE.


Uzun A. 1

Medipol University, Gynecology and Obstetrics, Istanbul-Turkey 1


Cerebrovascular disease (CVD: stroke) is an obstetric mortal emergency that is associated with neurological severe sequelae which increases its risk in rare pregnancy. SVH occurs as a result of occlusion or perforation of the vessel. Hypertension is the most important risk factor. It is usually seen in preeclampsia and antiphospholipid syndrome in the second, third trimester and postpartum periods. Headache, impaired consciousness, nausea, focal neurological disorders, convulsion is the most common clinical picture.


23-year-old Gravide1 Parity 0 There was no emergency problem during pregnancy follow-up. At 38th gestational week, fetal bradycardia at NST: 80 / min was seen and emergency caesarean section was performed. In the postoperative 2nd hour, sudden loss of consciousness and 1-minute long-lasting generalized tonic-clonic contraction were detected. Anus resuscitation was performed. In the follow-up, blurred consciousness, tendency to look to the left and to the left to the left, cooperation limitation, and tonic-clonic focal seizure in the left-upper-extremity, which lasted for 2 minutes were observed. TA 140/90, pulse 80, htc: 36,4%, hb12 g / dl, plt148000 (10e3 / μl), tsh3,7 (MIU / ML), 2 glucose: 114 (mg / dl), complete urine: protein ( –), urea: 14 (mg / dl), creatinine: 0.52 (mg / dl), total protein 4 (mg / dl), albumin: 2.1 (g / dl), SGOT: 30.5 (U / L), SGPT: 19.4 (U / 1), Na: 128.8 (mmol / l), K: 4 (mmol / l), Ca: 7 (mg / dl), Mg: 3 (mg / dl), CRP: 26 (mg / l), vit b12: 330 (pg / ml). Brain MR: acute infarct area of bilateral lentiform nuclei was seen in right posterior parietal region.

Contrast-enhanced MR-venography and echocardiography were normal. In the EEG, a common paroxysmal anomaly was detected on the left frontal area. Coraspin 300 mg1 * 1, fraxiparin 0.6 2 * 1, tegretol 400 CR 2 * 1 alfamet3 * 1 treatment was started. Congenital lupus AV block was detected in the baby of the patient. After 1 week, MRI showed regression of lesions, and he was discharged 10 days later. Cerebrovascular disease is a rare obstetric emergency with 25% mortality and 25% neurological sequelae. CVD is caused by occlusion or perforation of the vessel. The occlusion of the vessel causes ischemia, perforation leads to hemorrhagia. Preeclampsia and antiphospholipid syndrome are the most common etiological factor in the second, third trimester and postpartum periods. She has headache, impaired consciousness, nausea, focal neurological disorder, and convulsion. In the postpartum second hour, sudden loss of consciousness, generalized tonic clonic seizure, focal clonic seizure in the left upper extremity was applied positive.


CVD is a high obstetrical emergency. Emergency diagnosis and treatment are important in prognosis. Reduction of brain edema and anticonvulsant therapy is essential in patients with CVD.


Kascak P. 1, Hlavacik M. 1

Faculty Hospital, Ob/Gyn, Trencin-Slovakia 1


Aim of our retrospective study was to define percentage of successful vaginal births after cesarean delivery (VBAC) and compare this to planned and emergency repeat cesarean delivery.


We have retrospectively analyzed all deliveries after one cesarean delivery in our department for the last 15 years (2002 – 2016). We have also analyzed possibility of VBAC after two previous cesarean deliveries.


During the study period, we have performed 23 660 deliveries, out of those 3 832 were cesarean deliveries (16.2%). 1 679 women were already after one previous cesarean delivery (7.1%). Elective repeat cesarean section was done in 882 women (52.5%). The rest, 797 women, had an attempted vaginal delivery (47.5%). In these, a successful vaginal delivery was in 642 cases (80.5%) and in the remaining 155 women (19.5%) we were forced to perform emergency repeat cesarean section. There were no significant differences in perinatal mortality or morbidity in newborns or in mothers (uterine rupture, emergency hysterectomy, injury of urinary bladder) between the groups. We have performed detailed analysis of VBAC and selected obstetric indicators for the last seven years (2009 – 2016). In this detailed analysis, we observed these success rates of VBAC: 92% in women with history of at least one previous spontaneous vaginal delivery, 72.1% in women without this history, 83.6% in women with spontaneous start of labor, 58.3% in women with induced labor, 80.7% in newborns < 4000 grams, 66.1% in newborns ≥ 4000 grams and 71.8% in women with history of failure in the mechanisms of labor (dystocia). The most common indication for emergency repeat cesarean section was non progressing delivery and fetal hypoxia. Separately, we describe first experience of attempted vaginal delivery in women after two previous cesarean deliveries.


We have confirmed high success rates of VBAC, which is associated with low risk of complications in mother and fetus. Comparing our data to literature, where we have witnessed an explosion of VBAC with subsequent rapid decline, our VBAC rates are stable during the study period. In the last years we have attempted, albeit in strictly selected population, VBAC after two previous cesarean deliveries.


Herraiz I. 1, Permuy C. 1, Sacristán L. 1, Zamoro-Lorenci M. 1, Quezada M. 1, Gómez.Arriaga P. 1, Villalaín C. 1, Galindo A. 1

Hospital Universitario 12 De Octubre. Instituto De Investigación Imas12. Universidad Complutense De Madrid, Obstetrics and Gynecology, Madrid-Spain 1


Expectant management of early-onset preeclampsia (PE) is recommended until 34 gestational weeks as long as the maternal and fetal status remains uncomplicated. However, the appearance of adverse outcomes is difficult to predict with the commonly available diagnostic tools. Our aim is to analyze if the sFlt-1/PlGF ratio is more useful than other common parameters performed at the time of diagnosing early-onset PE to predict adverse outcomes and time-to-delivery interval.


Retrospective cohort study of 88 consecutive cases of early-onset PE (diagnosed before 34 weeks using NHBPEP criteria) in our tertiary hospital during the period 2016-18. Iatrogenic delivery decisions were made following current guidelines. sFlt-1/PlGF was measured at the time of diagnosis (+/-3 days) together with other routine lab tests including: protein:creatinine ratio, transaminases (ALT and AST) and serum creatinine. 12 cases were excluded: absence of sFlt-1/PlGF result (n=3), inability to expectant management (n=7), lost to follow-up (n=2). The association between the sFlt1/PlGF ratio and other routine parameters with subsequent adverse outcomes: maternal death, eclampsia, stroke, HELLP syndrome, subcapsular hepatic hematoma, pulmonary edema, placental abruption, and acute renal failure, as well as the time-to-delivery interval was analyzed. Previously described sFlt-1/PlGF cutoffs of 85 and 655 for aid in preeclampsia diagnosis and increased risk for delivery in 48 hours were used for analysis.


76 cases of early-onset PE with intended expectant management were finally included. Fetal growth restriction was present in 48/76 (63.2%) cases and 18/76 (23.7%) developed adverse outcomes (with some women suffering more than one complication: 9 HELLP syndrome, 6 abruption, 3 pulmonary edema, 2 renal failure, 1 subcapsular hepatic hematoma). None of the parameters studied at diagnosis obtained a good prediction of the subsequent appearance of adverse outcomes, with areas under ROC curves of 0.65 (95%CI 0.50-0.80) for platelets, 0.61 (95%CI 0.45-0.77) for sFlt-1/PlGF, and < 0.60 for mean arterial pressure, protein:creatinine ratio, transaminases (ALT and AST) and serum creatinine. Mean (SD) gestational age at PE diagnosis was 29.7 (3.0) weeks. Mean (SD) time-to-delivery interval was 11.1 (9.7) days. The median (25th-75th centile) of the sFlt-1/PlGF ratio in cases delivered <= 2 days, 2-7 days and >7 day were 609 (319-1243), 346 (197-556) and 206 (128-373), respectively (p<0.001) as shown in the Figure. In 70/76 (92.1%) and 12/76 (15.8%) cases a value of the sFlt-1/PlGF ratio above 85 and 655 was measured at PE diagnosis, respectively. In the latter, the development of adverse outcomes was observed in 5/12 (42%) cases vs. 13/64 (20%) in PE cases with sFlt-1/PlGF ≤655 (p=0.14). The mean (SD) time-to-delivery interval was of 4.4 (7.5) vs. 12.1 (9.3) days, respectively, p<0.01. The relative risk for delivery in <= 2 days with sFlt-1/PlGF ratio >655 was of 5.3 (95%CI 2.7 – 10.6), p<0.01.


None of the parameters obtained at early-onset PE diagnosis were useful to accurately predict the development of adverse outcomes. However, the value of the sFlt-1/PlGF ratio was closely related to the time-to-delivery interval. Especially, a sFlt-1/PlGF value above 655 increases 5 times the risk of delivery in the next 48 hours.


Kornacki J. 1

University of Medical Sciences, Division of Reproduction, Department of Obstetrics, Gynecology and Gynecological Oncology, Division of Reproduction, Poznań-Poland 1


The study aimed to assess serum levels of two components of endothelial glycocalyx (EG), syndecan –1 (Sdc-1) and hyaluronan (HA), as markers of endothelial injury as well as concentration of soluble fms-like tyrosine kinase 1 (sFlt-1) in patients with two forms of preeclampsia (PE), placental and maternal PE.


Blood samples were collected in the third trimester of pregnancy from 20 women with placental PE, 20 with maternal PE , and 20 with normal pregnancy for the assessment of serum levels of Sdc-1 and HA. All patients were hospitalized between 2015 and 2018 at the Division of Reproduction of Poznan University of Medical Sciences. Preeclampsia was characterized by hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥ 90 mmHg on two occasions) and proteinuria (≥ 300mg/24 h), both of which found for the first time after 20 weeks of gestation. Placental PE was diagnosed if the intrauterine growth restriction (IUGR) of a fetus was additionally found. IUGR was diagnosed if ultrasound-estimated fetal weight was below the 10th percentile according to local growth charts and the Doppler criteria for placental insufficiency were also met. Maternal PE was diagnosed if no IUGR was found.


Mean serum concentrations of Sdc-1 was 6,29 ng/ml in the whole group of patients with PE (placental and maternal PE). It was significantly lower than that in the healthy pregnant women (11 ng/ml, p<0,001). The serum level of Sdc-1 did not differ significantly between the two groups of patients with PE.

In contrast, the mean serum level of HA was significantly higher in the whole group of patients with PE (236,2 pg/ml) than in the control group (113,9 pg/ml). However, the concentrations of HA did not differ between patients with placental and maternal PE. Serum level of HA in the three groups of patients is shown in Figure.

No significant correlation was found between gestational age at the onset of preeclampsia and the concentration of Sdc-1 and HA in both studied groups.

The concentration of sFlt-was the highest in patients with placental PE (3,71 ng/ml). Both the levels of sFlt-1 in women with placental and maternal PE (3,22 ng/ml) were significantly higher than in the control group (0,3 ng/ml). There was no statistical difference between concentrations of sFLt-1 in patients with two forms of PE.


1. Evaluation of serum concentrations of HA in patients with PE seems to be more useful in the assessment of endothelial injury than that of Sdc-1.

2. The degree of EG damage is comparable in patients with placental and maternal PE.

3. The significance of lower concentration of Sdc-1 in patients with preeclampsia than in normotensive pregnant women needs further evaluation.

4. Mechanism of endothelial injury in women with placental PE is probably more sFlt-1 dependent than in patents with maternal form of PE.


Erol A. 1, Kırbaş A. 1, Çelen Ş. 1, Çağlar T. 1

University of Health Sciences, Zekai Tahir Burak Women’s Health Education and Research Hospital, Perinatology Department, Ankara-Turkey 1


To present as a case of twin pregnancy with complete type hydatiform mole and coexisting alive fetus (CHMCF)


A 19-year-old primigravid patient was referred to our clinic with a preliminary diagnosis of CHMCF at 26th gestational week. We examined an enlarged uterus (compatible with 30 weeks of gestation) and alive fetus consistent with 26 weeks of gestation. There was no evidence of fetal anomaly on admission. A normal-appearing placenta was present along the posterior uterine wall, and a separate large cystic mass was seen on the anterior wall, most consistent with complete mole (Figure 1-2). Serum β-hCG value was 134.342 mIU / ml, free T4 was 1.36 ng / dl, TSH was 0.489 uIU / ml. Other laboratory tests were normal and blood pressure (BP) was 110/70 mmHg. In addition, transabdominal ultrasonography and chest X-ray were normal. CHMCF was considered, and the family was informed about complications that may occur as a result of continuation of the pregnancy, risks of gestational trophoblastic disease (GTD) and treatment options particularly. The family did not accept invasive diagnostic tests and termination. The antenatal steroid (betamethasone) doses for fetal lung maturation was completed at 26 weeks. At 28 weeks of gestation, the patient’s clinical condition deteriorated. Her BP spiked to 190/110 mmHg with severe headache, visual symptoms and active vaginal bleeding that was accompanied with severe preeclampsia. Intravenous magnesium sulphate was given to prevent seizures. Delivery was performed by caesarean section and a viable normal appearing female fetus (birth weight 1230 g, Apgar scores 6, 7 at 1 and 5 minutes, respectively) and placenta were delivered without complications. The separate mass of multiple grape-like cystic vesicles was removed by suction curettage to ensure complete removal of the molar tissue (Figure 3). There were no signs of placenta previa or invasion anomaly. On postoperative day 1, β-hCG was 19096 mIU/ ml, and 3452 mIU / ml on the third day. She recovered well in 3 days of hospitalization and discharged. The diagnosis of complete type hydatiform mole was confirmed by pathology. At 2 months follow up her β-hCG levels were normal. She is healthy at one year follow up without any evidence of persistent GTD and her baby is doing well.


CHMCF is a rare obstetric condition. The estimated incidence is about 1 in 22.000-100.000 gestations. Management of these cases poses a clinical dilemma with inherent risk of severe maternal complications like abortion, preterm delivery, preeclampsia, thyrotoxicosis, antepartum hemorrhage, intrauterine fetal death, placenta accreta and GTD. Fetus also carries the significant risk of malformations, chromosomal abnormalities and extreme prematurity. Most of such pregnancies are terminated prematurely either because of persistent hemorrhage or severe preeclampsia and nearly three fourth of the cases do not go beyond 20 weeks of pregnancy. Continuation of CHMCF is an acceptable option but the chance of a live term birth is <50%, with nearly 33-50 % of the mothers developing GTD after the delivery. Therefore, counseling to the family and an individualistic approach is important.


Velegrakis A. 1, Doulaptsi M. 2, Matalliotakis M. 1, Demosthenous E. 1, Sifakis S. 3

Venizeleio General Hospital, Department of Obstetrics and Gynecology, Heraklion-Greece 1

University of Crete, Department of Otorhinolaryngology – Head and Neck Surgery, Heraklion-Greece 2

University of Crete, Department of Obstetrics and Gynecology, Heraklion-Greece 3


Idiopathic unilateral peripheral facial nerve paresis, Bell’s palsy, is a rare complication during pregnancy and puerperium and it is controversial whether pregnant women have a poorer prognosis compared to non-pregnant patients. We present a case of Bell’s palsy that developed 72 hours postpartum, in a woman presenting with HELLP syndrome and eclampsia.

A 28 years old pregnant woman, G3P2, with 2 uncomplicated vaginal deliveries at term in her obstetrical history and without any other medical history, presented for the first time at 36w+5 GA due to uterine contractions. The woman was a refugee from Syria that had come to Greece a few days ago and unfortunately, due to her state, she had not received a proper antenatal maternal and fetal surveillance during pregnancy. Initial assessment included BP measurement, laboratory tests, cardiotocography and ultrasound fetal scan. BP was 190/120 mmHg.,blood and urine tests showed Hct: 43.6%, PLT:110000, SGOT:140, SGPT:58, LDH:693, Uric acid:8,4, proteinuria, and sonography revealed a SGA fetus at <10th centile with EFW 2100gr; all of which indicated severe preeclampsia and HELLP syndrome. After nephrologic consultation, immediate induction of labor was decided but soon after, the woman developed eclamptic seizures which led us to an emergent cesarean under general anesthesia. The newborn, a male 2120gr with a good Apgar score was transferred in the NICU and was discharged a few days later in excellent condition. However, mother was transferred to the ICU of University Hospital immediately after the operation and stayed intubated and in shock for 2 days. On 4th day postpartum, he was discharged from the ICU and transferred to the Nephrology Department where she stayed for 5 more days, and efforts were made to control hypertension and regulate her impaired renal function. On the 9th day postpartum, she developed puerperal sepsis and was transferred again to the Obstetrics department where she received aggressive antibiotic treatment. She was discharged from the hospital 15 days after delivery.

Moreover, 72 hours postpartum, the patient reported a sudden muscular loss on the left side of the face accompanied by an inability to smile, close the eye and raise the eyebrow. History, clinical examination, laboratory, and imaging investigation excluded trauma, infection, CNS pathology, and tumor as possible causes. The patient was diagnosed as having unilateral peripheral facial nerve paresis House-Brackmann Grade III-moderate dysfunction. High doses of intravenous prednisolone were given, with gradual tapering. Within three months, facial nerve function had fully recovered.


There have been reports in the literature that there is an association between facial nerve paresis and hypertensive disorders of pregnancy, and some authors have suggested that facial palsy may be a precursor for preeclampsia. However, in our knowledge this is the first report of a woman with overt eclampsia and HELLP syndrome that develops Bell’s palsy shortly after labor, in which aggressive corticosteroid treatment resulted in an optimal outcome with full function recovery.

Obstetrics – Maternal nutrition


Santiago M. 1, Olivar J. 1, Reyes L. 1

Far Eastern University – Dr. Nicanor Reyes Medical Foundation, Obstetrics and Gynecology, Manila-Philippines 1


Anemia is a major global problem that affects women and is prevalent during pregnancy. Effective management is needed to prevent adverse pregnancy outcomes. Ferrous iron salts are the preparation of choice and recommended for both prevention and treatment of iron deficiency anemia (IDA). However, most commonly available iron supplements are poorly absorbed, with gastrointestinal disturbances as side effect.


To compare the efficacy of iron amino acid chelate and ferrous sulfate in the treatment of IDA among pregnant women seen at the out-patient department of a tertiary medical center.


This is a single-blind randomized controlled trial. Included were women 18 to 40 years old, with singleton pregnancies diagnosed with IDA without any co-existing fetal and maternal complications. Twenty four participants allocated on each treatment arm who took their assigned treatment twice a day for 90 days. Hemoglobin, hematocrit, MCHC, MCV, RDW & serum ferritin levels were taken at baseline and on days 30, 60 and 90 from initiation of treatment. Mean blood parameters were compared before and after treatment between two treatment arms as well as the mean difference of blood parameters on days post-treatment from the baseline using T-test. Adverse effects between two groups were compared using Chi-square.


No statistically significant differences in the mean blood parameters between Iron amino acid chelate and Ferrous sulfate on days 30 and 60 of treatment. There is significantly higher hematocrit and MCHC and lower RDW in Iron amino acid chelate group on day 90 after treatment. All CBC parameters on days 30, 60, and 90 post-treatment compared to baseline level were significantly increased for both treatment arms. However, day 90 level of serum ferritin significantly increased in the Iron amino acid chelate group.


Iron amino acid chelate is comparable to Ferrous sulfate in the treatment of IDA among pregnant women as it showed positive effects on CBC parameters up to day 90 of treatment. In improving serum ferritin level, iron amino acid chelate shows some promise. Iron amino acid chelate was found to be superior to ferrous sulfate as it achieved optimum treatment response even at a lower dose with lesser adverse effects. Improved oral iron treatment tolerability leads to better compliance to long-term therapy resulting to successful treatment outcome.


Balci S. 1, Esin S. 1

Baskent University Medical Faculty, Obstetrics and Gynecology, Izmir-Turkey 1


Hyperemesis Gravidarum(HG) is a disease with severe nausea and vomiting, beginning before the 22nd week of pregnancy. In studies conducted in different populations, approximately 0.3% and 2% of all pregnancies were affected. Although HG is thought to be a psychological disease, its pathophysiology has not been solved. Some meta-analyzes revealed the association of HG with depression and anxiety during pregnancy. The relationship between various hormones in the pathophysiology of HG has also been shown; however, a definitive study has not yet been published. Another reason for HG is Helicobacter Pylori infection. Human intestinal microbiology is profoundly effective in human health and diseases through its complex structure and mutual host-microbial interactions. A healthy microbiota has important functions in energy collection and storage, trophic and metabolic functions and protection against pathogens. It interacts with mucosal epithelial cells, thereby allowing maturation and maintenance of the host immune system, which affects the microbiotic composition. As a result, microbial dysbiosis has been associated with a number of immune and metabolic diseases. HG is a disease in which pregnant women present with gastrointestinal system symptoms and some associated metabolic changes. When literature is examined, it is seen that HG is examined in many different aspects. However, this issue has never been evaluated in terms of microbiota.


The aim of this study was to investigate the intestinal microbiology of 20 patients, 10 of whom had normal pregnancies and 10 of them were HG and the differences between the two groups were planned. PUQE (Pregnancy Unique-Quantification of Emezis) scoring is an interrogation test used to determine the severity of pregnancy nausea and vomiting. According to the test results, patients in the middle and severe disease groups were identified as HG patients. Stool flora scan was routinely planned for all patients. After 3 days of incubation, colonies were counted and the results were expressed as colony forming units per gram feces (c.f.u./g feces).All data were evaluated statistically and their relationship with clinical condition was discussed.


According to the PUQE test, there was a significant increase in Clostridium spp. and Candida spp. types and a significant decrease in Bifidobacterium spp. type in patients with hyperemesis gravidarum compared to normal pregnancies. At the same time, there was a significant difference between the group with HG and the group with normal pregnancies in terms of flora dysbiosis.


An intensive colonization by Candida spp. plays an active role in the breakdown of the intestinal barrier by the competition in the use of nutrients, leading to the loss of the established intestinal flora, which often contributes to the increase of intestinal permeability. Clostridium spp. do not have any beneficial properties for the microenvironment of the bowel. On the contrary, a significant amount of bioactive amines, histamine and gases (sulfur, CO2 and H2) can be released with proteolytic properties and can cause severe bloating. Bifidobacterium spp is one of the health-friendly bacteria in the actinobacteria family. It is effective in stimulating the immune system. The increase in Candida spp and Clostridium spp and the decrease in Bifidobacterium may be involved in the formation or exacerbation of HG. Our results suggest that gut dysbiosis may be a factor in HG.


Turgut E. 1

Gazi Üniversity, Obstetric and Gynecology, Ankara-Turkey 1


Pregnancies after cardiac transplantation carry high risk to the patient, fetus, and allograft and need to be closely monitored by an integrated team that includes a cardiovascular surgeon, cardiologist and a perinatologist in specialized centers. Preconception counseling is recommended for both evaluation of allograft dysfunction or vasculopathy and in terms of risk of recurrence of the underlying cardiac disease in offspring. Medications should be reviewed for teratogenic risk prior to conception Maternal risks are allograft rejection, infection, hypertension, and preeclampsia. Fetal risks include spontaneous abortion, premature delivery and low birth weight. We report a case of successful pregnancy in the cardiac transplant recipient.


A 30 year-old patient were first evaluated preconceptionally. She underwent cardiac transplantation due to viral myocarditis and dilated cardiomyopathy eleven years ago. Since then she was under immunosuppressive therapy and no allograft rejection has been noted. Routine blood tests and ultrasonography revealed no abnormality with normal left ventricular function on echocardiography. Drug doses were regulated with cyclosporine 250 mg/day, azathioprine 200 mg/day and low dose prednisolone. Patient were informed about potential risks during pregnancy for both mother, fetus and allograft rejection. She got pregnant spontaneously. She was carefully followed-up during pregnancy by cardiovascular surgeon, cardiologist and an obstetrics team experienced in high-risk pregnancies. Pregnancy went on very well without any fetal and maternal complications. At 38th weeks of gestation she had mild hypertension. She delivered, normal male infant 2970 g, APGAR score 9/10 with cesarean section under general anesthesia. She was carefully monitored postpartum she was discharged at 6th day postpartum without any complication.


Physiologic adaptive changes in the cardiovascular system which occur during pregnancy may lead to clinical problems in the cardiac transplant recipient. Patient should be carefully for by a multidisciplinary team throughout pregnancy and the postpartum period.


Judistiani R. 1, Nirmala S. 2, Gumilang L. 2, Sukandar H. 1, Irianti S. 3, Handono B. 4, Setiabudiawan B. 5

Faculty of Medicine Universitas Padjadjaran, Public Health Department, Bandung-Indonesia 1

Faculty of Medicine Universitas Padjadjaran, Bachelor in Midwifery Program, Sumedang Indonesia 2

Dr. Hasan Sadikin Hospital, Obstetrics and Gynecology Department, Bandung Indonesia 3

Faculty of Medicine Universitas Padjadjaran, Post Graduate Study in Obstetrics and Gynecology Specialty, Bandung-Indonesia 4

Faculty of Medicine Universitas Padjadjaran, Child Health Department, Bandung-Indonesia 5


Anemia in the third trimester has been identified as a risk factor for maternal and fetal morbidity that might lead to mortality in the perinatal period. The need for finding the best marker to predict anemia in the third trimester has become more important, especially in countries with low resource setting, where laboratory marker examinations are expensive. Hepcidin was named as the king of markers for iron deficiency, but it may not be applicable in pregnancy. The fact that the prevalence of anemia increased by trimesters in the cohort study, has triggered this study which aimed at defining the best marker among hepcidin, ferritin or soluble transferrin receptor (sTfR) in the first trimester to predict anemia in the third trimester.


This diagnostic study was nested on the cohort study of vitamin D and its impact during pregnancy and childhood in Indonesia. Pregnant women were recruited in the first trimester from four cities in West Java, Indonesia. They were screened for first trimester hepcidin, ferritin and sTfR level in the sera which were measured by ELISA, and complete blood count (CBC) in all trimesters which was done by impedance method measurement (Sysmex XP-100, Japan). Only subjects with complete data were included in analysis. Diagnostic study was performed to compare the three markers by finding the receiver operating curve (RoC), likelihood ratio (LR) and risk estimate (RR).


One hundred and eighty one pregnant women were eligible for analysis. The result of this study showed that serum ferritin level in the first trimester was the best marker to predict anemia in the third trimester of pregnancy. Hepcidin and sTfR performed poorly. A new cut off point of ferritin level below 27.23 ng/ml yielded the best ROC with 67% area under curve (95% CI 60%-75%, p <0.0001, Youden index J 0.28) and LR (+) 3.07 (95% CI 1.8-5.3) and specificity 86.29 % (95% CI 79.0%-91.8%). These last figures were better than the previously used cut off point of ferritin level below 30 ng/ml.


This study provided evidence that serum ferritin level in the first trimester was best to predict anemia in the third trimester. It will be valuable in targeting subjects for more rigorous approach for the prevention and treatment of anemia in pregnancy, especially in low resource setting. The usefulness of ferritin as the marker for treatment of anemia in pregnancy would need a carefully designed randomized controlled trial.

Obstetrics – Preterm labor


Wolf H. 1, Pinborg A. 2, Hegaard H. 3, Huusom L. 1

Hvidovre University Hospital, Department of Gynecology and Obstetrics, Hvidovre Denmark 1

Copenhagen University Hospital, Rigshospitalet, Fertility Clinic, Juliane Marie Center for Women, Children and Reproduction, Copenhagen-Denmark 2

Copenhagen University Hospital, Rigshospitale, Research Unit, Women’s and Children’s Health, Juliane Marie Center for Women, Children and Reproduction, Copenhagen-Denmark 3


Previous meta-analyses have suggested that antenatal treatment with magnesium sulphate (MgSO4) to women at imminent risk of preterm birth seems to decrease the risk of cerebral palsy. Despite this, the European EPICE cohort study recently revealed an almost non-existing use of MgSO4 for fetal neuroprotection among children born before 32 weeks of gestation. The reluctance to adopt this practice across European centres may be due to limited understanding of the neuroprotective mechanism including concerns about the optimal dose and timing of treatment. Such reluctance may also be due to concerns regarding the robustness of the evidence presented in previous meta-analyses. A recent trial sequential analysis adjusting for risk of random error due to repetitive testing estimated that data from additional 400 women are needed before accepting MgSO4 as evidence-based fetal neuroprotection. Hence, the objective of this study was to evaluate MgSO4 as a neuroprotector in preterm birth before 32 weeks of gestation in a clinical trial.


In this multicentre, placebo-controlled, double-blind trial, we randomly assigned 560 women at imminent risk for delivery between 24 and 32 weeks of gestation to receive MgSO4, administered intravenously as a 5-gram bolus followed by a constant infusion of 1 g per hour or matching placebo. The primary outcome measure was moderate-severe cerebral palsy. Secondary outcome measures included mortality, the combined outcome of moderate-severe cerebral palsy and mortality, and short-term neonatal outcome measures. Follow-up of surviving children was done at or beyond 18 months of corrected age by a clinical assessment in combination with the Ages and Stages questionnaire (ASQ) which is a standardized, age-related, validated questionnaire containing questions that can reveal signs of cerebral palsy. The trial was registered at (NCT01492608).


560 women underwent randomization and gave birth to 680 children. Gestational age at enrolment and at delivery was 28.7 weeks (SD 24.0-31.8) and 30.1 weeks (SD 24.0-41.3) respectively. 42 children died before reaching the age of 18 months. Follow-up by clinical assessment was achieved for 100% of the remaining children. The ASQ was completed for 97% of the children at the time of abstract submission.

All women and children will be included in an intention-to-treat analysis after unblinding of the trial in July 2019. Data will be analysed by the end of August for presentation at the 14th World Congress of Perinatal Medicine.


The results from this randomised clinical trial will be added to the previous meta-analysis to obtain firm evidence for MgSO4 as a neuroprotector and determine whether it should be used as standard therapy for women in preterm birth.


Herkiloglu D. 1, Ayvaci H. 1, Pekin O. 1, Sahin S. 1

Zeynep Kamil Women and Children Diseases Education and Research Hospital, Department Of Obstetrics and Gynecology, Istanbul-Turkey 1


The aim was to evaluate the effectiveness of pessary use in patients with cervical insufficiency or with cervical length less than 25 mm before the 25th week of gestation and to evaluate the examination and the findings.


In our study, among the pregnancies between the 16th and 24th gestational weeks, 60 pregnant women with a preterm delivery history and / or cervical length less than 25 mm were included. Among these 60 patients, 43 of them had short cervix, 17 of them had cervical insufficiency. According to the findings of the examination was applied to the patients pessary. Once a month, cervical culture and urine cultures were taken from patients who experienced pessary. Pessaries of pregnant women with 37 weeks of gestation were removed. Before reaching the 37th gestation week, pessaries were withdrawn in patients who had ongoing vaginal bleeding, premature rupture of membranes in unstoppable actions despite tocolytic treatment.


Among 60 patients who experienced pessary, 21 of them gave birth before 28 weeks, 39 of them gave birth after 29 weeks and beyond. Those who gave birth after 34 weeks were 31 patients and those who gave birth before 34 weeks were 29 patients. The presence of cervical funneling before pessary application shows a statistically significant difference in terms of patient’s giving birth before or after 28 weeks (p = 0.033). In patients with cervical funneling, there was a significant increase in birth before 28 weeks. Depending on whether or not patients applying with pain need for tocolysis, it shows statistically meaningful difference in terms of patient’s giving birth before or after 34 weeks (p = 0.001) (OR 7, 61, 95% GA 2.4-24.6). In the group without need for tocolysis, there is a meaningful increase in birth after 34 weeks. In patients with short cervical, cervical length below 20 mm, the cervical length over 20mm and cervical insufficiency history did not seem to have any statistically significant difference in terms of patient’s giving birth before or after 34 weeks (p= 0,154).


Our findings showed that, alongside the defined cervical risk factors, cervical funneling and need for tocolysis were important in pessary application. Further studies are needed on this subject.


Shibata T. 1, Inamura T. 1, Ueno T. 1, Yamada T. 1, Takeda T. 1, Uno K. 1, Tano S. 1, Suzuki T. 1, Harata T. 1, Izawa T. 1, Kishigami Y. 1, Oguchi H. 1

Toyota Memorial Hospital, Gynecology, Toyota-Japan 1


The rate of Cesarean section (CS) in Japan has increased to 25%. There are few reports about trial of labor after Cesarean (TOLAC) in preterm delivery and outcomes in neonates. We performed this retrospective study to reveal the safety of TOLAC in preterm delivery and associated neonatal respiratory complication.


From 2005 to 2017, patients who had prior CS and neonates born between 28 and 36 weeks of gestation were enrolled. The primary outcomes were the success rates of TOLAC in preterm and the neonatal respiratory outcomes of TOLAC and CS group. We defined respiratory disorder as a condition requiring oxygen therapy in neonatal intensive care unit (NICU). The following outcomes were also studied: weeks of gestation, neonatal weight, 5-minute Apgar score, the rates of intubation and chorioamnionitis. Criteria for TOLAC: Only one previous cesarean, and former CS was conducted lower and transverse section, no history of myomectomy, singleton and vertex presentation, no contraindication of vaginal delivery. All patients had contents of emergency CS and taken pre-examinations for CS in emergency.


In this period, total 112 patients with prior CS had preterm delivery. 17 patients were excluded due to placental abruption, severe preeclampsia or severe fetal growth restriction. 44 patients tried TOLAC and the other 51 patients received CS. Our study showed high success rates of TOLAC (100%) and no uterine rupture in this preterm periods. The rates of neonates who were admitted to NICU because of adverse respiratory disorder was significantly higher in CS group (27.2% vs 52.9%, p<0.05). There were no differences in Apgar score at 5 minutes, intubation and chorioamnionitis rates between two groups.


In preterm deliveries, CS rate is significantly higher than that in term deliveries. TOLAC in preterm is thought to be safe for mothers. CS compared with vaginal delivery is known to be associated with increased odds of respiratory distress and five minute Apgar less than 7 in preterm neonates. The weeks of gestation and neonatal weight were not significantly different. In this study, the rate of respiratory distress was significantly higher in CS than TOLAC group. These differences can be related to the failure of lung fluid clearance after CS, especially in preterm neonates. TOLAC in preterm is thought to be safe also for neonates. Immediate CS at onset of labor in preterm period, only in the reason of prior CS, is not recommended for both mothers and neonates for these patients.


All TOLAC in preterm succeeded and proved to be a reasonable strategy also for neonates to decrease respiratory disorder. TOLAC in preterm delivery can be safe and feasible for both pregnant women and neonates.


Bartha I. 1, de la Fuente M. 2, de la Calle M. 3, Martín-Boado E. 3, Martínez-Sánchez N. 3, Bartha J. 3

University Hospital La Princesa, Allergy, Madrid-Spain 1

University Hospital Virgen De La Salud, Pediatrics, Toledo-Spain 2

University Hospital La Paz, Obstetrics And Gynecology, Madrid-Spain 3


Atopic disease has risen up in the last decade. The atopic condition may influence fertility increasing it due to the Th2-cell cytokine profile, but the mechanism is yet unknown. The aim of this study is to evaluate the relationship between pregnant women with diagnosis of hay fever or not and their influence to their perinatal outcomes.


In total, 503 pregnant women with atopic condition were compared with a general obstetric population composed by 40354 pregnant women. Atopic condition included allergy to pollen, grasses, olive, cypress, false banana, arizonic, coniferous, waves, pollinosis and hay fever. Rates of preterm delivery (< 37 weeks’ gestation), low birthweight (< 2500 g), neonatal acidosis (pH < 7.20), low 5 minute Apgar’s score (< 7) and Cesarean section due to fetal distress were analysed. Chi squared was used for comparisons. Statistical significance was set at 95% level (p < 0.05).


The rates of both preterm delivery and low birthweight were significantly higher in women with atopic conditions (16.6% Vs. 9.8% for preterm delivery and 14.1% V. 8.0% for low birthweight; p < 0.000001 for both). On the contrary, the rate of caesarean section due to fetal distress was lower in the atopic group (1.8% Vs. 4.4%, p = 0.004). However, the rates of low Apgars’s score and neonatal acidosis were similar in both groups.


Women with atopic conditions are at higher risks of both preterm delivery and low birthweight. Inflammatory mechanisms should be furtherly studied.


Kadivnik M. 1, Milić Vranjec I. 1, Kocuta Petrović M. 2, Muller A. 1, Kralik K. 3, Arvaj N. 4, Bebek D. 4, Krstanović I. 3, Sijanović S. 1, Wagner J. 4

University Hospital, Faculty of Medicine, Department of Obstetrics and Gynecology, Osijek-Croatia 1

University Hospital, Department Of Obstetrics and Gynecology, Osijek Croatia 2

Faculty of Medicine, Department of Medical Statistics and Medical Informatics, Osijek-Croatia 3

Faculty of Medicine, Medical Genetics Laboratory, Department of Medical Biology and Genetics, Osijek-Croatia 4


Preterm delivery is defined as delivery occurring before 37 weeks of gestation, and is a major public health problem throughout the world. Approximately 1 in 10 babies are born preterm. Based on gestation, preterm birth is subdivided into three different cohorts: extremely preterm (< 28 weeks of gestation), very preterm (28 to < 32 weeks of gestation) and moderate or late preterm (32 to < 37 completed weeks of gestation). The aetiology of preterm birth is multifactorial and includes different pathologies, genetic and environmental factors.


One of the genetic factors implicated as a factor for the occurrence of preterm birth is genetic polymorphism in progesterone receptor gene (PGR). The aim of this study is to evaluate whether polymorphism in the progesterone receptor gene both in mother and foetus is associated with susceptibility to preterm birth.


A total of 105 women with preterm birth and 108 women who delivered at term were genotyped for progesterone receptor gene polymorphisms (rs10895068, rs1042838, rs1042839) using Taqman assays and real time PCR. Cord blood was collected from their babies (108 at term and 117 preterm infants) and genotyped as well. We investigated a possible association between progesterone receptor gene polymorphism and occurrence of preterm birth.


We found no significant difference in frequency of genotypes between premature and babies delivered at term (Fischer’s exact test, p<0,05) and between women with preterm birth and women who delivered at term. We did find that frequency of genotypes for rs1042838 and rs1042839 between extremely preterm, very preterm and late preterm ladies differ significantly (Fischer’s exact test, P=0.03). We also found that age and BMI of mothers is not connected with the occurrence of preterm birth in out cohort (ANOVA test, p<0,05).


This study suggests that genetic variation in the PGR gene of mother may trigger preterm labour. Prior information on the genetic composition of women could help in the identification and management of women at risk of preterm birth complication.


Alamsyah Aziz M. 1, Krisnadi S. 1, Setiabudiawan B. 2, Handono B. 1

Universitas Padjadjaran, Obstetric & Gynecology, Bandung-Indonesia 1

Universitas Padjadjaran, Pediatrics, Bandung-Indonesia 2

Preterm labor is one of the most universal causes of perinatal mortality throughout the world. One of the pathophysiologic mechanisms which caused preterm labor is the activity of mother and fetus’s HPA axis. Maternal biologic stress, such as hypoxia and stress condition, could trigger preterm labor through the activation of HPA axis. When HPA axis is activated, then the up regulation of hormones level which affects myometrium contractility will be occurred. Vitamin D is being known to have the role on the mechanism of HPA axis. This is an experimental research which used human smooth muscle uterine myometrium cell line PHM1-41 as an in vitro experimental subject model, treated by hypoxia oxidative stress condition and added by vitamin D. After PHM1-41 cells have been cultured for 24 hours on hypoxia condition and added by vitamin D, the PHM1-41 cell viability was measured using spectrophotometry. The result showed that the lowest PHM1-41 cell viability, which is 88.57 + 4.48, appeared on 300 nM vitamin D3 administration, while the highest PHM1-41 cell viabilty, which is 96.21 + 2.13, appeared on 10 nM vitamin D3 administration.


Öcal D. 1

Dr. Zekai Tahir Burak Women Health Care Education and Research Hospital, Perinatology, Ankara-Turkey 1


The aim of this study was to evaluate oxidative stress via thiol disulphide balance which is a new method of demonstration of oxidative stress, during labor according to the type of the birth.


This study was conducted between February 10, 2017 and May 10, 2017 at Dr. Sami Ulus Women Health Education and Research Hospital, Ankara, Turkey. A total of 60 singleton healty pregnant aged 20 years and over were included in the study. Thirty pregnant women whose pregnancy resulted in normal vaginal delivery and 30 pregnant women whose pregnancies resulted in elective cesarean delivery were included.


There was a statistically significant difference between prenatal thiol and total thiol levels in normal delivery and cesarean section (p = 0.001 and p <0.001, respectively). There were statistically significant differences in postpartum thiol, total thiol and disulfide levels in both groups (p = 0.001, p <0.001 and p = 0.003, respectively). On the other hand, there was no statistically significant difference between the study groups in terms of all three indexes (p > 0.05). There was no statistically significant difference in terms of thiol, total thiol, disulfide and indexes in the prenatal and postnatal period (p > 0.05). Total thiol, disulfide values and index 2 and 3 were significantly lower in the cesarean group after cesarean section, while index 1 was found to be statistically significantly higher (p <0.05).


Our results suggest that antioxidant mechanisms are activated earlier in normal delivery and cesarean delivery reduces stress on the mother. However, there is need for studies that are more comprehensive and evaluated the effects on the fetus for definite results.


Alamsyah Aziz M. 1, Garnida Syahbana C. 2, Sulaiman Effendi J. 2

Universitas Padjadjaran, Obstetrics & Gynecolgy, Bandung-Indonesia 1

Universitas Padjadjaran, Obstetrics & Gynecology, Bandung-Indonesia 2

Predisposing of preterm pregnancy includes activation of HPA axis, infection, decidual bleeding. Vitamin D affects the HPA axis by affecting the increase in uterine contractions by muscle strength, and also affects the body’s defense mechanism against bacterial infections. The presence of premature contractions is thought to be due to low levels of vitamin D in the body. The aim of this study was to compare the difference of 25-hydroxy-vitamin D3 in preterm parturient patients compared with non preterm parturient. This research is a comparative analytic research with cross sectional approach. The subjects of the study were women with preterm parturient versus non preterm parturient, which consisted of 46 people divided into two groups. In both groups, serum 25-hydroxy-vitamin D3 was examined by Electro-chemiluminescence Immunoassay (ECLIA) method. The study was conducted at Dr. Hasan Sadikin Bandung in August 2017 – September 2017. The results showed the median value of 25-hydroxy-vitamin D3 levels preterm parturient patients was 17.26 ng/ml, while in non preterm parturient 24.30 ng/mL. The difference of 25-hydroxy-vitamin D3 levels in both groups was significant with p <0.0001. The study concludes there is relation between vitamin D with preterm labour in Hasan Sadikin Genereal Hospital.


Güvey H. 1

Düzce University, Obstetrics and Gynecology, Düzce-Turkey 1


The term ‘angular pregnancy’ is defined as implantation of embryo in the endometrium of the lateral angle of the uterus, medially to the uterotubal junction. Angular pregnancy is commonly confused with interstitial pregnancy and cornual pregnancy. Interstitial pregnancy is defined as the ectopic gestation developing in the uterine part of the fallopian tube. It is a very rare type of ectopic pregnancy and has high rate of complications. Although it may occur in an abnormal uterus both congenital and acquired, the cornual pregnancy is always intrauterine and located medial to the insertion of fallopian tube. We aimed to present a preterm labour and retained placenta case as a result of a continued angular pregnancy.


A 41-year –old G2P1 patient who had vaginal bleeding admitted to Obstetrics and Gynecology Department of Düzce University Hospital. According to her last menstruel period, she had 7 weeks pregnancy. Her vaginal 2 D sonogram demonstrated that uterus was subseptate and there was 7 week gestation with a heart rate of 170bpm in right angular region of uterus. There were similar findings in vaginal 3D ultrasound and also myometrial thickness was 5mm. After informing the patient about the prognosis, pregnancy continued with periodic examinations. At 29 weeks of gestation, following the rupture of membranes, a1000 gr female neonate was delivered vaginally. After delivery, placenta didn’t separate spontaneously and we couldn’t remove the placenta totally with manual intervention and bum curettage. There was 6cm rest placental tissue on right cornual region according to ultrasound. Then 1mg/kg single dose methotrexate and broad spectrum antibiotic injection was administered to the patient. Her liver function tests, hemogram, crp levels was in normal levels. One week after delivery, retained placental tissue spontaneously and totally separated. After removal of placenta no bleeding and infection sign was noted.


Angular pregnancy is a rare condition and there are few case reports in literature. Most of the time, diagnosis and differentiation from interstitial and intrauterine pregnancy of angular pregnancy could be difficult. Ultrasound findings that suggest an angular pregnancy include a gestational sac that is primarily surrounded by endometrium with adjacent thicker myometrium (>5mm) noted. While a small number of angular pregnancies reach to term, 38% of them results with spontaneous abortion and 23% with uterine rupture. If gestational sac descends into the uterine cavity term delivery is possible. But counselling and discussing with the patient is essential. If pregnancy continues, the increased risk of preterm delivery, placental abruption, growth restriction, and postpartum endometritis could be seen. Even spontaneous abortion or termination can be complicated with improper separation of placenta. In some selected cases placenta could be left in situ and methotrexate could be applied in order to preserve fertility. In our patient we preferred this approach and after methotrexate injection placenta completely removed.


Angular pregnancy requires attention from beginning to end in terms of mortality and morbidity.


Ladella S. 1, Ng S. 1, Javangula M. 1

UCSF, Obstetrics & Gynecology, Fresno-United States 1


Preterm birth defined as delivery before 37 weeks gestation, increased in the United States from 9.6% to 9.8% in 2016. Preterm birth rate, a leading cause of neonatal and infant mortality increased in California to 8.6% in 2016. Fresno County California, has one of the highest preterm birth rates at 10.1%. African American women have the highest preterm birth rates at 15.7% compared to other ethnicities. Several studies showed an inconsistent correlation between anemia and preterm birth (PTB). Due to the high PTB rate in Fresno County, it is important to research modifiable and reducible risk factors. Our objective was to study the association of anemia with preterm birth in our patient population while addressing the health disparities and risk factors associated with preterm birth in the African American population.


A retrospective cohort study was performed on patients who delivered at Community Regional Medical Center, Fresno, California from January to December 2015. Data was abstracted from 906 ICD coded electronic patient records. Exclusion criteria included hemoglobinopathies, history of LEEP, cone biopsy, uterine abnormalities, tobacco use, prior PTB, IVF pregnancy and multiple gestations. Data collected on 300 preterm and 606 term deliveries included delivery gestational age, third trimester hemoglobin, ethnicity, parity, and maternal age. Maternal anemia was defined as hemoglobin concentration < 12.0 g/dL based on WHO standards which was also our institutional lab standard. The Chi Square test was used for data analysis.


Our study showed a significant association of anemia with preterm birth (89%), compared to term deliveries (62%, p = 0.04). In addition, there was a significant correlation of anemia with increasing parity (p=0.015), and increased risk of preterm delivery with advanced maternal age (p=0.002).

When compared to other ethnicities, African-American (AA) patients showed a significantly higher percentage of preterm birth (43%, p<.05), an increased incidence of anemia (74% p<.05), and lower mean birth weight neonates (p < .01).


In our study population, the incidence of preterm births is significantly higher in pregnancies complicated by anemia based on third trimester hemoglobin. A significantly greater health disparity is observed for anemia, preterm birth and low birth weight among the African American patient group when compared to other ethnic groups. It is necessary and important to screen and treat patients in the second trimester for anemia, in addition to implementation of new health awareness educational programs for the African-American patient groups, to help reduce adverse pregnancy outcomes while improving maternal and neonatal health conditions.


Uzaldi İ. 1, Gürsoy Pala H. 1, Konuralp B. 1

Tepecik Training and Research Hospital, Perinatology, Izmir-Turkey 1


By comparing three-dimensional fetal lung volumes and pulmonary artery pressures in pregnant women with gestational diabetes mellitus and normal glycemic index; We aimed to determine the effect of low lung volume and high pulmonary artery resistance on respiratory distress in newborns of gestational diabetes mellitus.


Forty pregnant women diagnosed with gestational diabetes mellitus aged between 24-32 weeks and 43 women with normal glycemic index were included in the study. Pregnant women; age, gestational week, fetal biometry, fetal pulmonary artery blood flow and fetal lung volumes were compared. Lung volume was calculated by rotational technique including VOCAL imaging program on three-dimensional ultrasound.


Main pulmonary artery pulsatility index values were significantly higher in pregnant women with gestational diabetes mellitus (mean 4.021 ± 2.010) compared to pregnant women with normal glycemic index (mean 2.227 ± 0.8061) (p = 0.002). There was no statistically significant difference between the pregnant with gestational diabetes mellitus (mean 31.78 ± 13.23) and those with normal glycemic index (mean 33.06 ± 10.00) in terms of fetal lung volumes calculated by three-dimensional ultrasonography.


Pulmonary artery pulsatility indices in gestational diabetes mellitus were found to beincreased in resistance compared to normoglycemic pregnant women. Although the measurements of pregnant women with gestational diabetes mellitus were higher than those of normoglycemic pregnant women in biometric measurements of pregnant women; There was no significant difference between the two groups in the comparison of fetal lung volumes. This shows that although the measurements of pregnant women with gestational diabetes mellitus are larger than gestational age, fetal lung volumes do not increase at the same rate and remain small. In conclusion, relatively low lung volume and increased pulmonary pulsatility index in pregnant women with gestational diabetes mellitus may be considered as predisposing factors that may cause postpartum respiratory distress.

Obstetrics – Perinatal infections


Khalil M. 1, Uldbjerg N. 2, Thorsen P. 3, Møller J. 4

Phd – Department of Obstetrics and Gynecology, Lillebaelt Hospital, Gynecology and Obstetric, Odense-Denmark 1

Aarhus University Hospital, Department of Obstetrics and Gynecology, Aarhus-Denmark 2

Ouh, Department of Obstetrics and Gynecology, Odense Denmark 3

Lillebaelt Hospital, Department of Clinical Microbiology, Lillebaelt Hospital, Vejle-Denmark 4


The aim of this study was to compare the two strategies, the risk-based approach and the culture-based screening, for identification of vaginal colonization with GBS, using an intrapartum rectovaginal culture as reference standard.


All pregnant women attending the prenatal clinic at Lillebaelt Hospital, Kolding, Denmark, over a 15-month period between April 2013 and June 2014 were invited to participate in this prospective observational study. For the antepartum culture-based screening approach, we obtained vaginal and rectal culture samples and for the reference standard paired vaginal and rectal culture samples were collected during labor. Risk factors were 1) prior EOGBS, 2) GBS bacteriuria during pregnancy, 3) temperature ≥38.0oC intrapartum, and 4) rupture of membranes ≥18 hours.


The intrapartum rectovaginal GBS colonization rate was 30% (32/108) among participants with risk factors, and 15% (76/794) among participants without risk factors. The culture-based screening had a sensitivity, specificity, PPV, NPV, and LH+ in predicting intrapartum GBS carriage of 78%, 95%, 78%, 95%, and 17, respectively; and the risk based approach of 21%, 90%, 30%, 85%, and 2, respectively.


The culture-based screening performs considerably better than the risk based approach for identification intrapartum GBS colonization.


Jeremic I. 1

Polyclinic Jeremic, Polyclinic Jeremic, Belgrade-Serbia 1


HPV infection is an epidemic of modern age with the highest number of infected girls between 18 and 30 years of age. Due to the alerted immune status during pregnancy the spreading of HPV infection is progressive .During the labor any retention of the child in the birth canal leads to aspiration of HPV particles witch further represents the most common cause of laryngeal papillomatosis in children.


The study involved 60 pregnant women between 18 and 30 years of age diagnosed with genital warts in early and advanced stages that were treated with RF technique which enables the smooth vaginal delivery with no signs of HPV infection on genito-anal region. Radio wave technique involves a special combination of radio wave access evaporisation and radio wave melting. Radio wave access evaporisation causes the evaporation of HPV infected cells and by radio wave melting we get the bloodless removal of condyloma.


With colposcopic examination we reveal subclinical stages of genital warts on the mucous membrane of the labia and the entrance to the vagina, which provides conditions for their immediate removal. The result of radio wave therapy is a bloodless surgical field with a precise and controlled removal of all forms of genital warts in one act throughout pregnancy. Operation is performed only under local anesthesia with a minimum damage to the surrounding healthy tissue, rapid recovery without accompanying infection, bleeding, recurrence, and a complete protection to the mother and fetus.


Genital warts during pregnancy represent a risk to the fetus during vaginal childbirth regardless of the severity of the clinical picture. Absence of colposcopic diagnosis, avoiding removing warts in the pregnancy, use of the wrong treatment leads to progress of condylomata as for outputting an infection of the fetus, by aspiration of HPV particles in the birth canal.


Tsivtsivadze E. 1, Novikova S. 1, Bocharova I. 2, Dulaeva E. 1, Budikina T. 3

Moscow Regional Scientific Research Institute of Obstetrics and Gynecology, Obstetrics, Moscow-Russia 1

Moscow Regional Scientific Research Institute of Obstetrics andGynecology, Neonatology, Moscow-Russia 2

Moscow Regional Scientific Research Institute of Obstetrics and Gynecology, Diagnostic Laboratory, Moscow-Russia 3


Epilepsy is the most common neurological disorder in women of reproductive age. The inflammatory process in the cns leads to the induction of convulsive syndrome, which negatively affects the condition of the newborn. The aim of the study was to improve perinatal and obstetric outcomes in patients with epilepsy.


From 2014 to 2016, 129 pregnant women with epilepsy were under observation. Pcr was used to diagnose viral infections, antibodies to neurospecific proteins s-100, gfap, mbp and ngf were studied, and interferon status was determined. Group i – 59 pregnant women, who had a reduced level of neuroantibodies, negative pcr diagnosis and normal interferon status. Group ii included 42 pregnant women with positive pcr diagnostics, a high level of antibodies to the nbp, a decrease in ifn α serum <4 u / ml. In pregnant women of the ii group interferon alpha-2b was used. A second examination was performed before delivery.


At the moment of delivery in group ii the level of neurosensitization decreased by 2.5 times, the virus dna was not detected. Spontaneous delivery in group i – 83%, in group ii 76.2%, in comparison group 82.2%. With an apgar score 8 –9 85% of children were born. Hypoxia in labor occurred in 15% in the i group, 11.9% – in ii. Signs of intrauterine invection in children from mothers of group i were revealed in 16.7%, from mothers of group ii – in 4.8%. In the study of nsp in children of the i group, significant hyposensitization was found, in group ii – within the limits of reference values.


The inclusion of interferon alfa-2b in the complex of ongoing treatment prevented the development of severe forms of iui and perinatal cns damage in newborns.


Mimura N. 1, Nagamatsu T. 1, Morita K. 1, Taguchi A. 1, Kumasawa K. 1, Iriyama T. 1, Osuga Y. 1, Fujii T. 1

The University of Tokyo, Department of Obstetrics and Gynecology, Bunkyo-Japan 1


Placental dysfunction has been described as a pathological factor developing fetal growth restriction in congenital human cytomegalovirus (HCMV) infection. Previous reports about HCMV infection to trophoblast suggested that syncytiotrophoblast (STB) is resistant to HCMV infection, and that HCMV infection interferes with differentiation of human trophoblast. But the underlying mechanisms have not been clarified. This study aimed to investigate the impact of HCMV infection on gene transcriptome in cytotrophoblasts (CTBs) associated with the placenta dysfunction.


This study was conducted under the approval of our facility ethics committee. Human placentas were obtained from term deliveries of the women with written consent. CTBs isolated from the placentas were infected with AD169rev, a HCMV strain with infectability to epithelial cells. CTBs were collected at 72 hours after infection. The transcriptome profiles were compared between CTBs groups with and without infection by cap analysis gene expression (CAGE) sequencing method. Bioinformatic tools (KEGG pathway analysis) were utilized in the analysis of the gene expression data. The syncytialization of the cultured trophoblast cells with and without HCMV infection was assessed by hCG secretion and by immunostaining for cell surface desmoplakin.


A total of 629 differentially expressed genes (DEGs) were identified in comparison between the groups with and without infection. Within 629 DEGs, 456 DEGs were up-regulated and 173 DEGs were down-regulated in CTBs with infection. KEGG pathway analysis demonstrated that DEGs were enriched in the signaling pathways related to cell cycle, focal adhesion. Importantly, most of the genes known to be up-regulated with syncytialization ware suppressed in the cultured trophoblast cells with HCMV infection. Additionally, this gene suppression under HCMV infection was concurrent with the reduced hCG secretion. The cell fusion evaluated by protein distribution of cell surface desmoplakin revealed that HCMB infection reduced the cell fusion of cultured CTBs. These findings imply that HCMV infection has negative impact on the syncytializing process that is indispensable for the maintenance of villous function in the placenta.


HCMV infection interferes with gene expression profile and functional differentiation in trophoblast cells. Suppression of syncytialization might be a HCMV survival strategy to expand the infection and would be associated with the placental dysfunction observed in the pregnancy with congenital HCMV infection.



Tukbekova B. 1, Kizatova S. 1, Dyussenova S. 1, Erimbetova N. 1, Mamlina Z. 1

“Karaganda Medical University”, Department “Children Diseases №2”, Karaganda Kazakhstan1


The problem of congenital infections is particularly relevant in modern conditions due to the prevalence and severity of inflammatory processes, is one of the leading in obstetric practice, perinatology, due to the high level of infection of pregnant women, mothers and parturient women and the risk of impaired fetal development and the birth of a sick child. The aim of the study was the clinical analysis of statistical data obtained during the research of children in the first 3 months of life with congenital infections, the identification of the features of its course using enzyme immunoassay, polymerase chain reaction and morphological studies.


The work was carried out on the basis of the department with the defeat of the central nervous system for young children in regional children’s clinical hospital in Karaganda. We have studied the dynamics of the incidence of congenital infections over a 5-year period. Clinical diagnosis of congenital infections, ELISA and PCR examination, retrospective analysis of case histories for 2013 were used.


Based on the results of the study, it was found that in 2018, compared with 2013, the diagnosis of congenital infections in our region increased 6.5 times and amounted to 14.3%. In the structure of congenital infections continues to lead CMV infection, and its detectability has increased almost 2 times and amounted to 84%, against 44.6% in 2013. In the structure of congenital infections was dominated by mono infections (61.6%) over mixed infections (38.4%). CMV infection is followed by herpetic infection (HSV) in 16% of cases. The largest part (75%) of mixed infections was also represented by Herpes simplex virus infections (CMV+HSV), the association of CMV with Mycoplasma infection was found in 25.0%. Chlamydia, toxoplasmosis were not diagnosed in any case. Thus, the structure of VUI is dominated by Herpes simplex virus infections.

The generalized course of congenital infections decreased significantly from 21% in 2013 up to 6% in 2018 year. In 2018, the clinic of asymptomatic carriage of CMV began to meet more (24%), mortality decreased, which indicates, perhaps, the improvement of diagnosis in the early stages of development, timely examinations in pregnant women, the application of the clinical protocol of CMV in children developed in 2013. Premature infants accounted for 12% of all newborns.

We found that in 45% of cases, congenital infection occurred as an acute infectious process with signs of inflammation in various organs (meningoencephalitis, pneumonia, hepatitis, interstitial nephritis). In 24% of CMV had a subacute course with the formation of the stigmas of dysembryogenesis and malformations.


The problem of congenital infections at the present stage requires the development and implementation of measures to improve the health index of women, reduce the level of sexually transmitted diseases, as well as the need for rehabilitation of children with lesions of central nervous system and congenital malformations of internal organs, requiring mandatory operational correction, timely to improve the quality of life of this category of children.


Judistiani R. 1, Girawan D. 2, Chandra E. 2, Ermaya Y. 3, Chalid M. 4, Aziz M. 5, Effendi J. 5, Mulyono D. 6, Proasetyo D. 3

Faculty of Medicine Universitas Padjadjaran, Public Health, Bandung-Indonesia 1

Faculty of Medicine Universitas Padjadjaran, Internal Medicine, Bandung-Indonesia 2

Faculty of Medicine Universitas Padjadjaran, Child Health, Bandung-Indonesia 3

Faculty of Medicine Universitas Hasanudin, Obstetrics and Gynecology, Bandung-Indonesia 4

Faculty of Medicine Universitas Padjadjaran, Obstetrics and Gynecology, Bandung-Indonesia 5

Eijkman Biomolecular Institute, Jakarta-Indonesia 6


The increasing number of Hepatitis B Virus (HBV) antigen positivity among children under five years old in Indonesia had driven this study to explore how big was the protection toward HBV infection from vaccination program for all newborns in 1987 that would be reflected in positive anti HBs proportion among pregnant women.


Pregnant women in Bandung, West Java, were screened for three HBV infection markers, HBsAg, anti HBc and anti HBc by ELISA. Classifications were made based on combination of the three markers.


Two hundred twenty two of the targeted 500 subjects had completed the screening. Approximately 66% of these women were between age 20-34. 95 % had 2 children or less, 80% of the family income was less than 250 US dollars a month. There were 46 women (39%) who had at least one medical procedure prior to current pregnancy. A small proportion (7%) of these pregnant women had familial or personal-behavioral risk factors for HBV infection. Almost all of the women (99.5%) did not recall nor having any record of previous HBV vaccine. Anti HBs negative were found in 72.4% of these women and only 20.4% were found with isolated positive anti HBs resulting to most probably HBV vaccinations. Chronic HBV infection was found in 8 (3.6%) pregnant women and 2 cases of isolated HBsAg positive. One pregnant woman was suspected to be infected with mutant HBV which needs further exploration. The results indicated that the HBV vaccination program is strongly indicated among women of reproductive age. The rarity of evidence for HBV vaccination among pregnant women would be a constraint to the elimination program, as FDA still classified the HBV vaccine in class C that animal reproduction studies had shown an adverse effect on the fetus and there are no adequate and well-controlled studies in human. Other recommendation was that women with risk factors for hepatitis B should be vaccinated during pregnancy and vaccination to all health care personnel should be encouraged, considering the loss from transmission to newborn form these routes were also high. Other study to assess possible mechanisms of non-responder or the need for new vaccine was inevitable.


The large proportion of pregnant women in this study was not protected from HBV infection, despite vaccination program for all newborns started more than 20 years ago. HBV vaccinations for women in reproductive age and especially among pregnant women are urgently needed in Indonesia.


Papitashvili A. 1

Tbilisi Medical University Geomedi, Ob/gyn, Tbilisi-Georgia 1


At least 5.2% of pregnancies are complicated by clinically overt viral infectious illnesses and many more may be affected by silent viral infection. Evidence of fetal infection may be different structural damage and fetal death. Maternal signs and symptoms of infection are often nonspecific. Identification of fetal viral infection is possible by immunologic and special molecular biology techniques. Even if samples are obtained, may be difficult the accurate interpretation of the results.Ultrasound scanning is capable of detecting most of the grave alteration typical of the fetal viral infection.However to establish the significance of named capability the further elaborated studies is required.

The aim of our study was to determine the value of ultrasound examination to detect the alterations specifically for fetal viral infection.

Materials and methods

Screening ultrasound examination were performed in 2578 healthy pregnant women in 2nd and 3rd trimester(group1).Ultrasound examination also were performed in untreated 79 pregnant women in 2nd and 3rd trimester infected by intrauterine viral infection,identified primary by biochemical markers(group2).


Using screening USD the following specific changes in the fetus and placenta has been detected in group 1: hydrocephaly 4 (4.0%), anencephaly 1(1.3 %); IUGR 13(17.3%); calcification of fetal liver, brain or/and kidney 9(12.0%); mitral stenosis 1(1.3%); placenta calcification 8(10.7%); placental intercotiledon gap dilatation 9(12.0%); fetal-placental circulation abnormalities 31(41.3%). Total 75 cases (associated malformations 39 cases). Damaged fetus was identified in 36 pregnant (1.36% of group 1). Using next the biochemical testing, in 23 of them (62.0% of 36 pregnant) the persistent infection has been detected. In 13 pregnant(38.0%of 36 pregnant) the persistence of infection was not detected. Included in group 2 pregnant with primary detected by biochemical markers persistence of viral infection had following specific changes: calcification of fetal organs and placenta 28(31.4%); CNS structural damage 11(12.6%); IUGR 8(9.0%); different fetal malformation 5(5.5%); fetal-placental circulation abnormalities 37(41.5%). Total 89 of cases (associated malformations in 10 cases). Number of cases among 79 pregnant with damaged fetus: detected by primary screening ultrasound examination 51 (65.4% of group 2); none detected by screening ultrasound examination 27(34.6 %of group 2). The determined value of screening ultrasound examination to detect viral intrauterine infection is: Sensitivity 38.3%; Specifity 74.5%; Prevalence 52.0%; Negative predictive value 47%; Positive predictive value 62%; Negative likelihood ratio 0.82; Positive likelihood ratio 0.51.


Ultrasound scanning is capable to detect most of the grave alteration typical of fetal viral infection.Doppler studies can be used to evaluate the alterations in vascular flow that result from congenital viral infection.The use of the routine ultrasound examination as a screening test to detect intrauterine viral infection has a certain limitations and can be applied in combination with further serological testing.Combined study increases the specificity and sensitivity of and thereby the possibility of prognosis of the disease and the possibility of effective therapy.


Cui A. 1, Zhu L. 2, Cheng X. 1, Qu L. 3, Li H. 4, Qin G. 2

Nantong Maternal and Child Health Hospital Affiliated To Nantong University, Department Of Obstetrics and Gynaecology, Nan Tong-China 1

Nantong Third People, Center for Liver Diseases, Nan Tong-China 2

Affiliated Hospital Of Nantong University, Department of Gastroenterology, Nan Tong-China 3

Nantong Maternal and Child Health Hospital Affiliated to Nantong University, Department of Clinical Laboratory, Nan Tong-China 4


The association of hepatitis C virus infection with intrahepatic cholestasis of pregnancy (ICP) has been previously noted. Our study aimed to investigate the association between pre-exiting hepatitis B virus (HBV) infection, non-alcoholic fatty liver disease (NAFLD) and ICP.


A prospective cohort of 38,273 pregnant women was enrolled from Nantong Maternal and Child Health Hospital affiliated to Nantong University of China between January 1, 2012 and June 30, 2016. Data were collected from questionnaires completed by the pregnant women at their first antenatal visit. Pre-existing HBV infection and NAFLD were diagnosed based on detailed medical history. Liver function tests were measured at baseline and followed-up until the end of pregnancy. Poisson regression was used to estimate risk ratios (RRs) of ICP for women with HBV infection and NAFLD. The impact of HBV carrier or NAFLD on LFTs and pregnancy outcomes of ICP patients were also assessed.


The incidence rates of ICP among the pregnant women with HBV infection or NAFLD were significantly higher than those in women without pre-existing chronic liver diseases [3.68%, (42/1142) vs. 1.45% (546/37638) p<0.001; 8.47% (138/1629) vs. 1.23% (450/36644), p<0.001 respectively]. HBV infection and NAFLD were identified as independent risk factors for ICP (RR and 95%CI: 2.36, 1.72-3.23; 6.25, 5.16-7.58 respectively). ICP patients with HBV infection were more likely to have higher total bile acid (TBA) level than ICP patients without HBV. Besides, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), gammaglutamyltransferase (GGT) and total bilirubin (TBiL) levels of ICP patients with NAFLD were significantly higher than those in ICP patients without NAFLD. The incidence rates of preterm birth and caesarean section among ICP patients with NAFLD were significantly higher than those in ICP patients without NAFLD [36.96% (51/138) vs. 26.22% (118/450), p=0.015; 84.06 (116/138) vs. 73.11% (329/450), p=0.009 respectively]. Moreover, in singleton pregnancy, average birth weight and Apgar score of the newborns to ICP patients were significantly lower than those of newborns to ICP patients without NAFLD.


HBV infection and NAFLD may be associated with ICP. ICP combined with NAFLD has clear impact on maternal and neonatal outcomes. Therefore, we suggest that obstetricians should be more aware of the diagnosis of pre-existing chronic liver diseases especially NAFLD for improving perinatal health.


Psarris A. 1, Sindos M. 1, Theodora M. 1, Antsaklis P. 1, Loutradis D. 1, Daskalakis G. 1

“Alexandra” Maternity Hospital, National and Kapodistrian University of Athens, 1st Department of Obstetrics and Gynecology, Athens-Greece 1


To investigate the adherence to national guidelines regarding pertussis and flu vaccination during pregnancy in Greece as well as to evaluate the effect of an intervention aiming to increase the vaccination coverage rate during pregnancy at a tertiary maternity hospital.


During the retrospective part of our study we interviewed all women (n=197) who gave birth in Alexandra Maternity Hospital from March 2018 till May 2018, regarding their vaccination status against influenza and pertussis. All women who had not been immunized during pregnancy completed a questionnaire as to the reasons for not getting vaccinated. The prospective part of our study included active recommendation of both the flu and the TdapIPV vaccines to the outpatient maternity clinic in order to evaluate the acceptance of routine vaccinations during pregnancy.


Interestingly, most of the women (92.9%) had been vaccinated during their childhood in accordance with the national vaccination guidelines and almost all of them (98%) declared their intention to immunize their children, but only 16.2% had been vaccinated against influenza during pregnancy and none of them (0%) had been inoculated with one shot of Tdap (or Tdap IPV) during pregnancy. A significant percentage of pregnant women (65.5%) replied favorably to being immunized during pregnancy as long as their doctor endorsed it. However, most doctors never recommended vaccination during pregnancy (73.6% of our cases). As for the reason for not get inoculated, 65% of women did not get immunized because their doctor did not suggest it, 18.8% due to the fear of possible side effects to the fetus and themselves. During the prospective part of our study inoculation against influenza and tetanus, diphtheria and pertussis was offered to pregnant women. Immunization reception was high with 94.9% out of 195 women getting inoculated against influenza and 92.8% against pertussis.


The rates of routine immunizations during pregnancy in Greece are surprisingly low. The lack of compliance with the national immunization guidelines appears to come as a result of physician hesitancy to endorse vaccination of pregnant women. In contrast, pregnant women appear to have faith to the recommendations of their doctors as we showed during the second part of our study. Furthermore, there is a considerable increase in the prevalence of neonatal pertussis cases in Greece, emphasizing the need for pertussis immunization during pregnancy.


Voroshilina E. 1, Zornikov D. 1, Plotko E. 2

Ural State Medical University, Microbiology, Virology and Immunology, Yekaterinburg Russia 1

“Garmonia” Medical Center, Obstetrics and Gynecology, Yekaterinburg-Russia 2

Aerobic vaginitis (AV) is a form of non-specific vaginitis, characterized by genital inflammation, increased numbers of leukocytes and parabasal cells, and proportional decrease of lactobacilli in vaginal smear. The diagnosis is based on wet mount microscopy which is subjective. In order to evaluate vaginal microbiota of 333 women (aged 16-69) with AV (according to microscopy), real-time PCR (RT-PCR) test was performed with “Femoflor” kit (DNA-Technology, Russia), following the manufacturer’s instructions (DNA-Technology; Russia). Once the amplification reaction was over, the special software (DNA-Technology; Russia) was used to automatically calculate the total bacterial load (TBL) and the proportion of particular species and groups of bacteria in relation to the TBL in the given sample. The quantity of identified microorganisms was expressed in genome equivalents per 1 ml (GE/ml). The kit allows us to detect the following groups of vaginal inhabitants: Lactobacillus spp., gram-positive facultative anaerobes (Streptococcus spp., Staphylococcus spp.); gram-negative facultative anaerobes (Enterobacteriaceae spp.); obligate anaerobes (Gardnerella vaginalis/Prevotella spp./ Porphyromonas spp.; Eubacterium spp., Sneathia spp. / Leptotrichia spp./ Fusobacterium spp., Megasphaera spp./ Veillonella spp./ Dialister spp.;Lachnobacterium spp./ Clostridium spp.; Mobiluncus spp./ Corynebacterium spp.; Peptostreptococcus spp., Atopobium vaginae), mycoplasmas (Mycoplasma hominis, Ureaplasma urealyticum, Ureaplasma parvum), yeast-like fungi (Candida spp.).

Depending on the proportion of lactobacilli and opportunistic microorganisms (OM) in the TBL, three types of vaginal microbiocenosis were identified. Normocenosis — normal state of vaginal microbiota when the proportion of lactobacilli is more than 80 % of the TBL. Apparent dysbiosis (AD) is a variant of vaginal microbiota dominated with various opportunistic bacteria: the proportion of lactobacilli is less than 20 % of the TBL and the diverse microbial community constitutes more than 80 % of the TBL. Moderate dysbiosis (MD) is an intermediate state of vaginal microbiota when the proportion of lactobacilli decreases and constitutes less than 80% but more than 20 % of the TBL. The proportion of OM is more than 20 % but less than 80% of the TBL. Depending on the prevalence of obligate anaerobes or facultative anaerobes, three dysbiotic variants of AD or MD can be identified: aerobic, anaerobic or mixed.

Normocenosis was detected by RT-PCR in 67 cases (20.12%), but in 16 (4.8%) cases the quantity of mycoplasmas was more than 104 GE/ml, in 12 cases (3.6%) quantity of Candida spp. was more than 104 GE/ml. (8.4%) MD — in 88 (26.4%) and AD in 178 (53.4%) of 333 women with AV. 5 samples (1.5%) met the criteria of aerobic MD and 25 samples (7.5%) met the criteria of aerobic AD. Therefore aerobic dysbiosis was determined in 30 patients (9%) whose microscopy results met the criteria of AV. 75 samples (22.5%) met the criteria of anaerobic MD and 131 samples (39.3%) met the criteria of anaerobic AD. 8 samples (2.4%) met the criteria of mixed MD and 22 (6.6%) — the criteria of mixed AD. So dysbiosis associated with predominance of obligate anaerobes in vaginal microbiota was determined in 236 (70.9%) women with AV according to microscopic findings.


Cai M. 1, Hao Y. 1, Zhong J. 2, Gu G. 3, Qin G. 1

Nantong Third People’s Hospital, Nantong University, Center for Liver Diseases, Nantong, Jiangsu Province-China 1

Affiliated Hospital of Nantong University, Department of Obstetrics and Gynaecology, Nantong, Jiangsu Province-China 2

Nantong Third People’s Hospital, Nantong University, Department of Obstetrics and Gynaecology, Nantong, Jiangsu Province-China 3


To investigate the efficacy of telbivudine (LdT) in blocking mother-to-child transmission (MTCT) of Hepatitis B Virus (HBV) during late pregnancy


A total of 651 pregnant women aged 18-40 in Nantong Third People’s Hospital and Hospital affiliated to Nantong University with positive hepatitis B surface antigen (HBsAg) and HBV DNA were enrolled between January 2011 and December 2015. Patients with HBV DNA≥106 copies/mL (n=251) received LdT during late pregnancy according to the patients will, while 136 high viral patients with HBV DNA≥106 copies/mL who did not take LdT therapy and 268 low viral patients with HBV DNA<106 copies/mL served as the controls. Results: At 7 month and 1 year postpartum the basal HBV DNA serum level of treated patients, declined significantly (p<0.001), while no obvious decline was observed in the untreated high viraemic controls (p<0.05) and untreated low viraemic controls (p<0.05). The ALT level of the patients did not decline in untreated low viraemic controls, and decreased after the use of liver-protection drugs in untreated high viraemic controls. In LdT group, 134 (53.4%) patients achieved normal ALT level before delivery, and more than 80% patients kept normal level of ALT at 7 months postpartum (83.7%) and 1 year postpartum (87.3%). Only 1 infant (0.4%) in LdT group was HBsAg positive at 7 months, while 14 (5.2%) in the untreated low viraemic controls (p<0.001) and 15 (11.0%) in untreated high viraemic controls (p<0.001). Univariate analysis revealed that LdT treatment was associated with lower risk (odds ratio=0.05, 95% confidence interval 0.01-0.38; p<0.001) and HBV DNA levels was associated with higher risk (odds ratio=1.39, 95% confidence interval 1.17-1.64) of infant HBsAg positivity at 7 months.


In conclusion, maternal antiviral treatment with LdT during late pregnancy can effectively reduce the viral load and promote liver function recovery. Moreover, it can also reduce the MTCT rate of HBV.

Obstetrics – Postpartum hemorrhage


Mollamahmutoğlu L. 1

Zekai Tahir Burak Women”s Health Education & Research Hospital, Perinatology, Ankara Turkey 1


The criminalization of abortions in South Korea has led to discrimination and stigmatizations for generations of women. These laws leave women in one of Asia’s most developed countries being treated like second-class citizens. Due to the calls of the women and girls across South Korea on the government to reform the Criminal Act to guarantee Access to safe and legal abortion services, first steps have been achieved in year 2019, 36 years later than Turkey. This paper presents the first 1000 Menstural Regulation procedures” related trial after the legislation of the Population Planning Law No 2827 that came in to force in 1983,at the biggest maternity hospital in Ankara


A prospective cohort was carried out on 1000 pregnant women up to 8 weeks of gestation undergoing menstrual regulation by carman aspiration technique to evaluate the complications. Carman aspirations were performed by practitioners who accomplished the course of Family Planning under the observation of obstetricians/gynecologists. The demographics and contraceptive methods were recorded. Rates of procedure related abnormal bleeding, uterine rupture, infection, ongoing pregnancy were evaluated.


Majority of the women were in 26-31 (36,9%) age group. Educational levels were as follows: Illiterate (n=236, 23,6%), primary school (n=600, 60,0%), secondary school and lycee(n=146, 14,6%), high level education(n=18, 1,8%). According to previous pregnancies: in 540 women (54.0%) five or more pregnancies occurred, whereas 94(9.4%) of them were primiparous. Contraception methods at any time included intrauterine device (n=162, 16.2%), oral contraceptives(n=84, 8.4%), condoms (n=49 4,9%), withdrawal (n=420, 42,0%), vaginal spermicide/ovules (n=42, 4,2%), vaginal lavage(n=90,9%), calendar methods(n=20, 2,0%), combined methods (n=18, 1,8%). 196 (19.6%) women used no methods of contraception. Early complications included bleeding (n=4, 0.4%), pelvic pain (n=15, 1.5%), uterine perforation (n=2, 0.2%), laceration of the cervix (n=1, 0.1%), vomiting (n=11 1.1%). Two women in whom uterine perforation occurred underwent laparotomy and primary suturization of the perforation site. Late complications included infection(n=9, 0.9%), incomplete abortion (n=8, 0.8%), ongoing pregnancy (n=6, 0.6%), leukorrhea (n=7, 0.7%).


Establishment of the safe abortion clinics in Turkey was an important landmark for the improvement of both the reproductive health and social status of the of the women earlier than Asian countries


Kanza Gül D. 1

Medipol University, Gynocology and Obstetric, Istanbul-Turkey 1

Amniotic fluid embolism (AFE) is a rare and fatal obstetric emergency. AFE is triggered by the transition of amniotic fluid to maternal circulation during pregnancy, delivery or postpartum period. Suddenly started dyspnea, cyanosis, hypotension, and rapid cardiac arrest should consider AFE. This process is usually followed by disseminated intravascular coagulopathy (DIC). Since mortality is the first 24-48 hours after diagnosis, emergency treatment and resuscitation are important in terms of prognosis


A 32-year-old patient with gravida 3, parity 2 normal birth was admitted to our clinic as oligohydramnios at 40 weeks + 4 days gestation. There were no features in her medical history and family history. In the obstetric evaluation, 2 cm cervical dilatation was observed and spontaneous amniotic fluid was observed. Induction of labor with oxytocin was initiated (500 ml of 5% Dextrose + 10 ü of 20 drops of oxytocin min). All vital signs were stable and NST was reactive for 7 hours after admission. While cervical dilatation was 4-5 cm, sudden loss of consciousness, hypotension (TA: 60/40 mmHg), bradycardia (20/min), respiratory depression and cyanosis developed, the patient was urgently intubated and ventilated, and adrenaline (1: 10,000 diluted solution 0.5 mg iv) was done The patient underwent cardiac arrest and underwent CPR. An emergency caesarean section was performed. A baby with a Apgar score of 5 was delivered. The uterus was atonic. Bilateral hypogastric artery ligation was performed. The patient was informed about the bleeding and hysterectomy was performed. In our patient who responded to CPR, a 2 cm thrombus was seen in the right atrium in the inoperable cardiac echo and thrombus was observed to be switched to the pulmonary artery within 2 min. Acute core pulmonale was present.

Intraoperative investigations revealed platelet 28000, hemoglobin 11g/dl, hematocrit 33%, leukocyte 12000, urea: 34, creatinine: 0.6, AST:34, ALT:38, LDH: 96 fibrinogen 64 mg. Peripheral blood smear was determined in terms of microangiopathic hemolysis findings and D-dimer 4094 nanograms / ml. It was implicated DIC. TA:60/30 mmHg, fibrinogen 1g, TDP 2U, Erythrocyte suspension 2 and dopamine (10 mcg / kg / min dilated by intramuscular route) were applied. An embolectomy was planned in consultation with cardiovascular surgery.

Bloody leakage was observed at the postoperative 5th hour by the cesarean incision. Abdominal drain was 300cc. Fibrinogen was detected 54 mg. Cryoprecipitate and 4 fibrinogen was applied. The hemorrhagic fluid from the abdominal drains 1400 ml in 15 min at 6 hours postoperatively. After relaparotomy venous doppler ultrasonography showed widespread thrombus in the upper and lower extremities and heparin infusion was started 2 hours after relaparotomy.

On postoperative day 4th patient was transferred to the obstetrics department from the intensive care unit.

In the microscopic examination of the hysterectomy specimen, the finding consistent with vernix casein and fetal squamous cell in uterine veins supports AFE. AFE is a rare, fatal obstetric emergency. They should be delivered quickly, cardiopulmonary support should be provided and coagulopathy should be early prevented.


Saremi A. 1, Seyedimoghaddam N. 1, Mahmoodinia Maymand M. 2

Sarem Women Hospital, Sarem Fertility & Infertility Research Center, Tehran-Iran 1

Sarem Women Hospital, Sarem Cell Research Center, Tehran-Iran 2


This study aimed at investigating the usefulness of a new technique for uterine suturing in order to control excessive hemorrhage during cesarean delivery complicated by placenta previa.


This study was conducted on 75 female subjects underwent cesarean and diagnosed with placenta previa by ultrasonography at Sarem Hospital from October 2013 to May 2018. Standard protocols were used to control hemorrhage. In 18 cases, due to the excessive hemorrhage, ‘Sarem plication suture technique’ was used to control hemorrhage in the lower segment of the uterus.


The Sarem plication suture technique was used for Eighteen subjects with excessive hemorrhage. Our results showed the less delivery-related complications in mothers due to excessive hemorrhage and the blood transfusion decreased also no mortality was reported. Moreover, no complications such as bladder or intestine rupture occurred also, there was no need for hysterectomy. In fact, in all cases, the uterus was preserved.


Sarem plication suture provided an efficient technique in order to control hemorrhage during cesarean delivery complicated by placenta previa. It also associates with less delivery-related mortality in mothers and uterus preservation.


Kanza Gül D. 1

Medipol University, Gynecology And Obstetric, Istanbul-Turkey 1


After intra-abdominal surgery, all patients can have a table of ileus along a variable period. Colonic ileus, spastic ileus, called colonic pseudo – obstruction, was first described by Ogilvie in 1948 years. This syndrome is characterized by distal column dilatation without mechanical obstruction. EPSBO is rare in the early postoperative period. It occurs within the first 30 days after surgery. The pathophysiology, diagnosis, treatment of adynamic ileus is different. Our case is presented to emphasize the difference of early postoperative small bowel obstruction and adynamic ileus syndrome.


The patient was admitted to the ward with the complaint of fever, abdominal pain, vomiting, abdominal sensitivity, inability to tolerate oral feeding, abdominal distension and post-caesarean section. During follow-up, CRP: 311 (mg / L) locoside: 187 sodium: 141 (mmol /L) potassium: 3,8 (mmol / L) (10e3 / osl) calcium: 7,5 (8mg / d /) albumin: 2 The fever of 5 (g/ dL) was 39 C. Abdominal radiography revealed air-fluid levels. A nasogastric catheter was inserted as a result of general surgery consultation. Liquid and electrolyte values were tried to be protected. Antibiotic therapy was added due to CRP and high fever. However, worsening of the general condition of the patient during the follow-up period and the second CT computed tomography of the perihepatic, right and left paracholic areas In the abdomen a total volume of approximately 200 ml measured free fluid, small bowel loops in the presence of significant dilatation and the radiograph of the needle pancreas with serohemorrhagic fluid, on the post-op 8. day diagnostic laparoscopy was plan. Hemorrhagic fluid lakes, localized serosal defects, thickening of the scar tissue, and adhesions were detected during diagnostic laparoscopy. The adhesions were separated. The abdomen was washed. Patient was followed by a drain. On post-op day 3, the patient was discharged on post-op 14th day after cesarean section with the decrease of CRP and leukocytosis, absence of fever, spontaneous gas and stool output and rapid recovery of patient.

Early postoperative small bowel obstruction is a rare entity different from postoperative adynamic ileus. Because the clinical septum and its findings may be confused with the postoperative adynamic ileus, keeping the conservative approach longer may result in intestinal necrosis. It is important to take the relaparotomy decision early. We discussed the case of epipoecosis who underwent relaparotomy on the 8th postoperative day 8 post-operative day.


EPSBO can be confused with postoperative adynamic ileus. it should not be delayed in making the decision of relaparotomy as long conservative follow-up may result in loss of ligament.


Damayanti I. 1, Fausihar S. 2, WIjaya L. 3, Harharah N. 4, Waspodo T. 5

Rs Hermina Grand Wisata, Obgyn, Bekasi-Indonesia 1

Rs Hermina Jatinegara, Obgyn, Jakarta-Indonesia 2

Rs Mitra Keluarga Kemayoran, Obgyn, Jakarta-Indonesia 3

Rs Puri Bunda, Obgyn, Denpasar-Indonesia 4

Rs Muhamadiyah, Obgyn, Kota Metro-Indonesia 5

Thalassemia is one of major hematologic diseases complicating pregnancy. It could affect fertility, fetal growth, labor, as well as puerperium period. In this case, we documented a thalassemia major patient with pregnancy complicated with wound dehiscence after cesarean section. 34 years old lady, G2A1 35 weeks pregnant was admitted with severe vomiting and malaise. She was a major thalassemia patient with bicytopenia (anemia and thrombocytopenia) receiving regular packed red cell transfusion since the last 24 years. Twenty-one days after caesarean section due to repetitive suspicious fetal monitoring, she suffered wound dehiscence until the level of abdominal muscle. The treatment was high protein nutrition, component correction followed with re-suturing and drainage. A well peri-operative preparation is needed in pregnancy with thalassemia to ensure good surgical outcome.


Findik F. 1

Dicle University Faculty of Medicine, Department of Obstetrics and Gynecology, Diyarbakir-Turkey 1


Placenta previa (PP) is seen in 0.4% of the births, although its frequency can vary based on the region. One of the most important risk factors is previous c-section. Most patients have painless vaginal bleeding. The presence of invasion is the most important point in the management of these patients. Recommended treatment in the presence of invasion is a c-section hysterectomy between 34-36 weeks of pregnancy. In recent years, uterine sparing surgery has gained importance.


This study included patients with PP diagnosis who were operated in our center between June 2017 and December 2018. The common feature of these patients was that their primary surgeon was the same doctor. All patients had at least one cesarean history. Patients who were operated before the 24th gestational week were excluded from the study. In this period, a total of 77 patients were operated with PP diagnosis. All patients were diagnosed by preoperative transvaginal ultrasonography. Placenta localization and invasion status were evaluated by USG. 49 patients (63.6%) were found to have anterior totalis and in 39 patients (36.4%) posterior totalis were found. Abdomen was entered by Pfannenstiel incision in all patients. The lower segment transverse incision was used in the uterus. Patients with placental abruption and bleeding from the placental bed were evaluated as invasion anomalies. While preoperative blood values were the last blood values before the operation, postoperative (PO) blood values were the values 3 hours after the operation. The amount of blood in the aspirator was calculated as the amount of bleeding. In addition to the demographic data of the patients, the duration of operation, amount of bleeding, the presence of invasion, the amount of erythrocyte transfusion given and the duration of PO hospitalization in the hospital were recorded.


The average age of the patients was 33 ± 5.3 (22-44), gravida 4.64 ± 2.1 (2-12), parity 3.17 ± 1.6(1-8), number of previous cesarean deliveries 2.46 ± 1.1 (1-4), gestational week 35.49 ± 1.7 (27-39.4). The operation time was 48.51 ± 13.9 (28-90) minutes and the bleeding amount was 698.05 ± 566.2 (50-2600). A total of 21 patients were given erythrocyte suspension and the overall mean was 0.61 ± 1.3(0-8) units.

Two patients had no invasion. The duration of PO hospitalization was 2,48 ± 2,2 (2-20). Bladder rupture occurred in two patients. In the long-term postoperative period, three patients developed uterovesical fistula. One patient developed hematoma causing infection within the bladder and required cystoscopy

None of the patients underwent hysterectomy. None of the patients underwent major artery ligation and uterine balloon tamponade was not used. No mother’s death reported.


PP is an increasingly prevalent obstetric condition. Although cesarean hysterectomy is recommended especially in patients with invasion anomaly, patients desire is to protection of the uterus. Surgical options without hysterectomy are prominent in these patients. Considering that the average age of menopause is 51 in Turkey, these patients will have their menstrual period more than 18 years. Surgery without hysterectomy is very important for patients who want to give birth.


Takeda T. 1, Shibata T. 1, Inamura T. 1, Ueno T. 1, Yamada T. 1, Tano S. 1, Uno K. 1, Suzuki T. 1, Harata T. 1, Izawa T. 1, Kishigami Y. 1, Oguch H. 1

Toyota Memorial Hospital, Obstetrics and Gynecology, Toyota-Japan 1


Disseminated intravascular coagulation (DIC) is characterized by the systemic activation of blood coagulation, and the two leading causes of obstetric DIC are placental abruption and postpartum hemorrhage, to which 37% and 29% of obstetric DIC cases are respectively attributed. The plasma antithrombin (AT) level is a powerful prognostic marker of DIC related to sepsis, malignancy, and liver disease. However, no previous studies had addressed the prognostic role of the plasma AT level in patients with obstetric DIC. The aim of this study is to investigate whether the plasma AT level has a prognostic role to predict the prognosis of patients with obstetric DIC.


We conducted a single-center, retrospective cohort study using records of our hospital from January 2007 to April 2017. Patients with obstetric DIC induced by placental abruption were considered eligible for the study. Obstetric DIC was diagnosed as a score of ≥8, based on the obstetric DIC score approved by the Japanese Society of Obstetrics and Gynecology. We evaluated data to identify the following outcomes: incidence of organ damage and lowest plasma AT activity level within 4 days after the onset of DIC. Organ damages are based on laboratory data, radiological findings and echocardiography. Categorical variables were analyzed using the Chi-Square test or Fisher’s exact test. Intergroup comparisons of continuous variables were performed using Student’s t-test or the Mann Whitney U test, as appropriate. A P value < 0.05 was considered statistically significant.


Twenty nine patients were enrolled in this study and 8 patients developed organ damages. According to the receiver operating characteristic curve analyses, the calculated value of the area under the curves for the lowest plasma AT activity predictive of organ damage was 0.729 (p = 0.035). At a plasma AT activity cutoff point of 60.5%, the sensitivity was 90.5% and the specificity was 54.5%. We assessed four possible confounders related to decreasing plasma AT activity by logistic regression analysis: hypertensive disorders of pregnancy (HDP), Cesarean delivery, the volume of transfused FFP and the initial albumin level. Consequently, HDP and the volume of transfused FFP were identified as prognostic variables.


This study demonstrated that lower plasma AT group (<60.5%) had higher incidence of organ damages. Since natural anticoagulants play an essential role in reducing hyper-coagulation associated with DIC, serum levels of anticoagulants should decrease during active DIC. Several studies have reported that serum level of plasma AT is significantly lower in septic DIC patients with poor prognosis, but no previous studies had addressed the prognostic role in patients with obstetric DIC.


As in other DIC, plasma AT activity can be a prognostic marker in obstetric DIC induced by placental abruption.


Melekoglu R. 1, Yilmaz E. 1

Inonu University School of Medicine, Obstetrics and Gynecology, Malatya-Turkey 1


We aimed to demonstrate the experience of our clinic in the management of pregnant complicated with the abnormally invasive placenta in the first trimester of pregnancy.


The records of patients who were treated for the abnormally invasive placenta in the first trimester of pregnancy during January 2016–March 2019 at Inonu University School of Medicine Department of Obstetrics and Gynecology were reviewed retrospectively.


During the study period, a first-trimester screening test was performed in 875 patients at the University of Inonu School of Medicine Department of Obstetrics and Gynecology. Of these, 4 (%0.4) were diagnosed with the abnormally invasive placenta in the late first trimester. Concurrently, 8 patients were diagnosed as cesarean scar pregnancy in the early first trimester of pregnancy (<10 weeks). The ages of the patients, obstetric history, pre-treatment β-human chorionic gonadotrophin (hCG) values, and treatment modalities were summarized in Table 1. All of the cases were multiparous and had at least one cesarean section previously. The history of uterine surgery or in vitro fertilization, which is considered to be a high-risk factor for scar pregnancy, was not detected in our cohort, but six patients had a history of abortion. All of the eight cases diagnosed in the early first trimester were treated dilation and curettage (D&C) under general anesthesia by ultrasonography guidance. Patients who reach the targeted β-hCG value discharged after the operation without complications. In case 9; systemic methotrexate (MTX) (1 mg/kg ) treatment implemented following uterine artery ligation before hysteroscopic evacuation. Hemorrhage occurred from the hysteretomy scar during the hysteroscopy procedure, and bleeding control was provided by laparotomy. The other three patients who underwent bilateral uterine artery ligation and segmental resection were discharged on average for 5 days, and no peri-operative surgical complication or post-operative infective complications were observed.


Patients with the abnormally invasive placenta in the first trimester should be informed about the short-term, and long-term complications, and the patient should be informed about the termination of pregnancy. Management of patients that opted termination of pregnancy in the late first trimester of pregnancy should be individualized according to the patient’s characteristics, perinatal sonographic findings and the experience of the center implementing the treatment. Segmental resection seems to be more effective for patients opted termination of pregnancy during the late first trimester of pregnancy due to the abnormally invasive placenta


Nikolaidou M. 1, Bourgioti C. 2, Konstantinidou A. 3, Zafeiropoulou K. 2, Moulopoulos L. 2, Fotopoulos S. 1

Iaso Maternity Hospital, Ob/Gyn Department, Athens-Greece 1

Aretaieion Hospital, School of Medicine, National and Kapodistrian University Of Athens, Department Of Radiology, Athens-Greece 2

Aretaieion Hospital, School of Medicine, National and Kapodistrian University Of Athens, Department Of Pathology, Athens-Greece 3


Placenta accreta spectrum (PAS) disorder is the leading cause of emergency peri-partum hysterectomy and may be associated with poor maternal outcome including massive hemorrhage, hysterectomy, bladder injury or even death. The aim of this study is to report our experience regarding surgical treatment of PAS and uterine preservation in particular; contribution of MRI in the prenatal surgical planning is also addressed


Between March 2016 and March 2019, 49 patients (mean age: 35.7 years, mean gestational age: 35.2wks) were evaluated prenatally with dedicated MRI (range: 28-34 gestational week, mean: 33.2wks) due to evidence of placenta previa in the second trimester ultrasound. All MRIs were reviewed by two experienced radiologists, prospectively. All 49 patients underwent C-section within 6 weeks (mean: 4 weeks) after the MRI by one experienced obstetrician. None of our patients received placenta in situ approach, methotrexate administration or endovascular assisted hemostasis; Pfannestiel incision was performed in all cases. Intraoperative/pathologic findings were used as the standard of reference. ROC curve analysis was performed to test the MRI predictive ability for PAS and extrauterine spread; possible association of the MRI features with poor maternal outcome including hysterectomy, massive blood loss and bladder repair was also tested.


PAS was intraoperatively identified in 38/49 cases (accreta/increta, n= 12; percreta, n=26). Bladder involvement was diagnosed intraoperatively in 22/38 and parametrial involvement in 11/38 patients with PAS disorders. There was excellent agreement (K >0.75, p< 0.001) between MRI and intraoperative findings for invasive placenta, bladder and parametrial involvement.

Interestingly, preservation of the uterus was achieved in 17/38 PAS patients (accreta/increta, n= 12; percreta, n=5); the rest of the cases (n=21) treated with cesarean hysterectomy. All the patients with bladder involvement (n=22) underwent bladder repair during the surgery (minimal, n=14, major, n=8); in two patients with bladder involvement radiofrequency (RF) ablation was successfully used for bladder detachment. All PAS patients required blood transfusion (range: 250-3500 ml, mean: 1043 ml); blood loss was greater in percreta cases (range, 500-3500 ml, mean 1445 ml). There was a significant association between each of the above adverse peripartum events and the presence of several MRI features including T2 dark intraplacental bands, increased hypervascularity within the placenta or placental bed and signs of myometrial distortion.

Most (n=40) of the deliveries were scheduled. Mean operation time was 81.5 min (range: 40-185 min); in percreta cases surgical times were longer (mean: 93.8 min (range: 60-185 min). All the patients were admitted to ICU for 24-hour monitoring and had an uneventful post-operative course; they were discharged on the post-operative day 4, without complications. In patients who underwent extensive bladder repair, the Folley catheter removed 8 days after the operation; none of them experienced permanent urinary problems. There was no need for re-operation in any of our patients. No maternal or neonatal mortality was recorded.


Prenatal treatment planning is essential for successful surgical treatment of PAS including uterine preservation. MRI is accurate in identifying the extent of PAS disorders thus, helping obstetricians to optimize patient’s care.


Özdemir E. 1, Turan Ö. 1, Zafer E. 1

Adnan Menderes University, Department of Obstetrics and Gynecology, Aydin-Turkey 1


Emergency peripartum hysterectomy (EPP) is usually the last resort for life-threatening intrapartum/postpartum hemorrhages. Its incidence is between 0.25-5.09 in 1000 deliveries, although it varies considerably from a region to another. In this study, we aimed to review our institution’s experience in EPPs in the last 5 years.


A 5-year retrospective chart review was accomplished for emergency hysterectomies that were performed for intrapartum and/or postpartum obstetric hemorrhage indication in Adnan Menderes University Research and Training Hospital’s Department of Obstetrics and Gynecology. Both vaginal and cesarean deliveries were included. Demographic characteristics, systemic illnesses, delivery routes, hysterectomy indications, intra and post-partum complications of these cases were analyzed.


Forty-one EPP cases were found in the review of our last-5-year obstetric records among the total of 4621 deliveries (0.88%). All cases were cesarean deliveries (CS). Mean age was 32.5±5.2 (Table 1). Majority of them were multigravida (n=38, 92.7%) and had previous CSs (n=34, 82.9%). Among the cases that had previous CS, 3 patients had 3 or more CSs in the past (7.3%). Twenty-eight cases (68.2%) had no systemic illnesses; gestational diabetes mellitus (GDM) was the most common systemic illness that was encountered for the rest (n=5, 12.2%). Placenta previa (PP) was the most common diagnosis in EPP cases (n=24, 58.5%) (Table 2) and there were total of 98 cases with placenta previa in the last 5 years. Other EPP indications were clinically diagnosed placental invasion abnormality (n=11, 26.8%), uterine atony (n=5, 12.2%), and systemic illness (n=1, 2.4%) (Table 2). However, after pathologic assessment there were 17 (41.5%) cases of invasion abnormality. Approximately half of the cases with complete PP (n=24, 45,8) had tissue confirmed invasion abnormality diagnosis. On the other hand, about half of the preoperative or intraoperative invasion abnormality diagnoses could not be confirmed by pathology (n=5, 45.5%). Pathology assessment of uterine and placental specimens from the cases with atony and systemic illness were reported as normal (Table 3).


Placenta previa diagnosis was the most common diagnosis related to emergency peripartum hysterectomies in our clinic even though approximately half of them were without placental invasion abnormalities. It would be appropriate to be ready for EPP in all cases with PP. In addition, our review once more indicated that cesarean deliveries have much higher risk for peripartum hemorrhage and hysterectomy. The most common emergency peripartum hysterectomy indications and the importance of a prepared mindset/early diagnosis will be discussed in this presentation.


Eyi E. 1, Öztürk F. 1, Alkan M. 2, Öz M. 3

Zekai Tahir Burak Women’s Health Education and Research Hospital, Perinatology, Ankara Turkey 1

Zekai Tahir Burak Women’s Health Education and Research Hospital, Radiology, Ankara-Turkey 2

Zekai Tahir Burak Women’s Health Education and Research Hospital, Gynecologic Oncology, Ankara-Turkey 3

Uterine rupture is lethal in pregnant women. We herein report placenta percreta-induced uterine rupture at 30 weeks of gestation. A 29-year-old pregnant woman, with previous cesarean, was admitted to the labor ward with the diagnosis of preterm labor and placenta previa. The gestational age as calculated by sonography was 30 weeks. Tocolytics and lung enhancing agents were administered. Sudden abdominal pain followed by syncope and the woman was taken into the operating theatre immediately. Fetus was in the abdomen and placenta was protruding from the incision site. Cesarean section was performed and a male infant with a 5 Apgar score, 1785 gram was delivered. During laparotomy, a 10 cm thrombosis extending into the right parametrium from the placental insertion site to the infundibulopelvic ligament was noted. Despite all uterine conservative measures, massive uterine hemorrhage necessitated, total abdominal hysterectomy. 7 units of erythrocyte suspansion,7 units of fresh frozen plasma, 2 units of thrombocyte suspension and 4 gram fibrinogen were administered in the peripartum period. At the second postoperative day, ultrasonography revealed a 5 cm thrombosis originating from the left ovarian vein extending into the vena cava inferior cava. Full anticoagulation started. Pathological analysis of the uterine specimen revealed placenta percreta to be the cause of the rupture. Uterine rupture should be considered in the differential diagnosis in all pregnant women who present with placenta previa/accreta with acute abdomen irrespective of the gestational age.

Obstetrics – Preterm Premature Rupture of Membranes


Rivera L. 1, Garcia M. 2

University of Santo Tomas, Dept.of Obstetrics and Gynecology, Manila-Philippines 1

University of Santo Tomas, Ept.of Obstetrics and Gynecology, Manila-Philippines 2


To compare two protocols for labor induction in pregnant women with prelabor rupture of membranes (PROM)


Subjects were recruited from the University of Santo Tomas Hospital (Private Division and Clinical Division). Pregnant women with a live, term, singleton fetus, cephalic presentation, a reactive Non stress test, who presented with PROM and a Bishop score of ≤5, with no previous Cesarean section, or other uterine surgery.


This is atwo-arm superiority, open label, randomized controlled trial. Pregnant women with a live, term, singleton fetus, cephalic presentation, a reactive Non stress test, who presented with PROM and a Bishop score of ≤5, and with no previous Cesarean section or other uterine surgery were randomly assigned to receive either intravenous (IV) oxytocin infusion or intracervical dinoprostone 0.5 mg gel followed 6 hours later by IV oxytocin infusion. In both groups, all patients were hooked continuously to an electronic fetal monitor and intermittent tracings were done every 2 hours. Once oxytocin infusion has been started, it was continued until delivery unless otherwise indicated. Antibiotic prophylaxis against chorioamnionitis was given with the usual prophylactic regimen of Ampicilin 2 grams intravenously as loading dose then 2g intravenously every 6 hours.


Vaginal delivery within 24 hours of labor induction increased significantly with intracervical dinoprostone gel followed by IV oxytocin infusion (87% versus 61%; RR: 1.43; 95% CI: 0.99 – 2.06; p<0.044). Comparable result was observed for nulliparous women included in the study population. The time interval from labor induction to active phase was significantly shorter in the dinoprostone-oxytocin group than in the oxytocin alone group (2.4 ± 2.1 versus 6.3 ± 1.4 hours; p<0.001). The time interval from labor induction to delivery was also significantly shorter in the dinoprostone-oxytocin group (6.3 ± 1.5 versus 10.4 ± 1.4 hours; p<0.000). Cesarean delivery rates were statistically similar in the dinoprostone-oxytocin and oxytocin alone groups (17% versus 40%; p=0.102). The neonatal outcomes were comparable in both groups, except for birth weight.


Intracervical dinoprostone 0.5 mg gel followed 6 hours later by an oxytocin infusion in term women presenting with PROM and an unfavorable cervix (Bishop Score of 5 or less) was associated with a higher rate of vaginal delivery within 24 hours, shorter time interval from labor induction to active phase of labor, and shorter time interval from labor induction to delivery, and no difference in maternal and neonatal complications was observed compared with oxytocin infusion alone.


Yilmaz Ergani S. 1, Koç S. 1, Moraloğlu Tekin Ö. 2

Sağlik Bilimleri Üniversitesi Etlik Zübeyde Hanim, Delivery Unit, Ankara-Turkey 1

Sağlik Bilimleri Üniversitesi Etlik Zübeyde Hanim, Başhekimlik, Ankara-Turkey 2


Comparison of prepartum platelet / lymphocyte, platelet / neutrophil and neutrophil / lymphocyte ratios and evaluation of prepartum-postpartum white blood, hemoglobin, platelet, lymphocyte, monocyte and neutrophil rates in pregnant women with and without premature rupture of membrane(PROM) at labor.


In this retrospective case control study, a total of 50 patients were enrolled. 25 women with PROM were compared with 25 women with painful pregnancy at term non-PROM. Patients with both groups were compared of age, gestational age, birth weight, birth sexuality. Data using spss 23 program in both groups for prepartum and postpartum hemoglobin (Hb), white cell (Wbc), monocytes, lymphocytes, platelets(Plt), neutrophil values and prepartum neutrophil / lymphocyte ratio(NLR), platelet / lymphocyte ratio(PLR), and platelet / neutrophil ratio(PNR) for comparison of Mann Whitney u test, Spearman correlation tests and chi-square tests were used. Statistical significance was accepted as p < 0,05.


The mean age distribution was 25.8 years, and the mean gestational age was 38, 3; the average birth weight was 3140. The distribution of some sociodemographic characteristics of the participants is given in Table 1. Male babies were born from 52% of PROMs, and 60% of female babies were born non-PROMs.

Comparison of the rates of wbc, hb, plt, lymphocyte, monocyte, neutrophil in the prepartum-postpartum evaluation is shown in Table 2. A statistically significant difference was found between Wbc, Neutrophil and Monocyte ratios (p <0.05).

A positive correlation was found between prepartum NLR and prepartum PLR in non-PROM (r = 0.67, p <0.01). A positive correlation was found between prepartum NLR and prepartum PLR (r = 0.72, p <0.01) and a negative correlation was found between prepartum PNR and prepartum NLR in PROM (r = –0.51, p <0.05). These relationships are shown in Table 3.


Postpartum Wbc, Neutrophil and Lymphocyte levels were found to be significantly increased compared to prepartum in all cases. Although there is an increase in the relationship between PLR and NLR in PROMs and non-PROMs, there is a negative relationship between PNR and NLR in PROM and it supports PLR increase. In future, these rates can be used to predict patients with PROM and PPROM. Since PPROM is an early-week variant of PROM, the results found in this study are also important for PPROM.


Güneş Gülcan A. 1, Kıyak H. 2, Gedikbaşi A. 2

Obstetrics and Gynecology, Şişli Etfal EAH, Istanbul-Turkey 1

Obstetrics and Gynecology, Kanuni EAH, Istanbul-Turkey 2


The aim of this study is to evaluate maternal, neonatal, fetal outcomes of pregnant patients diagnosed with premature preterm membranous rupture before 24 weeks with follow-up until birth and related factors affecting outcome.


This retrospective study was planned in screening patients applied to our clinic with confirmed preterm membrane rupture before the 24 + 0 gestational weeks, diagnosed between April 2012 and August 2017. Inclusion criterias were patients with singleton gestations between 14-24 gestational weeks and confirmed diagnosis of PPROM. Gestations complicated with a fetal anomaly, fetal death during application, families opting for termination of pregnancy and cases with multiple gestations were not included in the study. We recorded demographic characteristics, medical history, gestational age at diagnoses of PPROM, risk factors, parameters during follow-up and management, related data of delivery, maternal and neonatal complications in the postnatal period of the patients in our study.


The study included 192 patients, of whom in 21 (10,94%) patients intrauterine fetal death occurred. 67 (34,8%) of newborns were lost during follow-up in intensive care unit after delivery. Finally, 104 (54,16%) of these infants were discharged alive. We compared in two groups alive (n=104) and dead (n=67) patients medical data. Statistically significant variables in multivariate regression analysis affecting neonatal survival are amnion fluid volume, the presence of oligohydramnios and / or anhydramnios, duration of PPROM, average of first minute Apgar, average of neonatal birth weight. ROC analysis showed us that gestational week at birth was determinant for fetal death prediction.


57.14% of patients resulted with neonatal survival with diagnoses of PPROM before 24+0 gestational weeks. The most important determinants in these cases for survival were duration of PPROM, gestational age at birth and amount of amniotic fluid. There is no major complication 19,27% of infants.


Kong C. 1, Li Y. 1, To W. 1

United Christian Hospital, O&G, Hong Kong-Hong Kong 1


Many authoritative guidelines have recommended prescribing erythromycin as antibiotic prophylaxis in preterm prelabour rupture of membranes (PPROM). The aim of this study is to evaluate the spectrum of pathogens in PPROM and the effectiveness of erythromycin prophylaxis on these pathogens.


All pregnancies who were diagnosed to have PPROM and delivered >=24 week of gestation in an obstetric unit from 2013 to 2017 were retrospectively reviewed. The pathogens isolated from the maternal, placental and neonatal cultures and their sensitivity profile to various antibiotics were analyzed. The neonatal outcomes were evaluated.


The overall incidence of PPROM was 2.63%. Gram-positive bacteria were cultured in 18.4% of the PPROM patients, the commonest being Group B streptococcus (GBS) (14.6%), followed by Gram-negative bacteria (12.8%), the commonest being Escherichia coli (8.0%). Both Gram-positive and Gram-negative bacteria were significantly associated with early onset neonatal sepsis (p=0.036 and p=0.001). When each bacterial species was analyzed individually, Escherichia coli was significantly associated with early onset neonatal sepsis (p=0.004) but not for GBS (p=0.392).

Gram-positive bacteria had high resistance rates to commonly used antibiotic regime, with 42.2% of GBS and 50.0% of enterococcus and other streptococcus bacteria being resistant to erythromycin. Escherichia coli had high resistance rate to ampicillin (70.3%) and gentamicin (33.3%) but lower resistance rates to co-amoxiclav (3.6%) and intravenous cefuroxime (14.0%).


Gram-positive and Gram-negative bacteria were found in 29.1% of patients with PPROM. Administering erythromycin alone was insufficient to cover these bacteria in 67.7% of these patients with positive cultures.

Obstetrics – Fetal neurosonography and CNS anomalies


Çetin Yılmazlar N. 1, Zafer E. 1, Kurt Ömürlüoğlu İ. 2

Aydin Adnan Menderes University, Obstetric and Gynecology, Aydin-Turkey 1

Aydin Adnan Menderes University, Biostatistics, Aydin-Turkey 2


To evaluate the possible relation of cerebroplacental ratio (CPR) with fetal cranial biometric parameters measured by obstetric ultrasonography Fetal biometric development and its relation to CPR will be investigated.


Fifty-three apparently healthy pregnant cases in their second trimester were evaluated by obstetric ultrasound. Fetal cranial biometric parameters: biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), femur length (FL), the width of cisterna magna (CM), cavum septum pellucidum (CSP), lateral ventricle (LV); estimated fetal weight (EFW) were measured. Doppler ultrasound measurements for middle cerebral artery (MCA) and umbilical artery (UA) were also made to calculate CPR values. Demographic characteristics and fetal cranial parameters were statistically analyzed for their correlation with CPR (Table 2).


Demographics and descriptive statics were provided in Table 1. Correlation analyses revealed positive correlation between CPR and cisterna magna width (CM) (r=0.305, p=0.029). There was also a positive correlation between CPR and some other non-cranial parameters: AC, FL, gestational weeks and EFW (r=0.380, 0.374, 0.335,0.334 and p=0.005, 0.006, 0.014 and 0.016, respectively) (Table 3).


Our preliminary results indicated that fetal cisterna magna width is correlated with the cerebroplacental ratio. Possible explanations for this finding, including fetal cranial and cerebral vascular development, morphometric and volumetric implications will be discussed in detail.


Kavak S. 1

Firat University Faculty of Medicine, Obstetrics and Gynecology, Elazig-Turkey 1


Elabela is a hormone that plays crucial role in embryonic development. It regulates embryonic stem cell apoptosis, embryonic stem cell self-renewal, cardiovascular development, as well as proper endodermal differentiation particularly for early embryonic development. Its level is evaluated in much pathology in pregnancy. It is known that Elabela is expressed in neural tube. In this study, we investigated the serum Elabela levels in pregnant bearing fetuses with neural tube defects for the first time in literature.


Thirty cases were included in the study. Blood samples were collected from 15 pregnant women bearing fetuses with lumbosacral neural tube defects (Group 1) and 15 pregnant women bearing normal appearing fetuses (Group 2). Levels of Elabela in the blood samples were determined.


Age, gestational week, obstetrics history, body mass index and Elabela levels of the cases in Group 1 and Group 2 were similar. Mean serum Elabela levels was 6,4±1,7 ng/mL in Group 1 and 6,8±1,4 ng/mL in Group 2. There was no statistically significant difference in Elabela levels between the groups. (p>0,05, the Independent Samples Test).


In the present study, we determined that serum Elabela levels do not change in pregnant women with neural tube defect. Further studies are needed in this area.


Antsaklis P. 1, Anastasakis E. 2, Psaris A. 1, Theodora M. 1, Syndos M. 1, Daskalakis G. 1

Alexandra Maternity Hopsital, Fetal & Maternal Medicine, Athens-Greece 1

Naval Hospital of Athens, Obstetrics & Gynecology, Athens-Greece 2


To assess with 4-D ultrasound the differences in fetal behavior in pregnancies complicated by gestational diabetes (GDM), and to examine how glycemic control affects fetal neurobehaviour.


A 16 month prospective study, where Kurjak antenatal neurodevelopmental test (KANET) has been applied to assess fetal neurobehavior in pregnancies complicated by GDM, using 4-dimentional ultrasound Patients had regular ultrasound examinations after 28 weeks, when gestational diabetes was diagnosed, which were scheduled according to either the level of glycemic control orthe ultrasound findings (e.g. polyhydramnios, macrosomia and KANET score). Based on the KANET scores, the fetuses were considered as normal (≥ 14 points), borderline (6-13), or abnormal (0-5).


We studied 119 pregnancies complicated by GDM and 110 low-risk pregnancies, which represented the control group. Comparison of KANET scores in diabetic (119 patients) and non-diabetic pregnancies (110 pregnancies) showed differences in the fetal neurobehavior. The largest incidence of fetuses with abnormal and border line KANET scores was found in the group of fetuses with poor glycemic control, or ultrasound findings indicative of poor glycemic control (e.g. polyhydramnios, macrosomia etc.). KANET test scores appeared to improve, with improvement of glycemic control.


Evaluation of the fetal behavior in fetuses of diabetic pregnancies using KANET test has the potential to detect fetuses with abnormal behavior and this appears to relate with the level of the glycemic control, and the improvement of KANET score was related with the improvement of glycemic control.


Kesrouani A. 1, Nasr B. 2, Hachem R. 1, Rizk T. 3, Choueiry E. 4

Saint Joseph University, Obstetrics and Gynecology, Beirut-Lebanon 1

Fetal Care Center, Obstetrics and Gynecology, Beirut-Lebanon 2

Saint Joseph University, Neurosurgery, Beirut Lebanon 3

Saint Joseph University, Pediatrics, Beirut-Lebanon 4


Prenatally diagnosed encephaloceles have different ultrasound features and outcomes reported in publications. We aim to assess characteristics and outcomes of this entity in an unselected population.


It is a ten years retrospective observational study including 11 cases of prenatally diagnosed encephalocele. The ultrasounds were carried out in outpatient settings, by two experienced ultrasonographers. The maternal socio-demographic characteristics were reviewed along with ultrasound characteristics, associated malformations and final outcomes.


Diagnosis was done at a mean age of 18.7 weeks (13–25). In all cases, it was an occipital encephalocele. The first-trimester ultrasound was considered within normal limits in 9 cases. Associated anomalies were present in 6/11 fetuses. Growth retardation was noted in 2/11 cases. The outcome was termination of pregnancy in 9/11 cases. Parents who choose continuing the pregnancy were motivated by religious reasons


Prenatally diagnosed encephaloceles represent a heterogeneous group. Our Middle Eastern series is characterized by occipital localization and a high rate of associated abnormalities with most cases ending in termination of the pregnancy.

Obstetrics – Aneuploidy and fetal anomalies – first trimester


Balan A. 1, Moga M. 1, Dimienescu O. 1, Arvatescu C. 1, Dima L. 2

Faculty of Medicine, Transilvania University of Brasov, Department of Medical and Surgical Specialties, Brasov-Romania 1

Faculty of Medicine, Transilvania University of Brasov, Department of Fundamental, Prophylactic and Clinical Disciplines, Brasov-Romania2


Nuchal translucency is assessed by ultrasonography at 11 to 13 + 6 gestational weeks, and it is widely accepted that this is a handy marker of major genetic syndromes, including trisomy 21. First-trimester screening of nuchal translucency may reveal increased thickness of this structure even in fetuses with a normal karyotype. This paper aims to assess the clinical value of using high-resolution chromosomal microarray and to analyze the possible association between increased nuchal translucency and various abnormal chromosomal copy number variants detected by this innovatory technique in pregnancies with normal fetal karyotype and without morphologic anomalies.


This paper is a systematic review of the English literature published between 2010 and January 2019. We searched PubMed, Google Academic, and Web of Science databases for studies describing different copy number variants detected by chromosomal microarray in normal karyotype fetuses with increased values of nuchal translucency. Relevant articles were selected by using the MeSH keywords: nuchal translucency, normal karyotype, genomic microarray, copy number variants, submicroscopic chromosomal abnormalities, array CGH. Nuchal translucency was considered increased if the values exceeded 3.5 mm of thickness.


In all the included studies, nuchal translucency was over 3.5 mm and the karyotype analysis showed 46, XX or 46, XY. High-resolution microarray was performed on fetal blood samples by cordocentesis. The most common abnormal copy number variants detected were 12q21q22 deletion, 22q1.2 deletion, 22q11.2 duplication, and 10q26.12q26.3 deletion. Also, 2.1% not otherwise specified results of chromosomal microarray were detected in a group of pregnancies with normal karyotype fetuses and increased nuchal translucency. High-resolution microarray also detected the PTPN11 S502P mutation that was previously unreported but is suspected to cause the Noonan syndrome. Also, using the chromosomal microarray technique was detected a high rate of heterozygosity for spinal muscular atrophy. The pooled prevalence for variants with no clinical significance was 1.4% (95% CI, 0.5–4.0).


Even the studies seem to be controversial regarding the value of chromosomal microarray in the detection of abnormal chromosomal copy number variants in fetuses with normal karyotype and increased nuchal translucency, the majority opinion is that the use of genomic microarray is able to detect submicroscopic chromosomal abnormalities. A normal result of the chromosomal microarray associated with normal fetal karyotype, lack of any morphological anomalies and increased thickness of nuchal translucency usually provides an uneventful outcome of the baby, without an increased risk for developmental delay, but a careful follow-up might be developed.


Kuyucu M. 1, Konuralp Atakul B. 1, Adiyaman D. 1

Tepecik Training and Research Hospital, Division of Perinatalogy, Izmir-Turkey 1


The aim of this study is to analyse the indications of the prenatal invasive procedures and to evaluate the distribution of choromosomal anomalies according to the karyotype and the pregnancy results in patients with detected fetal chromosomal abnormality.


Indications of prenatal invasive procedures (chorionic villus sampling, amniocentesis, fetal blood sampling) and karyotype results which were performed between January 2016 – December 2019 were analyzed respectively. All invasive procedures including chorionic villus sampling in first trimester, amniocentesis and fetal blood sampling in second trimester were included. It was found that, mean gestational age at the time of chorionic villus sampling was 12.7 ( min 11-max 14), mean gestational age at the time of amniocentesis was 18.2 ( min 15 – max 30), mean gestational age at the time of cordocentesis is 21.9 ( min 18 – max 30 ) weeks.


Total number of prenatal invasive procedures were 2543 ( 2025 of all were amniocentesis (79.6%), 270 of all were chorionic villus sampling (10.6%), 248 of all were cordocentesis (9.8%). Indications of prenatal invasive procedure were classified as high risk in scanning tests, ultrasonographic existence of multiple soft markers in fetal anomaly ultrasonographic scan ( renal pelviectasis, cyst of choroid plexus, intracardiac echogenic focus, short femur length), existence of major anomaly, maternal age and anxiety, positivity or failure of noninvasive prenatal test, history of previous pregnancy with fetal chromosomal anomaly, hydrops fetalis, existence of at least one of strong soft markers ( hypoplasia of the nasal bone, increased nuchal thickness in first trimester, increased nuchal fold in second trimester, mild ventriculomegaly, hyperechogen intestines), other ( early intrauterine growth restriction, social indication, etc). The rate of chromosomal abnormality was found to be 23.5% (61/259) with CVS in the first trimester, 6.49% (131/2017) and 2.91% (7/240) with AS and CVS respectively. Total number of chromosomal abnormalities was 199 (7.8%) and the most frequent abnormal karyotype was autosomal aneuploidies (160/199). The most frequent indication for karyotyping in 113 fetuses with trisomy 21 was high risk in scanning tests (51/113 – 45.1%), in fetuses with trisomy 18 and 13 was the existence of major anomaly in fetal anomaly scan (14/33 – 42.4%) for trisomy 18, (6/13 – 46.2%) for trisomy 13. The rate of pregnancy termination was 76.1% (80/105) for trisomy 21, 54.5% (18/29) for trisomy 18 and 61.5% (8/11) for trisomy 13.


The rate of diagnosis using CVS is high due to the high symptom rate of fetal chromosomal abnormality in first trimester. There are not always ultrasonographic findings in trisomy 21 which is the most frequently seen fetal aneuploidy. First and second trimester scans have a great role in detecting the patients who need invasive procedure. Fetal ultrasonographic findings can play a role in guiding to invasive procedures for trisomy 13 and 18. It is beneficial to diagnose patients who have fetuses with chromosomal anomalies to offer the pregnancy termination as an option.


Eroglu S. 1

Baskent University, Gynecology and Obstetrics, Konya-Turkey 1

Neurofibromatosis (NF1) is an autosomal dominant genetic disorder that causes genomic or sporadic NF1 gene mutation as a result of a decrease in neurofibromin protein or loss of function. Although Cafe au late stains and neurofibromas are the most common symptoms, circulatory, skeletal defects and malignancies may accompany this syndrome. In the pathology of the disease, mostly vasculopathy causes perinatal and postnatal complications in women in the reproductive period. In this case, the patient who had bad obstetric results due to NF1 was evaluated in the light of the literature. In the follow-up, intrauterine growth retardation and fetal distress were detected, and she gave 590 g baby girl by cesarean section. There were no maternal complications. Although NF1 is a rare genetic disease, we believe that maternal and perinatal outcomes can be improved with regular follow-up and multidisciplinary approaches in women in reproductive period.


Eroglu S. 1, Ozdemir D. 1, Colak E. 1, Ozcimen E. 1

Baskent University, Gynecology and Obstetrics, Konya-Turkey 1

We report the prenatal diagnosis of case of Pentalogy of Cantrell in the first trimester. Sonographic evaluation revealed ectopia cordis, anencephalia, spinal dysraphism and omphalocele at 12 weeks’ gestation. The patient decides on elective pregnancy termination. The full spectrum consists of five anomalies: a midline supraumbilical abdominal wall defect, a defect in the diaphragmatic pericardium, a defect in the lower sternum, a defect in the anterior diaphragm, and various intracardiac anomalies (1). The prognosis depends on the severity of the lesions. The mortality rate is high; however, survival and prognosis ultimately depend on the type and complexity of the associated defects.


Erol A. 1, Özel Ş. 2, Cengaver N. 2, Kırbaş A. 1, Engin-Üstün Y. 2

University of Health Sciences, Zekai Tahir Burak Women’s Health Education and Research Hospital, Perinatology, Ankara-Turkey 1

University of Health Sciences, Zekai Tahir Burak Women’s Health Education and Research Hospital, Obstetrics and Gynecology, Ankara Turkey 2


Alpha-fetoprotein (AFP) is an important glycoprotein that is released from fetal liver and yolk sac during pregnancy. AFP during the early second trimester remains the most important biochemical marker for fetal open neural defects (NTD). Maternal serum AFP is also a component in the biochemical screening for fetal aneuploidy as well as adverse gestational outcomes. Although AFP may be elevated in a number of rare diseases such as maternal liver tumors, the elevation of AFP is generally attributed to feto-placental origin. In this paper, the details of the use of AFP in current obstetrics will be reviewed and the experiences of our hospital will be shared.


In this descriptive-retrospective study, 525 healthy pregnant women who admitted to our hospital at first trimester were included. Invasive diagnostic tests were recommended for patients with increased nuchal translucency (NT) value or with combined screening test result 1/270 and above (high-risk group). An increased NT was described as a measure greater than 99th percentile according to gestational age or exceeds a set threshold of 3 mm. Low-risk group underwent only AFP testing in the second trimester. Information on birth weight, birth week and as well as pregnancy complications was obtained from hospital records. Results: The mean AFP MoM value was 1.2 ± 0.45. The number of patients with AFP MoM 2.5 and above was 7, between with 2-2.5 MoM was 19. Open neural tube defect (NTD) was not detected in any of these pregnant women after a detailed ultrasound scan. Preterm delivery rate was 14.2% in the group with AFP MoM 2.5 and over, 15.7% in the group with between 2-2.5 MoM and 14.7% in the group with less than 2 MoM and no statistically significant difference was found between the groups (p > 0.05 for each group). In the patient group that applied invasive diagnostic tests due to high risk, mosaism 46, XY [37] / 46, XX [3] was detected in 1 patient after CVS and Trisomy 21 (Down syndrome) was detected in 1 patient after amniocentesis procedure. Demographic and laboratory data was presented in Table 1.


Aneuploidy screening tests should be offered to all pregnant women. The pregnant should be informed about the limitations, false positive and negative rates of the screening tests. Simultaneous or sequential use of screening tests is not recommended. Single AFP value may be used alone successfully in the screening of NTD. Detailed USG screening, genetic consultation and (if indicate) diagnostic testing should be recommended to all pregnant women complicated with increased AFP values.


Wijaya l. 1, Wibawa A. 2, Wibowo N. 2

Mitra Keluarga Kemayoran, Obstetric and Gynecology, Jakarta-Indonesia 1

Gulardi Centre MFM Policlinic, Obstetric and Gynecology, Jakarta-Indonesia 2

The most common pathology of vesicular ultrasound pattern of placenta is molar pregnancy. Hydatidiform mole coexistent with a twin live fetus (HMTF) is a rare entity, occurring in 0.005–0.01% of all pregnancies. Clinical information is limited and management is difficult due to the risk of pregnancy complications such as fetal death, vaginal bleeding, preeclampsia, hyperthyroidism, and the risk of persistent gestational trophoblastic disease. Recently, we experienced a case of complete hydatidiform mole with a healthy infant delivered at term. This case is interesting due to the molar tissue was disappeared after 9 weeks of gestation.


Adıyaman D. 1, Konuralp Atakul B. 1, Kuyucu M. 1, Pala H. 1

Tepecik Training and Research Hospital, Perinatology, Izmir-Turkey 1


This study aims to present the termination of pregnancy (TOP) rates in Turkey following a prenatal diagnosis of Trisomy 21, while clarifying the religious, educational and economic factors that affect the decision-making process in a secular country of which the 98% of the population is Muslim.


This prospective single-center study was conducted between January 2016 to July 2019 in a tertiary hospital with 136 pregnant women who were diagnosed with trisomy 21. After receiving written and oral informed consent, the educational, religious, and economic factors that influence the parental decision process were studied.


Mean maternal age was 33.81(17-48), and 6 pregnancies out of 136 were twins (4.4%). 11 pregnancy (8.1%) were obtained by assisted reproductive treatment. The highest karyotyping indication arose due to high risk in combined test in 42 patients (30.9%), and secondly, due to positive non-invasive prenatal test results in 17 patients (12.5%). There were no major/minor sonographic findings in 36 (26.5%) patients, while 58 patients (42.6%) had major sonographic findings. Most common major sonographic findings were cystic hygroma in 17 (12.5%) patients and cardiac malformations in 17 (12.5%) patients. Mean karyotyping week was 15.99±2.50, and amniocentesis procedure was executed in 94 patients (69.1%). 60 families (44.7%) were low-income, and 67 (49.3%) were middle class. 60 father (44.2%) and 75 mothers (55.2%) did not have a high school degree. The total TOP rate was 78.7% with 107 families, and 29 (21.3%) families rejected termination. 16 (14.9%) out of 107 families first decided to keep the pregnancy, but after a thinking period (12.18±7.12 days), they went through with the termination. Additionally, 4(13.7%) out of 29 families who first had decided to terminate the pregnancy, did change their decision, and the mean decision-making time for this group was 9.50±6.13 day. There was no statistically significant difference according to maternal age, gestational week, gravity and parity between the families who wanted the TOP and the ones who continue with the pregnancy (p=0.09, p=0.63, p=0.53, p= 0.21). 3 (2.2%) families out of 136 families were Syrian refugees, and none of them accepted the termination of pregnancy. TOP acceptance rates were significantly higher in families with high and middle-income families than low-income families (p=0.00, p=0.03). TOP rates of non-literate, primary and the middle school graduate mothers were significantly lower than the women with high school and undergraduate/graduate degree (p=0.02, p=0.41, p=0.00, p=0.00, p=0.01, p=0.43). Similarly, TOP rates in families with non-literate, primary school and middle school graduate fathers were significantly lower than in families with fathers who had a high school, and undergraduate/graduate education (p=0.02, p=0.04, p=0.00, p=0.00, p=0.01, p=0.04). 4 (3,7%) of the mothers defined themselves as non-Muslim, and all of them had accepted the TOP.


There are many studies all around the world investigating the TOP tendencies for Down Syndrome. However, there is limited data about the TOP rates and the other influential factors in Muslim countries such as Turkey. This study provides data about the TOP rates in Turkey and other factors that affect the TOP decision.

Obstetrics – Noninvasive prenatal test ( Fetal DNA )


K. Maisenbacher M. 1, DiNonno W. 1, Valenti E. 1, Yavari M. 1, Merrion K. 1, Buchtel K. 1, McKanna T. 1

Natera Inc., Medical Department, San Carlos Ca 94070-United States 1


Triploidy accounts for 1% of conceptions and approximately 10% of miscarriages. This finding is historically associated with first trimester loss, though later losses and live births have been reported. Identifying triploid pregnancies is important because of the associated perinatal complications. Using SNP-based products of conception (POC) testing and non-invasive prenatal testing (NIPT), we examined the incidence of triploidy at the typical time period for NIPT (available from 9 weeks) and later in pregnancy.


Genotyping results were produced on 40,729 fresh POC samples using SNP microarrays. Additionally, results were obtained on a total of 344,301 NIPT samples received over a one-year period.


For POC samples, 7.3% (2944/40,729) were triploidy, of which, 57.2% (1686/2944) were maternal in origin and 42.7% (1258/2944) were paternal in origin. Samples were categorized by GA: 9-13 weeks, corresponding with the most common GA among women screened by SNP-based NIPT methods, and 2nd/3rd trimester losses. 36.3% (958/2635) were from losses from 9-13 weeks GA; 5.9% (156/2635) were from losses after the 1st trimester. Of the 2nd and 3rd trimester losses, 35.3% (55/156) were paternal in origin and 64.7% (101/156) cases were maternal in origin.

For NIPT samples, 0.06% (207/344,301) were triploidy or vanishing twins. Of these, no clinical outcome data was available for 41.5% (86/207) cases. Of the 58.4% (121/207) cases with outcome information, 16.5% (20/121) were confirmed or suspected triploidy cases based on clinical outcome data (3 confirmatory genetic testing, 17 ultrasound data).


Triploidy is a diagnosis typically associated with early pregnancy loss, but it has been described into the 2nd/3rd trimester and in live births. In this study, over 1/3 of POC samples with triploidy were identified after 9 weeks gestation and almost 6% of these losses were in the 2nd or 3rd trimester. NIPT identified 20 cases of known or suspected triploidy with an average GA of 17.1 weeks (range 13-24 weeks).

As the debate over the appropriate number of conditions to screen for during pregnancy and when POC testing is necessary continues, it is clear that triploidy is a relevant condition for assessment in all patients, through either POC testing or NIPT screening. Due to the significant clinical impact of this diagnosis including the risk of maternal GTD, selecting NIPT and POC testing platforms that are able to identify these pregnancies can improve patient care during and post pregnancy. This study demonstrates that triploidy is a relatively common finding later in gestation, even into the 2nd and 3rd trimester.


Konuralp Atakul B. 1, Adıyaman D. 1, Kuyucu M. 1, Pala H. 1

Maternal Fetal Medicine Unit of Health Sciences University, Izmir Tepecik Training and Research Hospital, Maternal Fetal Medicine Unit, Izmir-Turkey 1


To test the hypothesis that placental volume measured by three-dimensional (3D) ultrasound correlated with fetal fraction.


This study was conducted in Maternal Fetal Medicine Unit of Health Sciences University, Izmir Tepecik Training and Research Hospital. This study included the prospective investigation of 272 pregnant women with a moderate risk were examined with 3D ultrasound by maternal fetal medicine specialist and screened with non-invasive prenatal testing (NIPT) by medical genetics specialist. Pregnant women were underwent placental volume measurement using three-dimensional ultrasound and virtual organ computer-aided analysis (VOCAL) software. On the day of the scan, blood samples of the patients were drawn for NIPT in the genetic laboratory. The association between gestational week, placental volume, placental thickness and fetal fraction was analyzed along with relevant clinical variables.


The median (interquartile range) gestational week, fetal fraction, placental thickness and volume were 15 week (5), 8% (4,38%), 2,27(0,80) cm and 94,211 cm3(81,191), respectively. Based on multivariate linear regression analyses, gestational week correlated well with volume measurements (rho:0,672 p<0,01). A modest association was found between placental thickness related to gestational week (rho:0,399 p<0,01). Fetal fraction was not showed an association with gestational week, placental thickness and volume.


In our study we did not find an association between fetal fraction and placental volumes measured by 3-dimensional sonography. We think that placental apoptosis rather than an increased placental volume may be the main source of the amount of fetal sequences released into the maternal circulation.


Loza H. 1, Calderon M. 1

Natal, Centro Materno Fetal, Prenatal Diagnosis, Quito-Ecuador 1

After decades of research, the noninvasive study of prenatal detection of aneuploidy using cell-free DNA in maternal blood is a reality. Different mass sequencing methodologies are already used in clinical practice. There are several methodologies able to identify fetal chromosomal abnormalities by massive sequencing and analysis of cell-free DNA in maternal blood. Massively parallel sequencing, digital analysis and technology selected regions of Parental SupportTM (PS) are accurate and reliable methods for detecting the most common chromosomal aneuploid cells, such as trisomy 21 (T21), trisomy 18 (T18), trisomy 13 (T13), monosomy X0 (Turner syndrome) and Klinefelter syndrome (XXY) by analysis of free fetal DNA in maternal blood.

Our study aims to identify the results of the first 100 cases of fetal DNA with the Panorama test in Quito-Ecuador. There were 10 in 2016, 35 in 2017, 37 in 2018 and 18 until the hour in 2019. The average age was 37.22 years. The gestational age was 12.66 weeks. There were 4 trisomies 21 (confirmed), 1 trisomy 18 (false positive), 6 no result, 2 healthy twins and the rest low risk. Fetal sex: 10 without results, 52 men and 38 women. The average fetal fraction was 9.8% and the average maternal weight: 139.8 kg.

The fetal DNA test is not accessible for most of the population, but the couples who can do it come out very satisfied to obtain accurate and early results. Unfortunately, there are still several incomplete results or that require a new sample and that causes little satisfaction in the mothers. The test is very recommended for the population at risk and hopefully can lower the price in the coming years.

The population still does not request microdeletions, although the basic test includes 22q11y is more common than the Edwards syndrome and is the most common after the syndrome of Down. In our experience we do not endorse any positive microdeletion.

Obstetrics – Aneuploidy and fetal anomalies – second trimester


Farajov A. 1, Baghirova E. 1, Jafarova U. 1, Guliyeva A. 1

Hospital, Hospital, Baku-Azerbaijan 1

Fibular aplasia, tibial campomelia and oligosyndactily ( FATCO ) ( OMIM 246570 ) is a very rare syndrome which was first described by Hecht and Scott (1981) , Courtens et al. (2005), reporting a further case. 14 cases have been reported worldwide (our case is not included). All cases with FATCO showed fibular aplasia, shortening and anterior bowing of the lower limbs at the distal third of the tibia with overlying soft tissue dimpling and oligosyndactyly. Mental retardation was not observed. Etiology of FATCO syndrome is still unknown nowadays. We represent 20 week male fetus with right sided fibular aplasia, tibial campomelia and oligosindactily. Femur, humerus, radius and ulna without alteration. In addition transitor supraventricular tachycardia (242 bpm) is noted. The heart anatomically was normal. Unfortunately it was impossible to observe the neonate postnatal, the family made decision of termination.


Şal H. 1, Özalp M. 1, Güvendağ Güven E. 1

Karadeniz Technical University, Department of Obstetrics and Gynecology, Trabzon-Turkey1

Walker-Warburg Syndrome (WWS) is a rare form of autosomal recessive congenital muscle dystrophy associated with brain and eye abnormalities. A survey in North-East Italy is known to have an incidence of 1.2 per 100,000 live births. Lysencephaly, hydrocephalus, pontocerebellar hypoplasia, microophthalmia, retinal dysplasia, cataract and genital anomalies are the most common accompanying malformations.

In this article, we wanted to present a case of WWS diagnosed in prenatal period.


A 26-year-old patient with a 16-week-6-week pregnancy (G2P1) according to her last menstrual period was referred to us for hydrocephalus. Ultrasonography revealed hydrocephalus, nasal bone hypoplasia, alobar holoprosencephaly, single umbilical artery, echogenic bowel compatible with 17 weeks and 4 days. Amniocentesis was performed for chromosomal sampling with a preliminary diagnosis of WWS. The fetal MRI result for investigation was reported as ventriculomegaly, cerebellar vermian hypoplasia and hypoplasia of the brain stem and right diaphragmatic hernia. The case was evaluated as WWS. Termination recommended. The family did not accept the termination.

WWS is a rare, genetically heterogeneous disease presenting with congenital muscular dystrophy, type II lysencephaly, hydrocephalus, cerebellar malformations and eye abnormalities. Fukuyama type Congenital Muscular Dystrophy (FKMD) and Muscle-Eye-Brain (MEB) disease are the syndromes that should be considered in differential diagnosis. Clinical findings are more severe in the WWS than in the FKMD, and patients are lost in the early period. Septum pellisidum, corpus callosum and cerebellar vermis agenesis are more common in patients with WWS. In addition, the clinical course was not as severe as in the WWS in MEB patients, and in the molecular studies, the MEB disease gene was localized to 1p32-34. Gene mutation studies have shown mutations in protein O-mannosyltransferase 1 and 2 (POMT 1 and POMT 2) for WWS, Fukutin-related protein (FKRP) for Fukuyama, and POMGnT1 protein gene for MEB.

The risk of recurrence in WWS with autosomal recessive inheritance is 25% and only central nervous system malformations can be detected by prenatal ultrasound. In suspected cases, further evaluation by fetal MRI should be done and genetic counseling should be given to the family.


Rodriguez R. 1, Reyna P. 1, Ayala R. 1, Galvan F. 1

Abc Medical Center, Obstetrics and Gynecology, Mexico-Mexico 1

The incidence of congenital anomalies in a twin gestation is as high as 6%. Esophageal atresia (EA) is a rare congenital malformation occurring in 2.37 per 10 000 live births and carries a high morbidity.

The prenatal diagnosis of EA without TEF can be difficult to make, but is suspected on ultrasound (US) with a small/absent fetal stomach bubble and polyhydramnios. A magnetic resonance image (MRI) is beneficial to strengthen the diagnosis. Recently biochemistry of the amniotic fluid (AF) has been used: gamma-glutamyl transpeptidase and alfa fetal protein are elevated in cases of EA.

With a prenatal diagnosis of EA, an intentional search for associated defects should be made since 50% of cases have other congenital anomalies and syndromic associations. VACTERL association is the non-random association of multiple congenital anomalies. The diagnosis is made with at least three of the following: Vertebral defects, Anal atresia, Cardiac defects, Trachea-esophageal fistula and/or Esophageal atresia, Renal anomalies, and Limb abnormalities.

There is no definite etiology for this association and occurs sporadically suggesting environmental causative factors. A genetic component is an emerging area of interest in its etiology: primary and secondary mitochondrial dysfunctions.

Overlaps between VACTERL association and mitochondrial disease exist: involvement of multiple organs, high variability of disease expression and multiple modes of inheritance. Teratogens (gestational diabetes, maternal smoking, alcohol and lead exposure) are associated to VACTERL and are known to impair mitochondrial function, suggesting that early prenatal exposure induce mitochondrial dysfunction.

VACTERL association has a frequency of 1-9/100,000. Mortality is an estimated 28%. Survivors undergo numerous surgeries throughout life, therefore prenatal diagnosis is important because prognosis and early neonatal management depend on the severity of the malformations observed. When two of the main VACTERL components are detected during prenatal ultrasound examination, a VACTERL association should be suspected, and pre-and post-natal screening should be performed to look for additional malformations. A 34-year-old primigravida (G1P0) with a 31.4 week dizygotic twin gestation, one twin with intrauterine growth restriction (IUGR) and the other twin with a prenatal ultrasound reporting absent gastric bubble, polyhydramnios and bilateral pelvicalyceal dilation, arrives at the obstetrical unit with preterm labor. Her medical history is non significant, receiving proper prenatal care with intake of prenatal vitamins and fetal lung maturation. Her pregnancy was interrupted via cesarean section, obtaining twin A without significant alterations and twin B with impairment of passage of orogastric tube placement during immediate neonatal resuscitation. The anomalous twin (B) was further examined and found to have multiple anomalies: butterfly vertebra in T8, VSD and PDA, pelvicalyceal dilation in left kidney, and EA type 1, integrating VACTERL association. The newborn underwent surgical correction for the esophageal atresia with care in the NICU and was discharged after approximately 60 days. Prenatal diagnosis of anomalies in twin pregnancies is important in order to counsel the parents. There should be an intentional screening for VACTERL association when presented with EA (absent/small gastric bubble + polyhydramnios), with aid in the diagnosis using MRI and AF biochemistry.


Sivri Aydin D. 1, Yayla M. 2

Atlas University Medicine Hospital, Department of Obstetrics and Gynecology, Istanbul Turkey 1

International Hospital, Perinatology Department, Istanbul-Turkey 2


The aim of the study was to categorize intracranial translucency findings in prenatally diagnosed chromosomal abnormalities, and to differentiate its distribution among them.


In this study which was planned as retrospective descriptive case series, first-trimester ultrasound data sets of the fetal brain are obtained from 53 fetuses with abnormal chromosomes (study group), and 135 fetuses with normal chromosomes (control group) in singleton pregnancies. We compared the study group with the control group, after matching them for clinical and sociodemographic parameters, for the positive and negative likelihood ratios, sensitivity, specificity, positive and negative predictive values and diagnostic odds for the normal visualization of the posterior fossa and the measure of the IT.


135 fetuses were ranged in normal (71,8%), and 53 fetuses were ranged in the study group (28,2%). IT was visualized in all chromosomally normal fetuses (100%) and inability to visualize the IT was 23 of 53 in chromosomally abnormal fetuses (43,4%). In fetuses whose IT could be visualized, the mean IT diameter of the fetuses with normal and chromosomally abnormal were 1,85±0,30 and 1,79±0,43 respectively. There was no statistically significant difference between the two groups (p=0,06).

Inability to visualize the IT was 24% for trisomy 21, 55,6% for trisomy 18, 80% for trisomy 13, 75% for triploidy, 100% for deletion (13) (q22). The odds ratio for presence of chromosome anomaly was 9,3 (95% CI 5,5-15,7) for inability to visualize the IT. Sensitivity, specificity, positive predictive value and negative predictive value of inability to visualize the IT for presence of chromosome anomaly were 43,4%, 100%, 100%, 81,8% respectively. False negativity and positivity were 56,6% and 0%, respectively.


According to our trial inability to visualize the fourth ventricle at posterior fossa during 11-13 weeks scan has a high specificity, positive and negative predictive value for the detection of some chromosome defects, especially trisomy 13. But its sensitivity is quietly low. The chance to be abnormal is at least 5-fold. This kind of inspection could play a role in the early diagnosis of major chromosomal malformations. While normal looking posterior fossa could satisfy against those malformations, abnormal findings can alert the inspector.

Obstetrics – Intrapartum ultrasonography


Kanatani A. 1, Nagamatsu T. 1, Shitara R. 1, Furuya H. 1, Hara A. 1, Seyama T. 1, Nakayama T. 1, Iriyama T. 1, Osuga Y. 1, Fujii T. 1

University of Tokyo, Obstetrics and Gynecology, Tokyo-Japan 1


In case of persistent breech presentation in term pregnancy, cesarean section is often planned with concern of poor fetal outcome following vaginal delivery. Therefore, prediction of non-cephalic birth in earlier timing during pregnancy is important for the planning of delivery. In Japan, fetal presentation is checked using ultrasonography repetitively in routine prenatal visits. Using the medical record on fetal presentation, this study aimed to clarify the transition of fetal presentation during pregnancy and to develop a novel approach to speculate the final presentation.


This study was conducted under the approval of ethics committee in the University of Tokyo. The data on fetal presentation later than 24 weeks of gestation (WG) until delivery was collected retrospectively by reviewing perinatal records of 1923 women who undertook perinatal management in our hospital from 2015 to 2016. Among them, 1173 women were primiparous and 750 multiparous. The transition of fetal presentation during the period after 24 WG was analyzed distinctively between primiparous and multiparous women. The approaches to predict non-cephalic birth based on the repetitive checking of fetal presentation were explored.


The incidence of non-cephalic birth was significantly higher in the primiparous (4.52%) than that in the multiparous (2.67%, p<0.05). Regardless of parity, the frequency of non-cephalic presentation was reduced rapidly after 30 WG, whereas the rate of non-cephalic presentation shift around 30% before 30WG. Among the women showing non-cephalic presentation at prenatal visit, the chance of spontaneous cephalic conversion until birth was higher in the multiparous than the primiparous. This difference was especially remarkable later than 34 WG and was statistically significant at 35 WG (32.0% in primiparous and 60.9% in multiparous, p=0.038). Among the women in whom cephalic presentation was detected at least once during 30 to 34 WG, the rate of non-cephalic birth was quite low (1.62% in primiparous and 0.74% in multiparous). On the other hand, among the women in whom cephalic presentation was not observed during 30 to 34 WG, rate of non-cephalic presentation at delivery was significantly high (50% in primiparous and 36% in multiparous).


The transition of fetal presentation 30 WG and later is especially associated with the final presentation at birth. Early planning for mode of delivery should be considered when non-cephalic presentation persists after 30 WG.


Botezatu R. 1, Iancu G. 1, Panaitescu A. 1, Peltecu G. 1, Gica N. 1

Filantropia Clinical Hospital, Obstetrics and Gynaecology, Bucharest-Romania 1


In order to predict uterine rupture during trial of labour after caesarean section (TOLAC) we considered scar thickness measurement in active labour. Also, we tried to correlate scar thickness with successful vaginal delivery after caesarean section (VBAC). In Filantropia Clinical Hospital from Bucharest Romania we offer TOLAC to all women with previous caesarean section evaluated as “ideal” at 38 weeks of gestation.


We used transabdominal serial ultrasonography to measure uterine scar with full bladder in labour. As inclusion criteria we considered pregnant women with only one caesarean section done minimum 2 years before, with current singleton pregnancy at term (more than 38 weeks of gestation) in cephalic presentation, estimated fetal weight less 4000g, in spontaneous labour with no other associated pathology.

Scar was measured at admission (before labour or during latent phase), at 4-6cm dilatation and at fully dilatation and descent.


96 patients met the inclusion criteria. 71 patients had a successful VBAC. Scar was measured systematically at all patients. There was 1 case of uterine rupture and 8 cases of scar dehiscence during caesarean section. In all these situations scar thickness at fully dilatation was less than 1mm. In all successful VBAC, scar thickness at fully dilatation was 1.5mm or more.


Even though recent studies failed to correlate uterine scar thickness before labour with prediction of uterine rupture, ultrasound made in labour and especially at fully dilatation could be a prediction factor for unfavourable prognosis and should be considered in current management of TOLAC. There were no correlations between uterine scar thickness and successful VBAC.


Garg P. 1, Gomez Roig M. 2

Chaitanya Hospital, Obg, Chandigarh-India 1

Sant Joan De Deu Hospital, Obg(hod), Barcelona-Spain 2


Our aim was (1) to evaluate a pre-induction ultrasound score for prediction of successful induction of labour by attaining active phase of labour and vaginal birth and compare it with the Bishop score in term nulliparous women, and (2) to formulate a prediction model to calculate probability of vaginal delivery for clinical use.


96 nulliparous women between 36-41 weeks gestation were recruited. All subjects fulfilled the inclusion criteria of a live singleton pregnancy, vertex presentation, intact amniotic membrane, in the absence of active labour with no contraindication to vaginal delivery. The patients were assessed by our ultrasound score comprising of 3 cervical and 2 fetal head parameters. These parameters were fetal head position, fetal head symphysis pubis distance relation, cervical length, funneling and posterior cervical angle. Each parameter was scored from 0-2, with a maximum score of 10.

A printout of each ultrasound study was produced, and measurements were performed using a scale and a protractor. The final ultrasound score was calculated by using the below pelvic ultrasound scoring system.

Table 1:

Parameters of pelvic ultrasound score

Score 0 1 2

Cervical length ≥3.5 CM 2.1-3.4 ≤2

Funneling Absent – Present

Posterior cervical angle ≤900 91-109 ≥110

Fetal head position OP OT OA

Fetal head symphysis distance relation Measurable Touching Not Measurable

A second obstetrician blinded to the sonographic findings assessed the modified Bishop score and recorded the findings. We calculated sensitivity, specificity, FPR, PPV, NPV and accuracy were calculated for both events, achieving active phase of labour and vaginal delivery. SPSS 20 was used for ROC curves plots and calculation of area under curve. Binary Logistic Regression model was prepared and probability of vaginal delivery for various scores was calculated.


Out of 91, 61(67%) achieved active phase of labour and 54(59%) had vaginal delivery. Our pelvic ultrasound score showed better sensitivity and specificity for both achieving an active phase of labour and vaginal delivery in comparison to the Bishop score. At a cut off of ≥ 5, the ultrasound score showed sensitivity of 79.3 %, specificity of 75.8 % for achieving vaginal delivery. Whereas, the Bishop score showed sensitivity of 66.7 % and specificity of 44.2 % respectively. A binary logistic regression model predicted 78.0% of the events correctly. Other consultants of hospital not involved in the study, also utilised our model and found it easily reproducible in successful prediction of probability of mode of delivery.


Our study shows that “Garg Ultrasound Score” can predict success of induction of labour. This proposed pelvic ultrasound score, if validated in larger multicentre studies, could help clinicians provide evidence-based counselling for predicting probability of vaginal delivery. This in turn, may allow women make a more informed decision before undergoing induction of labour.


Atasoy Karakas L. 1, Esin S. 1, Onalan G. 1, Kuscu U. 1, Zeyneloglu H. 1

Baskent University, Obs & Gyn, Ankara-Turkey 1


To assess clinical charecterististics and maternal-fetal outcomes of patients who were laparoscopically treated for adnexal mass or torsion with acute abdominal pain during pregnancy.


Medical records of 12 pregnant women with adnexial mass or torsion who were laparoscopically treated during pregnancy at Baskent University Obstetrics and Gynecology Department between 2011 to 2019 were screened. Demographic features, presenting complaints, operation time, estimated blood loss, postoperative hospital stay, physical examination, ultrasonographic findings, histopathologic findings, route of deliveries and complications were recorded.


Mean age of patients included in the study was 29 (± 4.04) years, mean gestational age at surgery was 11.4 (± 5.7) weeks and birth was 38 (± 2.9) weeks. Mean operation time was 77 (± 32.6) minutes. Mean length of hospital stay was 1.2 days. Median apgar score was 8 at one minute and 9 at five minutes. Mean baby weight at birth was 2377gr. Pelvic pain was the main complaint. All patients underwent low pressure laparoscopic surgery. Mean size of adnexial mass was 6.3 (± 5.5) cm. Among 12 patients, detorsion was performed in 6 patients and cystectomy was performed in 4 patients. Salpingoophorectomy was performed in 1 patients and cyst aspiration was performed in 5 patients. In one patient pathologic report was malignant. No operative complication was observed.


Adnexal torsion and adnexal masses should be kept in mind in a pregnant who presents with acute abdominal pain. Early diagnosis and treatment are important for organ preserving surgery.

Obstetrics – Multiple pregnancy


Yapar Eyi E. 1, Mollamahmutoğlu L. 1

Zekai Tahir Burak, Perinatology, Ankara-Turkey 1


Despite the attempts to reduce caesarean sections (CS), CS rates continue to increase.


We conducted a causal analysis from the electronic records of 887,683 women sent from public: 554,916 /630 688 (87.98%), private: 297,724/ 565 441(52.65%) and university 35, 043/70.171 (49.93%) hospitals by the implementation of the Robson’s mutually exclusive 10-group classification.


• Robson Group 1 constituted 22.0 % of the women and contributed CS rates with a ratio of 7.4%. Overall CS rate for this group was 32% (62 402/195 211). Rates in public, private, university hospitals were 19.4%, 52.6%, 47.0%, respectively.

• Robson Group 2 constituted 10.3 % of the women and contributed CS rates with a ratio of 7.4%. Overall CS rate for Group 2 was 59.6 % (54 450/91 322). Rates in public, private, university hospitals were 46.3%, 74.4%, 71.6%, respectively.

• Robson Group 3 constituted 22.0 % of the women and contributed CS rates with a ratio of 2.7%. Overall CS rate for Group 3 was 11.2% (25 032/224 300) and rates in public, private, university hospitals were 6.9%, 27.9%, 37.3%, respectively,

• Robson Group 4 constituted 7.6 % of the women and contributed CS rates with a ratio of 2.8%. Overall CS rate for Group 4 was 36.8 % (24 720/67 088) and rates in public, private, university hospitals were 26.3%, 56.6%, 60.0%, respectively.

• Robson Group 5 constituted 25.2 % of the women and contributed CS rates with a ratio of 24.4%. Overall CS rate for Group 4 was 97.0 % (217 314/224 118). Rates in public, private, university hospitals were 97.3%, 96.6%, 95.8%, respectively.

• Robson Group 6 constituted 2.3 % of the women and contributed CS rates with a ratio of 2.0 %. Overall CS rate for Group 4 was 86.0 % (17 510/20 352). Rates in public, private, university hospitals were 78.4%, 91.2%, 95.8%, respectively.

• Robson Group 7 and 8 constituted 1.7% and 1.3% of the women, respectively and contributed CS rates with a ratio of 1.3% and 1.2%.Overall CS rate for Group 7 was 88.0% (13 230/15 037)) and rates in public, private, university hospitals were 86.0%, 80.5%, 87.4%, respectively.; whereas overall CS rate for Group 8 was 97.0% (10 534/11 473) . and rates in public, private, university hospitals were 85.8%, 97.6%, 95.3%, respectively.

• Robson Group 9 constituted 1.3% of the women and contributed CS rates with a ratio of 1.3%. Overall CS rate for Group 9 was 90.4 % (10 288/11 380). Rates in public, private, university hospitals were 89.1%, 91.1%, 86.4%, respectively.

• Robson Group 10 constituted 3.2% of the women and contributed CS rates with a ratio of 2.2%. Overall CS rate for Group 10 was 70.5% (19 256/27 332) . Rates in public, private, university hospitals were 60.0%, 82.0%, 71.2%, respectively.


The highest percentage of Group 5 is the main obstacle in reducing CS rates. Consensus on the exact and reliable data collection, case selection for induction and pre-labour CS, improvement of the skills in obstetric practices are necessary.


Yapar Eyi E. 1, Mollamahmutoğlu L. 2, Anuk A. 1, Seckin B. 3, Esen M. 4

Zekai Tahir Burak Women, Perinatology, Ankara-Turkey 1

Public Health Department of Ministry Of Health, Reproductive Health Director, Ankara-Turkey 2

Zekai Tahir Burak Women, Obstetrics and Gynecology, Ankara-Turkey 3

Public Health Department of Ministry of Health, Reproductive Health, Ankara-4


Although prevention of iatrogenic multiple pregnancies due to an increase in both perinatal and maternal morbidity/ mortality has been regulated by legislation, a nationwide consensus on how best to facilitate the design of clinical practices to eliminate avoidable multiple pregnancy-related maternal mortality remains challenging.


We conducted a causal analysis from the electronic records of 1410 maternal deaths in multiple pregnancies through the National Maternal Mortality Registry System between January 2012 and March 2019. The age, gestational age, number of antenatal visits, pregnancy outcome, delivery route, time of death, cause of death, neonatal outcomes and any existing delay (phase 1, 2, or 3) and preventability of maternal death according to the results of the Maternal Mortality Review Reimbursement Committee were evaluated.


Among 1410 maternal deaths, there were 46 twin and two triplet pregnancies constituting 3.5% of the total maternal deaths in the era. Among these, 56.3% (n=27) and 39.7% (n=19) were categorised as direct and indirect maternal deaths, respectively. One case was an accidental death and in one woman the cause of death was not evaluable 11 out of 48 women had conceived through Assisted Reproduction Technology (ART), including two oocyte donations, eight in vitro fertilization procedures and one intrauterine insemination. 11(22.9%) women died before 22 completed weeks of gestation; 5(10.4%) women died between 221/7 and 28 weeks, and 26(54.2%) were between 281/7-366/7and 5 (10.4%) died after 37 weeks or more. Hypertensive disorders (n=10), cardiovascular disease (n=8), pulmonary thromboembolism (n=7) and sepsis due to chorioamnionitis(n=6) were the leading causes of deaths. 6 out of 11 maternal deaths in ART pregnancies were categorized as preventable whereas there were 8 phase 3 delays in 36 spontaneously conceived pregnancies. Among the preventable causes of deaths, phase 3 delays were related with multiple embryo transfer to high risk women, absence of systemic evaluation, hence high risk categorization and informed consent including the risk of death before ART, management of obstetric hemorrhage, delay in the diagnosis and management of cardiovascular disease, failure to recognize the signs of infection and delay in the diagnosis of the aggravation of the systemic diseases, failure in the administration of adjusted thromboprophylaxis, acute hemolytic transfusion reaction, hospital based drug contamination and the delay in the appropriate management of antenatal bleeding.


It remains important to emphasize to all women undergoing ART, particularly those with systemic diseases and older than 35 years, the value of a single embryo transfer in an effort to lower the risk of multiple gestation even after failed attempts and careful assessment for risk factors as 54.5% of the maternal deaths conceived through ART are considered to be preventable. The accumulation of specified homogenous data would facilitate the design of interventions to eliminate avoidable multiple-pregnancy related maternal mortality.


Spyroulis C. 1, Tsitlakidis C. 2

East Surrey Hospital, Obstetrics and Gynaecology, Redhill-United Kingdom 1

Bedford General Hospital, Obstetrics and Gynaecology, Bedford-United Kingdom 2

We present three cases: a) a primiparous woman who developed preeclampsia at 32 weeks and due to preeclampsia she developed a dilated cardiomyopathy 2 days after delivery, b)a primiparous with triplets (IVF) and c) a P2, with history of mitral valve surgery who developed dilated cardiomyopathy from the second trimester. The firs case was a 28 year old, fit and well, non-smoker, but her mother developed also dilated cardiomyopathy towards the end of her pregnancy. She attended the hospital at 28 weeks with significant swelling of both feet, very breathless, with chest pain. She had the investigations for PE which were negative. She developed preeclampsia at 32 weeks and she delivered by caesarean section at 36 weeks. She was on medications during the last 4 weeks of her pregnancy. She had an ECHO of the heart which shows that the left ventricle was slightly dilated and the ejection fraction was <45%. She was on clean from 32weeks till 6 weeks postnatally. She had also an MRI of the heart which was normal. She had a repeated ECHO of the heart 8 weeks later which was normal. The second case, she had significant symptoms of cardiomyopathy from the first trimester. She was on clean from 12 weeks and she had a cardiac ECHO and MRI at 16 weeks which showed that the ejection fraction of left ventricle was <35%. She was referred to a tertiary centre and was advised to reduce the number of triples with the use of KCL. The last case, she developed preeclampsia at 26 weeks and she was on medications for it. She also developed severe dilated cardiomyopathy (her ECHO of the heart was <35%) and she was very breathless. We referred also this case to a tertiary centre for further management

Peripartum dilated cardiomyopathy is a rare condition and occurs between late pregnancy to first three months of postpartum period. Some of the known risk factors in pregnancy is preeclampsia, which can predispose to cardiomyopathy and multiple pregnancy. The diagnosis is elusive and mainly based on the ultrasonographic measurement of the ejection fraction of the left ventricle. In order to diagnose dilated cardiomyopathy the ejection fraction of the left ventricle should be <45%. The symptoms dilated cardiomyopathy are: a) breathlessness, b) swollen ankles and feet and abdomen, c) fatigue, palpitations, d) chest pain, e) mitral regurgitation, f) different types of arrhythmias. The complications of dilated cardiomyopathy if left untreated are: a) heart failure, b) heart block, c) sudden death. The diagnosis is based on: a) history, b) clinical examination, c) ECG, d) holter, e) MRI, f) electrophysiology studies, g) coronary angiography, h) myocardial perfusion scan, i) trans-oesophageal echocardiogram. Dilated cardiomyopathy is treated with medication, like diuretic, anticoagulants to reduce the thrombosis risk, b) devices, like pacemaker, c) life style changes, healthy eating, minimise salt, causation of smoking, reduction of caffeine, d) surgery, like left ventricular assisted devises or heart transplant.

Peripartum dilated cardiomyopathy has an increased mortality rate of 25-50% and these cases, need multidisciplinary team management and if severe tertiary centre.


Yapar Eyi E. 1, Mollamahmutoglu L. 2

Zekai Tahir Burak Women, Perinatology, Ankara-Turkey 1

Ministry of Health, Public Health Department, Ankara-2


The scale-up of fertility clinics providing Assisted Reproductive Technology (ART) procedures to overcome infertility and the reach of oocyte donation approaches abroad although prohibited in Turkey may be associated with maternal deaths. Pareto diagram, being useful for decision-making that statistically separates a limited number of input factors as having the greatest impact on an outcome, either desirable or undesirable.


We conducted a causal analysis from the electronic records of 1410 maternal deaths conceived by ART through the National Maternal Mortality Registry System by implementing a Pareto diagram, based on the concept that 80% of the problems are traced to 20% of the causes The age, gestational age, number of antenatal visits, pregnancy outcome, delivery route, time of death, cause of death, neonatal outcomes and any existing delay and preventability of maternal death according to the results of the Maternal Mortality Review Reimbursement Committee were evaluated.


Among 1410 maternal deaths, there were 37 ART pregnancies constituting 2.6% of the total. 13 women had multiple pregnancies, including 11 twins and two triplets. Six of the women with a mean age of 47.8 (range 39 to 58). had conceived through oocyte donation. 15 women died in the antenatal period before 22 weeks of gestation. Four maternal deaths occurred after second-trimester termination of pregnancy. There were 6 maternal deaths between 221/7 and 366/7 weeks of gestation. Two maternal deaths occurred after 37 weeks and 10 in the puerperium. Cardiovascular disease (n=10), sepsis due to chorioamnionitis (n=5), infection (n=4), pre-eclampsia/eclampsia/HELLP syndrome /acute fatty liver of pregnancy (n=4), obstetric hemorrhage(n=3), pulmonary thromboembolism (n=3), brain disease (n=3), epilepsy (n=2), ruptured heterotopic pregnancy(n=1), tracheal stent dislocation (n=1), breast carcinoma (n=1) were the causes of deaths. 21 of the maternal deaths in ART pregnancies were categorized as preventable whereas there were 9 phase 1 and 15 phase 3 delays. Phase 3 delays were related with the transfer of more than one embryo to women with cardiac disease, delay in the diagnosis and management of the aggravating cardiovascular disease, failure to recognize the signs of infection and delay in the diagnosis/ aggravation of the systemic diseases, failure in the administration of adjusted thromboprophylaxis, delay in the diagnosis and appropriate management of obstetric hemorrhage and delay in the diagnosis of uterine rupture and tracheal stent dislocation.


The contribution of ART to rates of multiple gestations and poor maternal and perinatal outcomes remained substantial, emphasizing the value of a single embryo transfer. The presence of high-risk factors and the possibility of the aggravation of the condition due to the changes of pregnancy should necessitate reconsideration with a perinatologist and related specialists before applying ART as 56.8% of the maternal deaths were consşdered to be preventable.


Jelsema R. 1, Valenti E. 1, Martin K. 1

Natera, Inc., Medical Department, San Carlos-United States 1


Chorionicity is a primary factor that impacts prognosis for twin pregnancies, and chorionicity assignment early in pregnancy can improve perinatal outcomes. The objective of this study was to compare chorionicity assignment with zygosity determination by a single nucleotide polymorphism (SNP)-based NIPT.


Twin samples collected between Oct 2017-May 2018 were analyzed by SNP-based NIPT for zygosity (dizygous [DZ] or monozygous [MZ]). Data collected included provider-reported chorionicity (i.e., monochorionic MC, dichorionic DC, “don’t know”, or unspecified). Provider-assigned chorionicity was correlated with SNP-based NIPT zygosity determination.


A total of 4,885 twins received SNP-based NIPT zygosity determination. Chorionicity was recorded for 3,949 (80.8%) twins: MC (n=553,11.3%), DC (n=2,330,47.7%), and “don’t know” (n=1,066, 21.8%). In 41.0% of twins, chorionicity was either “don’t know” or unspecified; of those, 30.7% were identified as MZ. Of twins identified as MC, 3.4% were determined as DZ; 12.9% of DC twins were MZ.


This is the first large cohort of twins for which SNP-based NIPT zygosity was correlated with provider-assigned chorionicity. Almost half of twins under the “don’t know”/unspecified chorionicity were identified as MZ, for whom early, accurate chorionicity assignment is critical to assess adverse risk outcomes. The 3.4% discordance between “MC” cases identified as DZ, who are at extremely low risk for complications can be considered for decreased surveillance. Conversely, DC twins identified as MZ may benefit from reevaluated chorionicity given the severity of complications associated with MC twins. These data suggest that the use of NIPT-based zygosity in conjunction with ultrasound has significant utility for guiding patient care in twin pregnancies.


Kesrouani A. 1, Daou J. 2, Chalhoub E. 1, Sassine S. 1, Choueiry E. 3

Saint Joseph University, Obstetrics and Gynecology, Beirut-Lebanon 1

Saint Joseph University, Faculty of Medicine, Beirut-Lebanon 2

Saint Joseph University, Pediatrics, Beirut-Lebanon 3


Patients with triplets encounter many problems before and during pregnancy. Patients are often reluctant to vaginal delivery in these cases.


It is a retrospective study in a University Hospital from 2008 to 2016. Patients with a triplets pregnancy above 23 weeks were included, with an obstetrical outcome was considered acceptable by the obstetrician. We excluded cases with a maternal medical problems, history of cesarean or myomectomy, and placenta previa. We considered age, IVF history, preterm labor, maternal wish for way of delivery, preterm labor, trial of labor and final outcome for delivery.


Eleven patients were included in this study. Mean age is 28 years [22-39]. Prior IVF is reported in 7/11 patients (63%) and ovarian stimulation by oral or injection in 4/11 (37%) with no spontaneous cases of triplets. No major obstetrical problem was reported except preterm labor which occurred in all patients, treated with a mean latency period of 14 days [1 –74]. Two patients had cholestasis. In all cases T1 presentation is cephalic. After discussing benefits and risks of vaginal birth, couples were asked to think about it and give their answer when ready. Only 3/11 (27%) gave their approval. The remaining explained it by ’not wanting the risk’ and 5 of them said that they took the advice of the family for that. To be noted that the group who said no were all IVF patients. Among the three patients that accepted vaginal delivery, one patient changed her mind and asked for a cesarean upon admission. The second patient had a spontaneous labor at 35 weeks but finally had a cesarean section at 5 cm dilation because of an abnormal fetal heart in one of the babies who was small for gestational age. The third patient went into labor at 36 weeks and delivered smoothly with external version on T2 and T3. Babies had a normal outcome.


Vaginal delivery is still feared by pregnant women with triplets. Despite an advanced hospital setting and detailed explanations most of them choose cesarean section. IVF history and family advice push toward this option.

Obstetrics – Fetal interventions


Oğuz Y. 1, Yilmaz N. 2, Çelen Ş. 1, Çağlar T. 1

Zekai Tahir Burak Women’s Health Training and Research Hospital, Perinatology, Ankara Turkey 1

Zekai Tahir Burak Women’s Health Training and Research Hospital, Infertility, Ankara-Turkey 2

Cervical pregnancy is a rare type of ectopic pregnancy which is characterized by the implantation of gestational tissue into the endocervical canal under the internal os. It is associated with poor prognosis, high morbidity and mortality rates due to the risk of serious bleeding. Although methotrexate is the first choice in the treatment, there is still no consensus on the most appropriate approach. In this case report, we aimed to report the results of transcervical intracavitary methotrexate injection in 2 cases of cervical pregnancy

Case 1

A 37-year-old G2P0 women was admitted to the hospital, because of menstrual delay and mild hemorrhage. The vaginal part of the cervix was bluish and thickened. The transvaginal ultrasonography showed crown-rump length 3mm (compatible with 5 weeks, 6 days) and fetal heart beat positive cervical pregnancy. Her previous pregnancy was terminated by currettage. 50 mg/m2 methotrexate was injected into the cavity after ultrasound-guided aspiration of sac content by transvaginal route. Following this treatment, massive bleeding did not occur. Immediately after treatment ultrasonography showed an irregular sac located in the cervix and normal cervix was observed at 3 months after treatment.

Case 2

A 38-year-old G3P1Y1 patient was admitted to our clinic with the complaint of bleeding. Ultrasound showed crown-rump length 2.4 mm (compatible with 5 weeks and 5 days), fetal heart beat positive pregnancy in the cervical canal. 50 mg/m2 methotrexate was injected into the cavity after aspiration of ultrasound-guided sac content by transvaginal route. No massive bleeding was observed after the tratment. Immediately after treatment ultrasonography showed an irregular sac located in the cervix and almost resorptive sac is observed after 1 month the treatment.

Minimally invasive transvaginal approach to cervical pregnancy by transcervical intracavitary methotrexate injection is safe and allows to preserve the uterus and fertility in the women of reproductive age.


Yılmaz Yegit C. 1, Ince Z. 2, Aygün E. 2, Sarac Sivrikoz T. 3, Coban A. 4

Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Istanbul-Turkey 1

Istanbul University, Istanbul Faculty of Medicine, Department of Neonatology, Istanbul Turkey 2

Istanbul University, Istanbul Faculty of Medicine, Department of Perinatology, Istanbul-Turkey 3

Istanbul University, Istanbul Faculty of Medicine, Department of Neonatology, Istanbul-Turkey 4


Antenatal treatment with intrauterine blood transfusions has reduced perinatal mortality and morbidity related to Rhesus hemolytic disease dramatically. The aim of this study is to evaluate the antenatal management, the demographic and clinical characteristics and postnatal treatment modalities of the newborns who had undergone intrauterine transfusion (IUT) related to Rhesus hemolytic disease (RhHD).


The newborn infants with Rhesus hemolytic disease who were treated with IUT at least once in our center between January 2007-December 2016 were evaluated retrospectively. We recorded the clinical features of the patients, treatment requirements and comorbidities. Prenatal, natal and postnatal data were acquired from the patient records and the digital database of our hospital. For the postnatal management of the newborns American Academy of Pediatrics Subcommittee on Hyperbilirubinemia recommendations were accepted.


The study included 82 newborns, with 268 intrauterine transfusion procedures. A single IUT was needed in sixteen percent ( n=13) of the patients whereas 57 % (n=47) had received between 2-4 and 27 % (n=22) 5 or more IUTs. The first IUT was performed at a mean gestational age of 25.7±3.8 weeks and the last IUT was performed at 33.4±1 weeks. The first pretransfusion hemoglobin level was 5.5±2.8 g/dL (1.8-12.6). Bradycardia (n=9,11.4%), premature induction of labor (n=6, 7.6 %) and premature rupture of membranes (n=1,1.3%) were IUT related antenatal complications. The mean duration between the last IUT procedure and birth was 18.9±17.5 days. Preterm birth rate was 83% (n=68). Seventeen newborns (21%) were hydropic at birth. Postnatally, 10 % (n=8) of the babies did not require any treatment, 57 % (n=43) received phototherapy only and 33 % (27) of them needed exchange transfusion either once (n=16, 62 %) or more than one (n=11, 38 %). Top up blood transfusions were needed in 77 % (n=63) of the patients. Postnatal mortality rate was 8.5 % (n=7), all patients were hydropic and 4 of them died in first 48 hours.


Intrauterine transfusions reduce mortality and morbidity related to Rhesus hemolytic disease a result of appropriate and timely performed intrauterine transfusion procedures together with the development of antenatal and postnatal care facilities. Early detection of fetal anemia before the development of heart failure and hydrops fetalis, can improve clinical outcome dramatically.


Guerra M. 1, Maiz N. 2, Montaño I. 1, Haye M. 1, Gutierrez J. 1

Hospital Clinico San Jose, Ginecoobstetricia, Santiago-Chile 1

Hospital Vall De Hebron, Ginecoobstetricia, Barcelona-Spain 2


Intrahepatic cholestasis is the most frequent liver disease during pregnancy, it has a worldwide prevalence of 0.7-1% of pregnancies, being greater in Chile and Scandinavian countries (2-5%), and very rare in oriental and black races. It is associated with an increase in adverse perinatal outcomes such as preterm delivery, fetal distress and fetal death. The latter is still without precise cause, however it is suspected to be due to heart failure.


Primary objective: To study the difference in fetal heart function in patients with cholestasis and patients without cholestasis by determining the PR interval of the fetal heart. Secondary objectives: To study if there are changes in the TEI Index in patients affected with cholestasis and patients without the disease. To study the role of Ursodeoxycolic Acid in the treatment of cholestasis according to clinical, laboratory and echocardiographic parameters


PRCOL Trial refers to a multicenter longitudinal cohort study, carried out in 4 hospitals in Chile. Recruitment of patients began in August 2018. The patients were selected according to clinical and laboratory criteria, other associated pathologies were excluded, both maternal and fetal. Follow-up was done with laboratory and echocardiographic parameters and the time of delivery was scheduled according to severity (36 or 38 weeks) based on levels of bile acids (less than or greater than 40 umol / l).

Among the laboratory parameters mentioned in the follow-up are bile acids, total bilirubin, hepatic enzymes and prothrombin.

Regarding the echocardiographic follow-up, PR interval and TEI index parameters were used, performed by single and blinded sonographer in each participating center. Finally, Ursodeoxycholic acid (dose 15 mg / kg daily) was used for treatment and evaluation of clinical and laboratory response in all patients with confirmed cholestasis.


Regarding the preliminary results, of 55 patients affected by the pathology recruited to date, it has been possible to establish that in five patients a PR interval has been confirmed in the PC 95 and in one patient a first-degree atrioventricular block was detected(> 150 msec). Likewise, all the patients who presented alteration of the PR interval were found with bile acids over 40 umol/l. The TEI index has not shown a worsening in patients with cholestasis in any of the groups. And, finally, according to these preliminary results, ursodeoxycholic acid has a favorable effect in terms of the reduction of bili acids, transaminases, bilirubin and PR interval after 2 weeks of onset on average.


In our study, although partial to date, a trend has been seen in the increase of the PR interval with respect to the levels of bile acids in the severe range, although part of the recruitment of affected patients and the beginning of recruitment of control patients were missing. Within the next few months we hope to conclude the recruitment in the different centers and start the comparative statistical analysis, to obtain more solid conclusions.


Makatsariya A. 1, Bitsadze V. 1, Khizroeva J. 1, Vorobev A. 1, Ilyina A. 2, Mischenko A. 1, Mitryuk D. 3

Sechenov First Moscow State Medical University, Faculty of an Obstetrics and Gynecology, Moscow-Russia 1

Pirogov Russian National Research Medical University, Hospital Pediatrics Department, Moscow-Russia 2

State Medical and Pharmaceutical University «Nicolae Testemitanu», Department of Obstetrics and Gynecology, Chisinau Moldova 3


Neonates are the pediatric population at highest risk for development of thrombosis (VTE), and the incidence of the neonatal thrombosis is increasing.

Our aim to indicate the association between thrombophilia (genetic and acquired) in mothers and neonatal thrombosis


We observed 26 cases of neonatal thrombosis. In each case, we examined the mother for hereditary and acquired thrombophilia (FV Leiden, Prothrombin gene (G20210A), MTHFR (C677T), PAI-1 polymorphism and circulation of APA (LA, Cardiolipin Antibodies, Beta-2 Glycoprotein 1 Antibodies, Prothrombin Antibodies) and neonates for genetic thrombophilia. As a control we examined 50 pregnant woman with uncomplicated current pregnancy for hereditary and acquired thrombophilia and 50 theirs neonates for hereditary thrombophilia. Results: Neonatal thrombosis of the following localizations was detected: DVT (15), umbilical cord thrombosis (3), renal vein thrombosis (1), Catheter-associated thrombosis (4), ischemic stroke (1), fetal thrombotic vasculopathy (2).

There were no significant associations between prothrombin gene G2021A and Factor V Leiden mutation in two groups. Strongly significantly higher odds for neonatal thrombosis are present in patients with PAI, MTHFR gene mutation (heterozygote and homozygote pattern) and circulation of antiphospholipid antibodies. Higher odds are present for Protein S deficiency.

Table 1. Thrombophilia in mothers (genetic and acquired) and neonates (genetic only) Conclusions: This case-controlled study demonstrated significantly higher prevalence of genetic and acquired thrombophilia in women and neonates with thrombosis compared with women with normal pregnancies. Furthermore, strongly significantly associations between PAI and MTHFR mutations and neonatal thrombosis are demonstrated. The association between neonatal thrombosis and FV Leiden and Prothrombin gene G20210A mutations are controversial. Our study showed a high prevalence of multigenic (38,5%) and combined thrombophilia (30,8%) in thrombosis group compared with 12% and 6% in the control group. Fetal thrombotic vasculopathy is a disorder characterized by thrombosis of the fetal vessels and/or vessels of the fetal surface of the placenta leading to vascular obliteration and hypoperfusion. In our study both cases of FTV was associated with combined thrombophilia and septic complication. FTV associated with high incidence of hypoxic-ischemic brain injury and antenatal fetal death or early neonatal death – severe perinatal outcomes. FTV should be considered as one of the possible causes of renal and other venous thrombosis in newborns. Thus, pregnant women with genetic or acquired thrombophilia belong to a high-risk group for the neonatal thrombosis. Our study included a small number of patients, to evaluate a more accurate relationship required to perform randomized controlled trials and to determine potential benefits of administration of LMWH in order to provide prophylaxis of neonatal thrombosis in risk groups with genetic and acquired thrombophilia.

All patients with fetal growth restriction and severe fetal hypoxia (including cases of diagnosed maternal thrombophilia) should be excluded and screening of newborns for thrombosis and thrombophilia is recommended.

Obstetrics – Fetal MRI


Yamashita K. 1

Okinawa Nanbu Medical Center, Obstetrics & Gynecology, Okinawa-Japan 1

Not receiving prenatal care is one of the high-risk factors for the pregnant woman and the fetus. We present a 17-year-old primigravid woman whose fetus turned up with a serious congenital abnormality at the initial visit 25 weeks gestation. She had no idea for possibility of pregnancy, and she found herself pregnant by the fetal movement 2 weeks before the initial visit. At the initial visit, a giant fetal intraabdominal cystic mass, bilateral hydronephrosis and oligohydramnios were suspected, and the syst was estimated approximately 800 ml or more by ultrasound. Abdominal circumference of the fetus was difficult to measure and estimated fetal weight could not be calculated. Single umbilical artery made it difficult to establish whether the giant cyst was the fetal bladder or other organ. Although magnetic resonance imaging (MRI) was performed, it was difficult to make a definitive diagnosis. The cyst was punctured and aspirated to reduce the volume of the mass and perform ultrasound and MRI again. We diagnosed persistent cloaca because of the finding that one cavity was made by luminal structures with different wall which are thought bladder, vagina, and uterus. In addition, squamous cells were detected from the content fluid of the cyst. We diagnosed Potter sequence caused by anuria with persistent cloaca. On the other hand, lower urinary tract obstruction (LUTO) was thought as a differential diagnosis, but we couldn’t diagnose fetal gender by ultrasound nor MRI prenatally. Despite aspiration of the content fluid, the cystic mass became enlarged day by day. At 28 weeks of gestation, 2274 g of neonate was born. The neonate died 23 minutes after birth because of respiratory failure due to lung hypoplasia. The neonate had male-like external genitalia, but the testes were not palpable. Furthermore, the neonate was diagnosed with atresia of anus. We clinically diagnosed as persistent cloaca with female pseudohermaphroditism or LUTO with atresia of anus. However, it was difficult to confirm genetic gender and the underlying disease of the neonate because the mother and her family disagreed a chromosomal examination and autopsy. In this case, if diagnosed early in pregnancy, we may have been able to make a more accurate diagnosis and provide the fetus or neonate with the more appropriate treatment. We reaffirmed that not having a pregnancy check-up is one of the high-risk factors.


Boitor-Borza D. 1, Turcu F. 2, Fărcăşanu Ş. 2, Şimon S. 2, Crıvıı C. 1

University of Medicine and Pharmacy, Anatomy, Cluj-napoca-Romania 1

Babeş-Bolyai University, National Centre of Magnetic Resonance, Cluj-napoca-Romania 2


Ganglionic eminences are temporary structures which appear during the 5th week post-fertilization on the floor of telencephalic vesicles and dissapear until the 35th week of gestation. The aim of this descriptive study of morphological research is to depict the ganglionic eminences within the embryonic and early fetal brains by using micro-MRI.


Six human embryos and fetuses ranging from 21 mm crown-rump length CRL (9 gestational week GW) to 85 mm CRL (14 GW) were examined in vitro by micro-MRI. The investigation was performed with a Bruker BioSpec 70/16USR scanner (Bruker BioSpin MRI GmbH, Ettlingen, Germany) operating at 7.04 Tesla.


We describe the morphological characteristics of the ganglionic eminences at different gestational ages. The acquisition parameters were modified for each subject in order to obtain an increased spatial resolution. The remarkable spatial resolution of 27 μm/voxel allows visualisation of millimetric structures of the developing brain on high quality micro-MR images.


In our study we give the description of the ganglionic eminences within the embryonic and early fetal brains by using micro-MRI, which have not been previously documented in literature. Micro-MRI provides accurate images, which are comparable with the histological slices.


Staicu A. 1, Albu C. 2, Popa-Stanila R. 2, Boitor-Borza D. 1, Stamatian F. 2, Muresan D. 1

University of Medicine and Pharmacy, Obstetrics Gynecology, Cluj-napoca-Romania 1

Emergency County Hospital, Imogen Research Center, Cluj-napoca-Romania 2


Performing classic dissection techniques on small fetuses cerebral tissue is a difficult process to achieve, especially when a certain degree of maceration is involved as it is the case of arrested pregnancies.


To compare the diagnostic accuracy of post mortem magnetic resonance imaging (pm-MRI)operating at 7 Tesla intensity of the magnetic field with stereo-microscopic autopsy in describing the normal and pathological cerebral structures in the first and second trimesters of pregnancy.


Thirty-two human fetuses aged between 12 and 19 weeks of gestation were examined using 7 Tesla MRI. A Turbo High Resolution T2 protocol was used accordingly to the weight and crown-rump length of the fetuses. The subjects were selected from spontaneous and therapeutic abortions. A number of ten cerebral structures were systematically described. The images were analysed by a pediatric radiologist and two embryologists. After scanning, all fetuses were submitted to autopsy which was performed by a fetal pathologist, blinded to the imagistic findings.


Using the stereo-microscopic autopsy as gold standard, pm-MRI presented a sensitivity of 100% [CI 95 % 79.41-100] in detecting structural cerebral anomalies for a specificity of 88.24% [CI 95% 63.56-98.54], a positive predictive value of 88.89% [CI 95% 68.52-96.71] and a negative predictive value of 100%. Pm-MRI demonstrated a high accuracy of 93.94% [CI 95% 79.77-99.26] to identify cerebral anomalies, in a group with a malformation frequency of 48.48% [CI 95% 30.80-66.46].

The Cohen’s kappa coefficient of agreement was k=0.879 [95% CI 81-95], highlighting a very good concordance between the two methods, also supported by the McNemar test p=0.1573.


Pm-MRI at 7 Tesla has a great potential in describing the cerebral structural abnormalities in the first and second trimesters of pregnancy, very closed to the gold standard accepted nowadays.


Theodora M. 1, Bourgioti C. 2, Zafeiropoulou K. 2, Antsaklis P. 1, Koutroumanis P. 1, Sindos M. 1, Loutradis D. 1, Daskalakis G. 1

Medical School, National and Kapodistrian University of Athens, Maternal Fetal Medicine Dpt, 1

Dpt Obstetric Gynecology, Athens-Greece 1

Medical School, National and Kapodistrian University of Athens, Department of Radiology, Athens-Greece 2


The objective of our study is the correlation of 2D/3D ultrasound and MRI findings in cases of patients at high risk of accrete spectrum disorders with obtretric hysterectomy.


Twenty five cases of previa and increate/precreta placentas were study. For the ultrasonographic examination 2D/3D imaging were used and the data were collected in ISUOG preforma. MRI scans were performed with a 1.5T unit (Gyroscan NT Intera, Philips Healthcare). All patients were instructed to empty their bladder about 15min before entering the scanning room; then, all received orally 500ml of water. A short MRI protocol (< 30min) was designed with respect to the safety of mother and fetus. All MRIs were separately reviewed by two radiologists expert in genitourinary MRI who were aware of patients’ age and gestational age but were blinded to any other clinical or histological information.


Most common MRI findings were : placental heterogeneity (any degree) (88%), prominent intraplacental vascularization(61%), lumpy placental borders,(59%) , abnormal flow-void vascular network abutting the uterine serosa or extending to the vesicouterine interface or parametrial fat (52%) , signs of bladder invasion/ elongation (tenting) of the bladder dome (38%), myometrial thinning with or without disruption of the low T2 signal of the outer myometrium (36%) intraplacental dark bands on T2-W images (36%). Most common ultrasonografic finding were abnormal placenta lacunae (90%), loss of clear zone(88%), bladder wall interruption (35%), myometrial thinning (35%), Focal exophytic mass (65%), subplacental hypervascularity (61%).


Ultrasonographic and MRI findings in pregnancies high risk for placenta accreta spectrum disorders are similar and have the same sensitivity and specificity for prognosis of the surgical outcome. Low cost and real time examination are the advantages of ultrasound whereas MRI gives more information in case of posterior and fundal placenta.

Obstetrics – Fetal Surgery


Guinto V. 1

St. Luke’s Medical Center Global City, Obstetrics And Gynecology, Taguig City-Philippines 1

Sacrococcygeal teratoma (SCT) is the most common solid tumor in the fetus seen in 1 in 35,000 to 40,000 births.1,2 Ultrasound is the preferred diagnostic modality.3 The American Academy of Pediatrics Surgical Section classifies it according to the extent of the tumor where Type I is predominantly external and Type IV is located in the presacral space and mostly malignant.1 Tumor Volume to Weight Ratio (TFR) >0.12 before 24 weeks is best used to predict poor outcome.4 Other poor prognostic indicators are gestational age of <30 weeks, placentomegaly, hydrops, tumor rupture, tumor size>10 cm, solid tumor, increased vascularity and tumor volume growth rate greater than 150 cm3/week.2 Fetuses >28 weeks exhibiting high-risk signs are delivered and managed. Those less than the age of viability and have signs of hydrops are candidates for fetal surgery.2 Fetal surgery may result in 43% survival as opposed to 33.3% overall perinatal death rate in observed cases.2,5 Aside from a fetal anomaly scan, prenatal counselling is done emphasizing maternal risks of infection, hemorrhage, damage to nearby organs and loss of fertility.6 We present a case of a 34-year old nullipara with a 5-year history of infertility. She conceived naturally followed by an unremarkable prenatal course until a small solid sacrococcygeal teratoma type I was seen on routine ultrasound at 20 weeks. Subsequent congenital anomaly scan showed mild cardiomegaly, small pericardial effusion, rapid tumor growth of about 400 cm3 in 2 weeks (with TFR = 1) and placenta previa totalis. Progression of hydrops and continued rapid growth was seen on admission. The healthcare team presented the option of fetal surgery. Problems encountered were lack of prior experience in fetal surgery, lack of recommended instrument, ethical issues (maternal versus fetal safety) and the advanced stage of hydrops. The family and the team arrived at a decision to do the fetal surgery.6 Unfortunately, complications were encountered resulting in the delivery of the previable fetus. Lessons learned and recommendations shall be discussed.

Neonatology – Chorioamnionitis


Sezik M. 1, Savran M. 2

Suleyman Demirel University Faculty of Medicine, Department of Obstetrics and Gynecology, Isparta-Turkey 1

Suleyman Demirel University Faculty of Medicine, Department of Medical Pharmacology, Isparta-Turkey 2


Chorioamnionitis is associated with fetal brain injury and subsequent cerebral palsy. Although antenatal magnesium sulfate treatment has been shown to decrease cerebral palsy rates in preterm infants, the number needed to treat is relatively high. This may be due to reduced efficacy in subgroups of pregnancy comorbidities, such as increased intrauterine inflammation. In an effort to reveal knowledge gaps and future study perspectives, the present scoping review aimed to evaluate the relevant literature on the neuroprotective effects of antenatally administered magnesium sulfate in the setting of preterm chorioamnionitis.


We used “magnesium, or magnesium sulfate, or magnesium sulphate” and “chorioamnionitis, or intrauterine inflammation, or neuroinflammation” as keywords for searching PubMed, Google Scholar, and web of Science Core Collection databases. Only peer reviewed clinical studies on human subjects published in English as a full-text article were included.


Some recent cohort studies suggested that magnesium sulfate is not neuroprotective in pregnancies complicated by chorioamnionitis. An association between histological chorioamnionitis and magnesium sulfate treatment has also been reported, although this was not replicated in another retrospective cohort study. In a meta-analysis investigating participant characteristics for magnesium sulfate neuroprotection, rate of clinical chorioamnionitis was similar across pregnancies with or without magnesium sulfate treatment.


Several observational cohort studies have revealed a possible association between antenatal magnesium sulfate treatment and chorioamnionitis, probably leading to decreased fetal neuroprotection. However, some data do not support such a relationship. Properly designed translational and clinical studies investigating the effects of magnesium sulfate on chorioamnionitis and vice versa are needed.

Neonatology – Neonatal sepsis


Hadzimuratovic E. 1, Porovic S. 2, Hadzimuratovic A. 3, Brankovic S. 4

Pediatric Clinic University Medical Center Sarajevo, Neonatology, Sarajevo-Bosnia and Herzegovina 1

Public Health Center of The Sarajevo Canton, Pediatric Dentistry, Sarajevo Bosnia and Herzegovina 2

Pediatric Clinic University Medical Center Sarajevo, Nephrology, Sarajevo-Bosnia and Herzegovina 3

Faculty of Health Studies, Health Education, Sarajevo Bosnia and Herzegovina 4

The brain abscesses are possible but very uncommon complication of bacterial sepsis and meningitis in neonate. We report a case of multiple brain abscesses in preterm neonate as a complication of Serratia marcescens sepsis.The female preterm weighing 1990 g was delivered by ceasarian section at 32. weeks of gestation. Apart from moderate RDS, the baby was in a good condition with no indicators of perinatal infection. On the third day of life, the clinical status deteriorated and the sepsis screen was positive. The baby was intubated and, along with other intensive measures, treated with high doses of vancomycin and imipeneme. Serattia marcescens was isolated in hemoculture. The baby clinicaly improved in the following days, but the cranial ultrasound revealed multiple hypoechoic lesions in parietal lobes bilaterally. Magnetic resonance imaging of the brain showed multiple (five) hypodense lesions with the peripheral enhancement suggestive of intra-parenchymal abscesses. The neurosurgical consilium sugested the conservative treatment with antibiotics and weekly neuroimiging follow-up. The antibiotic treatment was conducted for a total of 8 weeks. The final MRI showed a total regresion of previous abscesses with the formation of small cavitations. The clinical and neurological examination of the baby was normal as well as EEG. The baby was discharged with recommedation of neurological follow-up.A multidisciplinary team approach, including neurosurgeons, neonatologists and infectious disease specialists, is needed for the desision on treatment of brain abscesses in neonate. Serial imaging is important in the assessment of the efficacy of treatment.


Anne R. 1, Dutta S. 1, Aggarwal A. 2, Chadha N. 3, Kumar P. 1

Post Graduate Institute of Medical Education and Research, Neonatology, Chandigarh-India 1

Post Graduate Institute of Medical Education and Research, Pulmonary Medicine, Chandigarh-India 2

Post Graduate Institute of Medical Education and Research, Senior Library Assistant, Chandigarh-India 3


Rapid diagnostic tests (RDTs) on cerebrospinal fluid (CSF) – white blood cell count (WBCC), glucose, and protein – are widely utilized to diagnose neonatal meningitis. No systematic review and meta-analysis (SRMA) on the diagnostic accuracy of these RDTs is published.


We performed an SRMA on studies (January 1, 1950-December 31, 2016) that assessed the accuracy of CSF WBCC, glucose and/or protein (index tests) in diagnosing meningitis among neonates and infants aged <90 days. Meningitis was defined as positive reference standard test [CSF culture or gram stain or polymerase chain reaction (PCR)]. We followed standard Cochrane Handbook methodology. We used Stata-14 for analysis. We included all study designs, where the authors had either published data showing cross-classification of index test outcome and disease status, or provided these data on request. We excluded studies on well-looking infants subjected to CSF examination; which had reference standard or index tests other than those specified; published in non-English languages and conference abstracts. We pooled studies for sensitivity, specificity, likelihood ratios (LR) and diagnostic odds ratios (DOR) only if their threshold values were within pre-specified ranges: 19-25/mm3 in term and 25-29/mm3 in preterm neonates, 30-40 mg/dl, and 120-170 mg/dl for term and 150-170 mg/dl in preterm neonates for WBCC, glucose and protein respectively.


From 13,211 titles and abstracts, after excluding duplicates and irrelevant studies, we selected 1023 full-text articles for review; further excluded 1003 based on full-text and included 20 studies for meta-analysis [WBCC: n=29,906 (18 studies); glucose: n=8,352 for glucose (10 studies); and protein: n=8,538 (11 studies)]. Area under Hierarchical Summary Receiver Operator Characteristic (HSROC) curves of CSF WBCC, glucose and protein were 0⋅89 [95% confidence interval (CI): 0⋅86, 0⋅91], 0⋅68 (95% CI: 0.64, 0.72), and 0⋅71 (95% CI: 0.67, 0.75) respectively. The pooled sensitivity of WBCC (n=9,191, 8 studies), glucose (n=1,370, 8 studies) and protein (n=8,419, 8 studies) was 77% (95% CI: 69%, 84%), 62% (95% CI: 43%, 78%), and 62% (95% CI: 50%, 73%) respectively. The pooled specificity was 77% (95% CI: 50%, 92%), 73% (95% CI: 38%, 92%) and 92% (95% CI: 79%, 97%) respectively. The pooled LR+ were 3.3 (95% CI: 1.4, 8.1), 2.3 (95% CI: 0.8, 6.9) and 7.8 (95% CI: 2.8, 21.7) respectively. The pooled LR-were: 0.30 (95% CI: 0.22, 0.41), 0.52 (95% CI: 0.28, 0.96) and 0.41 (95% CI: 0.30, 0.56). The pooled DOR were 11 (95% CI: 4, 32), 4 (95% CI: 1, 23) and 19 (95% CI: 6, 62) respectively. On meta-regression, study design, year of publication, diagnostic threshold and reference standard used were not statistically significant.


Overall, CSF WBCC had the best ability to diagnose meningitis in neonates and young infants, followed by protein and glucose. On pooling studies with threshold values within a pre-specified range of commonly used cut-off values, the pooled estimates of sensitivity, specificity, LRs and DOR were sub-optimal.

Our study was not funded by any source.

PROSPERO registration number: CRD42017060045.


Hoxha M. 1, Raka L2, Latifi-Hoxha S1, Salihu S1

UCCK, Neonatology Clinic, Prishtina-Albania 1


Health care-associated infections (HAIs) represent one of the commonest complications of healthcare. They complicate 5-10% of admissions to acute care hospitals in industrialized countries with average rate in EU of 7.2%.

Antimicrobial resistance (AMR) is another challenge closely related with HAIs. Inappropriate and irrational use of antimicrobials is the most important cause of emerging resistant microorganisms, their spread and persistence in the community and hospitals. Intensive care units (ICUs) represent the epicenter of HAIs in all settings. In developing countries 2/3 of patients develop HAIs.


The aim of this survey was to reduce morbidity, mortality and costs from healthcare-associated infections in Neonatal Intensive Care Unit (NICU) at Kosovo teaching hospital. Objectives were to estimate and identify the incidence, mortality, risk factors, causative organisms and their antimicrobial susceptibility patterns; identify targets for quality improvement.

Methods: Study took place at the NICU, University Clinical Centre of Kosovo (UCCK). ECDCD and Centers for Disease Control and Prevention criteria were used as standard definitions for HCAIs. All neonates admitted for more than 24 hours in ICU were enrolled in the study. They were observed five times per week. A prospective cohort study was performed during 5 months period, starting in September 15, 2017-February15, 2018. The dataset included: age, gender, LOS in ICU, MV days, underlying disease or conditions, therapy and clinical outcome. The following main infections were under surveillance: bloodstream infections, pneumonia, urinary tract infections and surgical site infections. Samples were processed at the department of Microbiology at NIPHK. The blood cultures have been processed in BacT/Alert automated system. Antimicrobial susceptibility was determined by the disk diffusion method according to the EUCAST criteria.


Total number of admitted and treated patients in NICU was 348, representing 5303 bed days. Total number of clinical microbiology samples taken from patients was 295, of which positive growth was retrieved from 82 samples.

Of 348 babies admitted in the ward, 65 babies acquired a health care-associated infection, with cumulative incidence rate of 18.6%. Total number of registered HAIs was 75. The most common type of HCAI was bloodstream infection (sepsis), representing 79.7%. The CVC-BSI (central venous catheter-bloodstream infections) rate was 18.9 per 1000 CVC days, the VAP(ventilator associated pneumonia) rate was 10.3 per 1000 device days, and CA-UTI (catheter associated urinary tract infections) rate was 23.2 per catheter days. Total average length of stay in the ward was 15.2 days. Babies who acquired an HAIs had an average length of stay of 27 days. The predominant microorganism isolated from clinical samples was Staphylococcus spp. with 19 cases (36.8%) .


Key recommendations driven by this study are to improve surveillance systems of HAI, enhance infection prevention and control in NICU and establish antimicrobial stewardship program.


Gatseva P. 1, Atanasova V. 1, Nedkova V. 2

Umhat-Pleven, Bulgaria, Neonatology, Pleven-Bulgaria 1

Umhat-Pleven, Bulgaria, Pediatrics, Pleven-Bulgaria 2


Hospital-acquired infections (nosocomial) infections (NI) are one of the leading causes for morbidity and mortality in the neonatal intensive care unit (NICU). NI result in different complications, prolonged and more expensive hospital stay. Their epidemiology changes over the years and studying them may be helpful in their prevention.


To analyze the incidence, etiology and risk factors of NI in NICU.


Prospective study in the NICU of Clinic of Neonatology, UMHAT-Pleven, Bulgaria, from 01.01.2018 to 31.12.2018

Inclusion criteria: all newborns with hospital stay above 72 hours, followed up until discharge. Patients’ groups: 1 – with proved NI, 2 – without NI, and 3 – with microbial colonization. Studied indicators: weight and gestational age at birth, congenital anomalies, congenital infections, postnatal morbidity, diagnostic/treatment procedures, outcome at discharge. NI criteria (CDC, 2008) are accepted: NICU stay > 72 hours; at least 3 new-onset clinical and laboratory indicators of systemic inflammation, plus 1 risk factor. Microbial colonization is defined as positive microbiological probe without criteria for NI. All diagnostic tests are carried out at the clinical and microbiological laboratories of UMHAT, Pleven.

The data are calculated using software statistical packages STATGRAPHICS v. 4.0; SPSS v. 13.0 and Microsoft Office 2016 for Windows. The significance of the conclusions is fixed by p < 0.05.


One hundred ninety-three newborns meet the inclusion criteria. NI is proven in 20 of the patients (10.4%), four of them with more than one NI episode. Twenty-five NIs are registered for a total of 3238 hospital days (7.7 NI per 1000 hospital days). Microbial colonization is detected in eight of the patients (4.1%). Groups 1 and 3 compared to Group 2 have similar characteristics: less mature (31.3±4.7 and 30.8±2.4 vs. 35.7±3.5 gestational weeks), with lower birth weight (1650±887 and 1488±347 vs. 2480±778 grams), more often required central venous line – CVL (65 and 63 vs. 22%), longer use of CVL (3±3 and 4±4 vs. 1±2 days) and gastric tube (29±26 and 28±19 vs. 6±11 days), prolonged hospital stay (36±27 and 36±16 vs. 14±12 days) – p < 0.001 for all indicators. Group 1 compared to Group 3 has a significantly higher incidence of congenital anomalies (50 vs. 25%), requires longer parenteral nutrition (20±22 vs. 11±8 days) and respiratory support (13±14 vs. 5±4 days). At discharge, 55% of Group 1 are clinically healthy, 25% have residual problems, 20% deceased. Groups 2 and 3 have a comparable outcome – 99 and 100% healthy children, respectively. NI analysis determines very wide range of the time of infection – from the 4th to the 76th hospital day. Seven of the NI cases are clarified etiologically, five of them are caused by gram negative strains, predominantly Klebsiella spp.


According to our data, the incidence of NI among the total NICU population is comparable to the literature data. The most important risk factors are congenital anomalies, the need for prolonged parenteral nutrition and respiratory support. We determined different that quoted in the literature etiology – predominantly gram-negative strains.


Lekic E. 1, Babovic S. 1, Vukicevic J. 1, Nesovic M. 1 Draga L1.

UCC Montenegro, Center Of Neonatology, Podgorica-Montenegro 1


Possible sepsis is one of the most common diagnosis made in the neonatal intensive care unit (NICU). The identification of neonates at risk for early-onset sepsis is frequently based on a constellation of perinatal risk factors that are neither sensitive nor specific. Diagnostic tests for neonatal sepsis have poor positive predictive accuracy. As a result, clinicians often treat well appearing infants for extended period of time, even when bacterial cultures are negative.


The study was prospectively conducted over a period of 12 mounts between 01.01.2015 to 31.12.2015.The purpose was to identifications the risk factors and bacterial microorganisms caused early-onset sepsis in preterm newborn infants.


The present study included 71 newborn infants diagnosed with sepsis. Out of 653 infants admitted from 01.01.2015 to 31.12.2015., 427 were born at term (TNB ), and 227 were preterm infants ( PTN ). They were divided into two groups: one comprised of at term newborn infants with proven sepsis – 32 cases (7,5%) and second group were preterm newborns with neonatal sepsis – 39 cases (17,3%). Blood culture was positive in 44 newborns ( 24 PTN and 20 TNB) with sepsis (62%). Out of 24 proven neonatal sepsis, early-onset sepsis was present in 8 PTN (28.6%) , and possible early onset neonatal sepsis were in 4 PTN, or half of the infants with proven neonatal sepsis. Late –onset sepsis in PTN was proven with blood cultures in 16 newborn infants, but in 11 PTN we did not isolate the pathogenic microorganism.

In the PTN dominant isolated pathogen in early-onset sepsis was E. coli, while in late onset sepsis were Klebsiella Pneumoniae and Staphylococcus CoN. Premature birth and low birth weight were among the most common neonatal sepsis risk factors. Maternal preeclampsia, PROM and perinatal asphyxia were also significant risk factors for earl-onset neonatal sepsis in the preterm newborn infants.


The clinical diagnosis of neonatal sepsis in the neonate is difficult, because many of the signs of sepsis are nonspecific and are observed with other noninfectious conditions, especially in the preterm newborn infants. Our data suggest that premature birth and low birth weight are a most common sepsis risk factor. Maternal preeclampsia, PROM and perinatal asphyxia were also significant risk factors for neonatal sepsis


Ünlü F. 1, Ünal S. 2

Tufanbeyli State Hospital, Child Health and Diseases, Adana-Turkey 1

Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Neonatology, Ankara Turkey 2


Neonatal sepsis continues to be an important cause of mortality and morbidity in spite of improvements in the diagnosis and treatment methods. Antibiotic therapy and supportive treatment are very important in neonatal sepsis. Pentoxifylline, a phosphodiesterase inhibitor, is used in neonatal sepsis as an immunomodulatory agent. The aim of this study was to evaluate the effect of pentoxifylline treatment on mortality and morbidity in newborn infants with sepsis who were followed-up and treated in our neonatal intensive care unit (NICU).


The study was performed in the Medical Science University Ankara Children Hematology and Oncology Training and Research Hospital. A total of 175 patients with proven, clinical and suspected sepsis followed up and treated in the NICU between January 2015-December 2017 were included in the study. Medical records of the neonates with sepsis who were treated with pentoxifylline (34 patients) and without pentoxifylline (141 patients) were recorded retrospectively.


A total of 1137 patients were hospitalized between January 2015 and December 2017 in our NICU, 175 of them were diagnosed with sepsis. Of the patients, 105 (60%) were male and 70 (40%) were female. We diagnosed neonatal sepsis izolated by blood culture in 31 (17.7%) infants. Among 175 patients, 82 (46.9%) were diagnosed with early onset neonatal sepsis (EONS), 78 (44.6%) were diagnosed with late onset neonatal sepsis (LONS) and 15 (8.6%) were diagnosed with very late onset neonatal sepsis (VLONS). Of the patients, 82 (46.9%) were preterm and 93 (53.1%) were born term. The most common clinical signs were respiratory distress symptoms (tachypnea, groaning, retraction) and determined in 66 patients (37.7%).

The most commonly isolated microorganisms in early onset sepsis were Klebsiella species in 11 (6,2%) patients, 5 of them were Klebsiella Pneumoniae. The most commonly isolated microorganisms in late onset sepsis were Klebsiella species in 5 (2,9%) patients, 3 of them were Klebsiella pneumoniae.

The mortality rate was 14.8%, and significantly higher in the premature, low birth weight infants, having congenital anomalies, applied inotropic therapy or mechanical ventilation, or pentoxifylline in our study. Premature and low birth weight infants was more applied pentoxifylline therapy. There were 34 patients given pentoxifylline treatment and 5 of them had shock. We thought that pentoxifylline therapy was given late. Mortality was higher in the patients given late pentoxifyline therapy (p=0.029*). One (3%) of the patients given pentoxifylline had seizures. We thought this might be the drug’s side effect and it was discontinued.


Although experimental studies revealed that pentoxifylline may decrease mortality in sepsis, we thought that the use of pentoxifylline in the premature or low birth weight infants and in the advanced stages of sepsis had no effect on mortality. In order to determine the clinical efficacy of pentoxifylline in neonatal sepsis and to determine it’s clinical efficacy on neonatal morbidities, prospective randomized controlled trials are necessary by experimental studies and more patient’s data at the molecular level.


Eyican E. 1, Ünal S. 2

University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Pediatrics, Ankara-Turkey 1

University Of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital, Neonatology, Ankara-Turkey 2


Urinary tract infection (UTI) is among the common infections in the newborn infants. The aim of this study was to determine the demographic characteristics of the neonates who were followed up in the neonatal intensive care unit (NICU), the most common symptoms, causative microorganism, underlying urinary system anomalies and the response to the treatment. The prognosis of the patients, complications and renal damage secondary to the disease following discharge were also identified.


The neonates whom were hospitalized between May 2015 and October 2018 at University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital in the NICU with a diagnosis of UTI were retrospectively evaluated.


Of the 190 patients included in the study, 125 (65,8%) were male and 65 (34,2%) were female and 56 (29,5%) were premature. The mean age of the neonates on admission was 15,7 ± 8,5 days (1-40 days). Among 190 neonates, 17 patients (8,9%) were diagnosed with nosocomial UTI. Among all the patients, 28 (14,7%) had prenatal diagnosis and 23 (12,1%) had hydronephrosis, 1 (0,5%) had meningomyelocele and 4 (2,1%) had cystic kidney disease. Admission complaint of the patients were as follows: 57 (30%) patients had jaundice, 39 (20,5%) had fever, 38 (20%) had vomiting and 34 (17,9%) patients had only jaundice. There were 174 (91,6%) patients with gram negative and 16 (8,4%) with gram positive bacterial growth by the urine cultures. In 53% of patients diagnosed with nosocomial UTI, 53% had klebsiella, 23,5% had E.coli, 17,6% had coagulase negative staphylococcus. Among the other 173 patients, E.coli was found in 55,4%, klebsiella was found in 34,6% of the patients. There were 25 patients diagnosed urosepsis and all of these patients determined the same pathogen on the blood and urine cultures. Urinary system ultrasonography (USG) was performed in all patients and pathologic USG sign was detected in 120 patients. Hydronephrosis were detected in 19 (10%) patients by both antenatal and postnatal USG. Voiding cystourethrography was performed 82 (43,2%) patients and 75 (91,5%) of these patients had vesicoureteral reflux (VUR). On follow-up, Dimercaptosuccinicacid scaning was performed in 43 (22,6%) patients, and 27 (62,8%) of these patients had renal scar. It was determined that the high-grade VUR alone had a 7 fold (OR: 6,9) more effective on scar development. In 72 (37,9%) of the patients, UTI recurred, and 44 (23,2%) of the patients were rehospitalized for UTI. These 190 patients were followed up for a median of 8 months (4-52) and 13 (6,8%) patients were developed complications. The risk of complications increased by 35 times more (OR: 34,59) in the cases developed renal scar.


Newborns with UTIs may present with nonspecific findings such as jaundice, vomiting, fever, prolonged jaundice or malnutrition. The neonates with these findings should be examined for urine analysis, urine culture and UTI diagnosis should be kept in mind. It should be noted that early diagnosis and treatment are very valuable in the prevention of long-term complications.


Baş M. 1, Gürsoy B. 1, Ergenekon E. 1, Türkyilmaz C. 1, Koç E. 1

University Of Gazi, Department Of Pediatrics, Neonatology Unit, Ankara-Turkey 1


Ralstonia picketti is an aerobe, non-fermantative , gram (-) bacillus. Nosocomial infections may be associated with contaminated commercial solutions used in patient care and laboratories. Altough it is an opportunistic pathogen, immunsupression may cause severe infections. There are few cases of newborn Ralstonia picketti infections in the literature. Four cases of Ralstonia picketti outbreak between 14-30 April 2019 in our NICU are presented.

Case 1: A 1440 gr girl was delivered at 33rd week. She was admitted due to respiratory distress. On the second day of life, she was intubated for increased oxygen requirement, tachypnea and abdominal distension and bloody vomiting that progressed to necrotizing enterocolitis. Owing to abnormalities in coagulation parameters, Vitamin K and fresh frozen plasma were administered. Inotrops were administered for circulatory failure. On 5th day, patient expired from DIC associated with sepsis and multiorgan failure and blood culture grew R. Picketti.

Case 2: A 750 gram male infant was delivered at 31 weeks gestation with severe IUGR. He was intubated and administered surfactant, umbilical vein-artery were catheterized and septic screening was carried out. TPN and antibiotic treatment were started. Echodardiography, on 2nd day of life revealed 2 mm PDA, enlargement in cardiac cavities and impairment in myocardial functions. PDA closure treatment was given. On 7th day, there was increase in oxygen need and septic screening was carried out. Blood culture grew R.Picketti. Free air was detected in abdomen. The patient was operated three times for NEC. Control bood culture was sterile on 6th day of treatment. Patient expired on 20th day of life.

Case 3: A 1340 gr female infant was delivered at 31 weeks gestation with IUGR. She was admitted due to respiratory distress. Umbilical vessels catheterization, septic screening was carried out. She received antibiotic treatment for five days. Umbilical catheter was withdrawn on 12th day of life and R. Picketti growth was detected in the catheter tip culture. In control evaluation, there was no increase in acute phase reactants and no growth in culture. No antibiotics were started . She was discharged on 35th day of admission.

Case 4: A 650 gr male infant was delivered at 27th weeks gestation with IUGR due to heart failure and preeclampsia in the mother. He was intubated, administered surfactant and umbilical vessel catheterization was performed. On 5th day of life blood culture grew R. picketti antibiotic treatment was revised. In follow up, general condition improved and patient was discharged on 70th day of admission.

Discussion: In all cases, there was invasive intravascular intervention during the time of bacteremia. Culture was sent from commercial solutions used in patients with no growth however later on microorganism was isolated from incubator reservoirs.


Ralstonia infection is likely to lead to sepsis in NICU. In the presence of Ralstonia picketti growth, care should be taken for protection of other patients, cultures should be sent from commercial solutions and medical devices. Early diagnosis, suitable antibiotic treatment and early determination of the source of the infection are important for preventing and treating infection.


Tas M. 1, Onal E. 1, Tapısız A. 2, Bas M. 1, Keles E. 1, Kenar A. 1, Hirfanoglu I. 1, Turkyilmaz C. 1, Ergenekon E. 1, Koc E. 1

Gazi University Faculty of Medicine, Neonatal Unit, Ankara-Turkey 1

Gazi University Faculty of Medicine, Pediatric Infection Unit, Ankara-Turkey 2


Gram (-) bacteria are the causative agents of neonatal sepsis and its environment and it is an important cause of morbidity and mortality. Preterm and very low birth weight (VLBW) infants are at greater risk. Multidrug resistance is also associated with higher mortality in newborns

In this study, we aimed to determine the antibiotic susceptibility and to evaluate the antibiotic susceptibility in clinical analysis with Gram (-) growth in our unit.


Between January 2018 and May 2019, 34 patients who had Gram (-) infected blood, CSF, urine, ETA and central catheters were hospitalized at Gazi University Neonatal Intensive Care Unit. Demographic characteristics of the patients showed birth weight and week and days of hospitalization. Antibiotic susceptibilities of gram (-) infections, mortality and clinical status of patients developing antibiotic resistance were investigated.


A total of 53 agents and 48 infections were detected in blood, CSF, urine, ETA and central catheters. The mean gestational weight of the patients was 1465 g (min 550-max 3610), and the mean gestational age was 29 weeks 3 days (min 22-max 38). 23 (68%) of the patients were male. The mean hospitalization day was 68 days (min 5 – max 300). Twenty-seven patients (79%) had prematurity and 15 (44%) were less than 1000 g. Of all patients who had Gr (-) infection during hospitalization, 12 (35.2%) were ex.

The most common Gr (-) infection was VIP, followed by UTI, CLABSI, late sepsis, and meningitis. (Table 1) The most common growth of Gr (-) microorganisms in our unit; Klebsiella spp. (25) followed by E.Coli (9). Klebsiella (10) and E.Coli (3) were ESBL (+). (Table 2)

Amoxicillin-clavunate resistance was found to be high and only eight of the agents were susceptible to E. coli (4) and Klebsiella (4). Aminoglycoside resistance was higher in gentamicin than amikacin. Amikacin resistance was only against Acinetobacter in one infection. Colistin resistance was detected only in Serratia (2) and ciprofloxacin resistance only in Pseudomonas (3). (Table 3)

Although aminoglycoside resistance was not high in 2018, in 2019 Gentamicin-resistant ESBL (+) Klebsiella spp. infection detected in eight patients and and six of them were ex. Six infection were detected in four patients followed up for Ralstonia Picketti growth. No resistance was found in the antibiograms. Although one patient had Ralstonia growth in his blood culture, the patient recovered without any treatment.


Despite advances in supportive care and antibiotic use, nosocomial sepsis is one of the most important causes of neonatal mortality and morbidity. Although Gram (+) agents are the most common causes of nosocomial infection, there is a risk of Gram (-) bacteremia, severe sepsis, septic shock and death.

In order to select the appropriate empirical treatment for nosocomial sepsis, each unit should determine the factors according to their infection and resistance rates, focus on forming a common language when starting and ending antibiotherapy. Standard treatment controls such as hand hygiene and avoiding unnecessary invasive preparations are best practices for hospital cleaning.


Kayki G. 1, Oktem A. 2, Celik H. 1, Yigit S. 1, Yurdakok M. 1

Hacettepe University, Neonatology, Ankara-Turkey 1

Sami Ulus Çocuk Hastanesi, Neonatology, Ankara-Turkey 2


In newborns, community-acquired lower respiratory tract infections, especially in winter, are the leading causes of admission to neonatal intensive care units. Although most of the cases are viruses, they may be accompanied by bacteria in some cases.


In this study, we aimed to determine the viral and bacterial agents in newborns with pneumonia in intensive care unit of our hospital.


This prospective observational clinical study was conducted between October 2015 and

October 2018. In these three years, viral and bacterial agents were screened by the Multiplex Real-time PCR method in nasopharyngeal fluid samples of newborns who were clinically and radiologically diagnosed as pneumonia and hospitalized in the neonatal intensive care unit. Congenital pneumonia and mechanical ventilator-associated pneumonia were excluded.


A total of 152 newborn infants included the study. The mean gestational weeks of the patients were 38 week (27 were preterm), the average birth weights were 3145 g. The most common cause of hospital admission was cough with 79 babies (51.9%), following by fever, nasal congestion and apnea.

Viral or bacterial agent was detected in 107 babies (70.3%). Viruses were detected as 101 (66.8%); 33 (21.7%) with RSV-A, 26 (17%) with RSV-B were the most common viral agents. In preterms the most common viral agent was Rhinovirus with 6 (22%). Bacterial agents were 12 (7.8%), the most common bacterial agent is Haemophilus influenza with 6 patients. Two of them were only preterm.

Seven (4.6%) infants had mixed (viral and bacterial) infection and 19 (12.5%) had multiple viral agents.


Screening of respiratory viral-bacterial infections by multiplex real-time PCR method in nasopharyngeal fluid samples is a reliable method with rapid results. Therefore, early identification of the pathogen may prevent unnecessary use of antibiotics.


Melekoglu A. 1, Yasar S. 2

Malatya Training and Research Hospital, Pediatrics, Malatya-Turkey 1

Biostatistics and Medical Informatics, Malatya-Turkey 2


The predominant pathogens of neonatal late onset sepsis (LOS) are coagulase-negative staphylococci, followed by gram negative bacilli and fungi. Prompt diagnosis of LOS is essential to improve treatment and to reduce mortality and long term neurodevelopmental sequelae. Generally gram negative pathogens are responsible for more severe illness and deaths than gram positive agents. Delta neutrophil index (DNI), which reflects peripheral immature granulocytes, is the difference between leukocyte subfractions identified by myeloperoxidase and nuclear lobularity channels. In this study, we aimed to determine the diagnostic value of DNI for the detection of gram negative late onset sepsis in neonates and compare its efficacy with C-reactive protein (CRP) and other hematological indices.


This retrospective observational study was conducted at a tertiary hospital and in newborns with gram negative LOS (n=42) and in age and weight matched healthy controls (n=49). Patients with perinatal asphyxia, patients undergoing surgery and patients with positive blood cultures for organisms considered to be contaminants were excluded from the study. DNI, white blood cell and platelet counts, mean platelet volume (MPV), platelet distribution width (PDW), CRP measurements and blood cultures were performed at the onset of symptoms. The diagnostic accuracy of markers was examined by ROC curve analysis both individually and in combinations. In all analyses, 0.05 was considered as the significance level.


There were no significant differences between the groups in gestational age, birth weight, gender, mode of delivery, Apgar score at 1 minute, frequency of intrauterine growth retardation, or exposure to antenatal steroids. The most commonly isolated microorganism was Klebsiella pneumoniae (59.5%). The mean DNI value was significantly higher in gram negative LOS group compared with the control group (8 ± 10, 0.4 ± 0.5, respectively, p<0.0001). In addition, the levels of CRP, MPV and PDW at the onset of sepsis were significantly higher and platelet counts were significantly lower in gram negative LOS group than the control group (p<0.001). DNI had a sensitivity of 81%, a specificity of 98%, a positive predictive value (PPV) of 97% and a negative predictive value of 86% with a cut-off value of 1.6% in the gram negative LOS group. Furthermore, the combination of DNI and CRP showed the highest sensitivity (98%), specificity (100%), and positive predictive value (100%).


DNI is a reliable and objective hematologic marker for gram negative neonatal LOS. Besides, it can be checked by complete blood count, of which results can be obtained within minutes and does not require additional cost and labor. The diagnostic capability of DNI may be increased by assessing CRP measurements simultaneously.


Pavicic Bosnjak A. 1, Stanojevic M. 2

University Hospital Sveti Duh, Department of Obstetrics and Gynecology Medical School University of Zagreb, Zagreb-Croatia 1

University Hospital Sveti Duh, Department of Obstetrics and Gynecology, Zagreb-Croatia 2


The aim of our study was to assess the incidence of late-onset sepsis (LOS), distribution of causative organisms and risk factors for LOS in infants born before completed 32 weeks of gestational age (GA).


A retrospective cohort study included preterm infants with less than 32 weeks of GA admitted to level 3 neonatal intensive care unit at University Hospital Sveti Duh Zagreb, Croatia, between January 2007 and December 2016. Excluded were infants with congenital anomalies or chromosomal diseases and these who were transferred to another hospital or died within the first week of life. LOS was defined as the first episode of a positive blood culture for a bacterial or fungal organism obtained after 72 hours of life. Minimum of 2 positive blood cultures were required to define Coagulase-negative staphylococci (CoNS) sepsis. Other data collected from medical records included GA, birth weight (BW), gender, mode of delivery, duration of antibiotic use, duration of mechanical ventilation, duration of parenteral nutrition, duration of supplemental oxygen, occurrence of chronic lung disease, pneumonia or necrotizing enterocolitis (NEC) and mortality rate before discharge. Chi-square and Mann-Whitney test were used for the statistical analysis. Stepwise logistic regression analysis was used to examine risk factors associated with LOS.


Out of the 359 infants, 239 (66.6%) were included in the study. Median GA was 29.9 (28.1-30.8) weeks, 78 (32.6%) had BW < 1000 g while 161 (67.4%) had BW <1500 g. Thirty two percent (n=76) were born from multiple pregnancies and 118 (49.4%) were born vaginal. Proven LOS was found in 58/239 (24.3%) of infants. Eighty four percent of all LOS cases occurred in infants with BW < 1000 g. The rate of LOS was 35.9% (n=28) for infants with BW < 1000 g, 21.7% (n=18) for infants 1000-1499 g and 15.4% (n=12) for those ≥ 1500 g (p=0.009). Gram-negative bacteria were isolated at a rate of 56.9%, gram-positive bacteria at 29.3% and Candida species at 13.8%. The most commonly infecting organisms were Klebsiella species (n=24, 41.4%) followed by CoNS (n=12, 20.7%). Mortality rate before hospital discharge was higher among infants with LOS compared to those without LOS (13.8% vs. 5.5%, p=0.047). In the univariate analysis risk factors significant for proven LOS were BW, duration of antibiotic use, duration of parenteral nutrition, duration of mechanical ventilation, duration of oxygen therapy, occurrence of pneumonia and NEC. Results of multivariate analysis demonstrated that the duration of antibiotic use for more than 12 days (OR 8.94, 95%CI 4.40-18.12; p<0.001) and NEC stage 2 or more (OR 6.47, 95%CI 1.34-31.13; p=0.020) were independently associated with the risk of proven LOS.


Incidence of proven LOS in our study was comparable to data from developed countries. Gram-negative bacteria were the most common cause of LOS in our cohort of preterm infants less than 32 weeks of GA similar to data from developing countries.

Neonatology – Problems of the premature neonate


M-Samedi V. 1, AbdulAziz A. 1, AlJouburi S. 1, Mugarab-Samedi N. 2

University of Calgary, Neonatology, Calgary-Canada 1

University of Calgary, Sciences, Calgary-Canada 2


Metabolic Bone Disease a common disease among prematurely born infants who are deprived of the intrauterine supply of minerals. On the other hand, levels of Vitamins D and K, that are both important in maintaining bone health and inhibiting inflammation, fallen in preterm with post-surgical gut, especially when associated with severe cholestasis. Low bone mineral density could be associated with high serum concentrations of undercarboxylated osteocalcin and low serum concentrations of vitamin K.


We present a case of Severe MBD in an extremely preterm infant with surgical NEC who developed morbid hypophosphatemia while kept NPO. Despite required phosphate infusions, his phosphate levels were suboptimal. He had recurrent episodes of prolonged bleeding that responded immediately to plasma and Vitamin K infusion. Vitamin K mediates the γ-carboxylation of glutamyl residues on several bone proteins, especially osteocalcin; thus, Vitamin K deficiency could aggravate MBD.


Patient’ Vitamin K level was evaluated by measurement of undercarboxylated osteocalcin, and vitamin D level was measured by 1,25 dihydroxy-vitamin D. Both levels were significantly lower compared to the healthy infants of the same gestational age.


Literature in older children supports the idea that optimal vitamin K status is associated with decreased bone turnover, even though it is not associated with the bone mineral content. Supplementation with vitamin K could carry an additional therapeutic advantage for post-surgical infants.


Atanasova V. 1, Georgieva D. 2, Veskov L. 1, Valerieva E. 1, Asanova A. 2

University Hospital, Clinic of Neonatology, Pleven-Bulgaria 1

Home of Medical and Social Care for Children, Home of Medical and Social Care for Children, Pleven-Bulgaria 2


Babies born between 22 and 27+6 gestational weeks (GWs) are extremely premature. Survival rate correlates inversely with the gestational age (GA). These babies are more susceptible to all complications of premature birth, both in the immediate neonatal period and after discharge from the nursery.


To evaluate early morbidity, residual clinical problems and survivor rate up to discharge at home of extremely premature babies.


134 newborns treated in NICU of University hospital, Pleven, Bulgaria from 2005 to 2018 are evaluated. Including criteria: life born, GA of 22-27+6 GWs, absence of life incompatible congenital anomalies.

The patients are divided in 2 groups: survivors – Group 1, and deceased – Group 2.

Studied indicators: pregnancy and birth history, anthropometric and maturity indices at birth, status at birth, morbidity, status and age at discharge.

The ICD 10th update criteria of life birth are accepted. GA is determined by postmenstrual age of the mother or by New Ballard score (1991). The adequacy of the anthropometric indices to the GA is determined by Fenton Growth Chart for girls and boys, 2013. The data were calculated using software statistical packages STATGRAPHICS v. 4.0; SPSS v. 13.0 and EXCEL for Windows. The significance of the conclusions was fixed by p < 0.05.


From all the 134 babies: 68 (51%) deceased; 66 (48%) survived – 33 of them (50% of survivors) with long-term complications. About 20% of the all newborns have a history of prenatal corticosteroid prophylaxis.

The limit of viability in our center (50% survivor rate) is 25th GW. The survivor rate increases from 0 (in 22nd GW) to 69% (in 27th GW).

More than a half of all deceased (63%) are younger than 7 complete days.

The deceased in the neonatal period suffer predominantly from intraventricular haemorrhage (IVH – 54%) and bleeding (39%). The more common diseases of the deceased after neonatal period are broncho-pulmonary dysplasia (67%) and IVH (42%). Almost all deceased are born in severe asphyxia.

The survivors are more mature (25.8±1.0 vs. 25.0±1.3, p 0.0001), weigh a hundred grams more (p 0.0000) and suffer less from asphyxia (66 vs. 82%, p 0.03) than deceased. We have not established a significant difference between groups according to the sex, way of delivery, number of fetuses in utero.

The Group 2 suffer more often from bleeding (33.8 vs. 9.1%, p 0.0005), IVH (51.5 vs. 36.4%) and intrauterine hypotrophy (16.2 vs. 7.6%) than survivors.


According to our data half of the extremely premature babies die in the NICU and a quarter of them are discharged at home with long term complications. Our treatment should aim to target premature birth not prematurity itself, as the latter is a consequence. The best neonatal medicine would be a therapy that allows uninterrupted development to continue to a healthy child as a result. It is difficult at bedside, in the moment of resuscitation, to predict the individual outcome.


Ben Hamad A. 1, Ben Thabet A. 1, Ben Amar S. 1, Regaieg C. 1, Hsairi M. 1, Charfi M. 1, Hamida N. 1, Regaieg R. 1, Bouraoui A. 2, Gargouri A. 1

University of Sfax, Neonatology, Sfax-Tunisia 1

University of Sfax, Neonatology, Sfax-2


The frequency of premature anemia is increasing with the improvement of extremely-premature-infants management. The incidence is 17 to 25%. Anaemia is maximal between 8 and 10 weeks of age. The treatment of anemia of prematurity was transfusion with red blood cells which leads to many complications. Erythropoietin is used to reduce red blood cells transfusion and to prevent anemia in preterm and very low birth weight infants. The objective of our study is to determine the risk factors of anaemia in premature infants and to assess the effectiveness and the safety of early initiation of erythropoietin in preventing anaemia in premature infants.


It is a retrospective comparative study including 160 cases of prematures ≤32 weeks of amenorrhea with birth weight ≤1500g who has been hospitalized between 1st January 2012 and 30th June 2014. The population of infants was divided into two groups: one group received erythropoietin, the other group was not treated. Erythropoeitin was administrated at dose of 250UI/Kg SC three time per week(450UI/Kg/week). The treatment was given for six weeks for a total of 18 doses. All infants received oral iron supplementation.


The annual incidence of prematurity was 6.72%, extremely premature newborns represented 1.2%. The incidence of late anemia was 6 per one hundred premature. The risk factors of early anemia were foetofoetal transfusion and over five-day-artificial ventilation. Predictive independent factors of occurrence of late anemia were the existence of early anemia and significant quantity of blood specimen collections during hospitalization. Forty-three percent of prematures were transfused at least once, with a total of 129 received transfusions. The transfusion took place during the first week of hospitalization in 11.3% of cases. The occurrence of hemorrhage and the significant quantity of blood specimen collections were the predictive factors to transfusions. The preventive therapy was based on martial supplementation and the use of recombined erythropoietin. Martial supplementation was received in 65% of cases; the middle age of treatment beginning was 17days with an average dose of 7.5 Mg/Kg/Day. Preventive martial supplementation leads to a significant reduction of late anemia frequency and the use of transfusions. 79 infants had received the erythropoietin (49.9%), it was associated to martial supplementation in 86% of cases. Erythropoietin has allowed a significant decrease of late anemia frequency and the use of transfusions. The only predictive factor of transfusions despite of the use of erythropoietin was early anemia.


Early administration of EPO is an efficient treatment to prevent premature anemia and to reduce the use of RBC transfusions and the volume of RBCs transfused.


Theodora M. 1, Dimopoulou S. 1, Antsaklis P. 1, Sindos M. 1, Loutradis D. 1, Daskalakis G. 1

National and Kapodistrian University, Maternal Fetal Medicine Dpt, 1 Dpt Obstetric Gynecology, Athens-Greece 1


Between mid-1980s and late 2000s several studies indicated increasing survival rates between newborns delivered around the 24th week of pregnancy. Rupture of fetal membranes during this period occurs in less than 1% of pregnancies, but leads to a great dilemma, which obstetric care providers have to face. When a pregnancy is complicated by periviable PROM, treatment options include immediate delivery of the periviable fetus or expectant management with the goal of achieving fetal viability. Continued pregnancy following PPROM at early gestations is correlated with high morbidity among surviving neonates. In this study we collected and evaluated data from neonates, that were born at our institution, following premature rupture of membranes during the periviable period.


This study was conducted in a tertiary care medical center. The study population consisted of 34 pregnancies complicated with premature rupture of membranes between 20 and 26+5 gestation weeks, from 01/01/2014 to 31/12/2017. We retrospectively evaluated pregnancy and immediate neonatal outcomes of neonates that were born after periviable premature rupture of membranes. Regarding comparisons of proportions, chi-square and Fisher’s exact tests were computed.


34 preterm deliveries were analyzed. 20 of the deliveries had gestational age (GA) <25 weeks and 14 had GA ≥25 weeks. Overall death rate was 44.1% and deaths occurred mainly in the group that had GA <25 weeks (92.9% vs. 10%, p<0.001). The most common disorders in total were Infection (52.9%) and Respiratory Distress Syndrome (50%), followed by Necrotizing Enterocolitis (20.6%), Intaventricular Haemorrhage (20.6%) and Acute Kidney Failure (17.6%). Bronchopulmonary Dysplasia was present in 14.7%, while less common disorders were Scleredema (2.9%), Seizures (2.9%) and Anemia (2.9%). Comparison of all disorders, suggested that Infection (7.1% vs. 85%, p<0.001), Respiratory Distress Syndrome (21.4% vs. 70%, p<0.001), Intaventricular Haemorrhage (0% vs. 35%, p=0.026), Necrotizing Enterocolitis (0% vs. 35%, p=0.026) and Acute Kidney Failure (0% vs. 30%, p=0.031) were more frequent in the group that had GA equal or ≥ 25 weeks as compared with the group that had had GA <25 weeks.


Overall, in the presence of premature rupture of membranes, neonates that were born before the 25th week of gestation have a high morbidity risk. Neonates that were born after the 25th week of gestation show an increasing number of adverse immediate neonatal outcomes. We observed a higher incidence in Infection, Respiratory Distress Syndrome, Intraventricular Haemorrhage, Necrotizing Enterocolitis and Acute Kidney Failure in the group with gestational age equal or more than 25 weeks.


Diana U. 1, Andreea B. 1, Laura Mihaela S. 2, Marius Alexandru M. 1, Cezar P. 1, Costin Vlad A. 1

Transilvania University, Department of Medical and Surgical Specialties, Faculty of Medicine, Brasov-Romania 1

University of Medicine and Pharmacy Tirgu-mureş, Neonatology, Tirgu-mureş-Romania 2


To compare mortality and serious morbidity rates between outborn and inborn live births at 22-32 weeks’ gestation.


Outcome data for outborn (born outside a tertiary perinatal center) infants compared with inborn (born in a tertiary perinatal center) infants were analyzed in a population based cohort study during four years in a public hospital in Brasov, Romania. Main outcome measures were infant mortality and serious morbidity rates to hospital discharge.


481 live births free of major malformations were recorded. 53 of 481 (11%) were outborn infants admitted to Neonatal Intensive Care Units; 90 died during hospitalization (14/53 outborns and 76/428 inborn). There were significant differences in rates of antenatal corticosteroids (43% vs. 13%, p=0.001), tocolysis (25%vs.6%, p=0.03) and cesarean section (59% vs. 29%, p=0.01). There were no significant differences in rates of necrotizing enterocolitis (5% vs.2%, p=0.2), intraventricular hemorrhage grade III or higher (14% vs. 21%, p=0.12), bronchopulmonary dysplasia (8% vs. 6%, p=0.42) and retinopathy of prematurity (8% vs. 13%, p=0.31).


Despite significant differences in perinatal intervention rates between centers, outborn infants admitted to Neonatal Intensive Care Units did not have substantially different rates of mortality or serious morbidity compared with inborns.


Özlü F. 1, Şimşek H. 1, Yapıcıoğlu Yıldızdaş H. 1, Satar M. 1, Hamitoğlu Ş. 1, Narlı N. 1

Çukurova University, Neonatology, Adana-Turkey 1


Evidence for surfactant use in term and late term neonates are less abundant.


In light of the paucity of data about surfactant use in this group of infants, we aimed to investigate surfactant use in infants with gestational age of ≥34 weeks (late preterm and term group-LP/T group) in the last 10 years and evaluated their prognosis in NICU.


6373 infants were admitted to Cukurova University NICU in 10 years. 4656 of 6373 infants (73.1%) were ≥34 gestational week (GW). 780 infants were treated with surfactant and 112 of them (14.4%) were in late preterm and term group. The rate of surfactant use in LP/T group was 2.4% (112/4656). Mean gestational week and birth weight of LP/T group were 35.6±1.8 (34-41) GW and 2632±653 (1100-5100) g respectively. 58 (52%) infants were male Surfactant therapy was used for respiratory distress syndrome in 48 infants (43%), for pneumonia in 44 infants (39%), for hypoxia in 20 infants [14 infants with diaphragmatic hernia, 2 infants with meconium aspiration syndrome and 4 infants with congenital thoracal anomalies]. Infants had ventilatory support for 9.3±11(1-66) days and hospitalized for 16.7±16.7 (1-96) days.72 infants (64%) were discharged, while 40 infants(36%) died.


Surfactant use in late preterm and term infants is low compared to preterm infants and mostly used for respiratory distress syndrome, pneumonia and intractable hypoxia due to diaphragmatic hernia, meconium aspiration syndrome and congenital thorax abnormalities.


Örs R. 1, Çimen D. 2

Konya Medova Hospital, Neonatology, Konya-Turkey 1

Konya Medova Hospital, Pediatric Cardiology, Konya-Turkey 2


Persistent pulmonary hypertension (PPHT) in the newborn is associated with morbidity and mortality, which may be secondary or idiopathic to many conditions. PPHT results in inadequate pulmonary relaxation after birth and shunt from the pulmonary to systemic circulation of oxygen-free blood. The main treatment is the treatment of underlying problem, as well as promising treatments such as oxygen support, mechanical ventilation, nitric oxide, phosphodiesterase inhibitors, prostaglandin analogs, endothelin receptor antagonists and extracorporeal membrane oxygenation. The optimal treatment approach is controversial. In this study, the findings of 28 babies who were diagnosed with PPHT and treated with sildenafil were retrospectively analyzed.


Twenty-eight infants diagnosed with PPHT between 01.02.2017 and 07.02.2019 were evaluated retrospectively. The diagnosis of pulmonary hypertension was confirmed by the presence or absence of an underlying congenital heart disease from the ductus arteriosus or patent foramen ovale to the right or left shunt, with pulmonary artery pressures measured echocardiographically equal to or higher than systemic arterial pressure in clinically suspected cases. Sildenafil was administered orally at a dose of 1 mg / kg / day.


The mean duration of sildenafil use was 26.4 ± 4 days (7 to 70 days). There was no decrease in systemic arterial blood pressure and oxygen saturation in any of the patients. Eighteen of the patients were male (58%) and 10 were female (42%). Mean gestational age was 32.4 ± 4.4 weeks (25.3-39 weeks) and birth weight was 1800 ± 890 g (990-3800 g).


There are not enough studies in the literature regarding sildenafil use in the treatment of persistent pulmonary hypertension. Although there are limited data in our study, considering that inhaled NO use is not always available in our country, we think that Sildenafil can be administered safely and effectively.


Seyrek L. 1, Uçar F. 1, Örs R. 2

Konya Göz Hospital, Ophtalmology, Konya-Turkey 1

Konya Medova Hospita, Neonatology, Konya-Turkey 2


To evaluate the efficacy of intravitreal bevacizumab in the treatment of retinopathy of prematurity (ROP)


Twelve eyes of 6 patients who were diagnosed as ROP and treated with intravitreal bevacizumab (AVASTIN®) between January 2019 and March 2019 were evaluated retrospectively. After obtaining informed consent from the family, 625 micrograms of intravitreal bevacizumab was administered to all eyes and regular follow-up was performed.


The mean birth week of the patients included in the study was 26.8 weeks (25-31), mean birth weight was 849 grams (705-975), and the mean injection week was 8,6 weeks (5-12). The mean follow-up period was 16 weeks (9-24). We treated four eyes of two patients with aggressive posterior ROP and eight eyes of four patients with zone 2 disease due to threshold disease. During follow-up, ROP regression was observed in all eyes at the first week post-injection and no asymmetric response was observed in any infant’s eye. A second intravitreal injection of bevacizumab was applied to two eyes of a patient who had reactivation during follow-up. During the follow-up period, none of the babies required additional conventional laser photocoagulation therapy. None of the patients had ocular and systemic side effects.


Intravitreal bevacizumab injection with close follow-up and appropriate timing is an effective treatment modality in ROP. Large clinical trials with long-term follow-up are required for systemic and ocular side effects.


Yilmaz Semerci S. 1, Yucel B. 2, Erbas İ. 3, Gunkaya O. 2, Cetinkaya M. 1

Istanbul Health Sciences University Kanuni Sultan Suleyman Training and Research Hospital, Neonatology, Istanbul-Turkey 1

Istanbul Health Sciences University Kanuni Sultan Suleyman Training and Research Hospital, Obstetrics And Gynecology, Istanbul-Turkey 2

Istanbul Health Sciences University Kanuni Sultan Suleyman Training and Research Hospital, Pediatrics, Istanbul-Turkey 3


Amniotic fluid (AF) is a compound bio-environment with a changing content by gestational time. AF pH can be affected by both maternal and fetal conditions such as preterm ruptures of membranes, gestational age, antenatal steroids, prematurity and fetal distress. However, there is no study that evaluated AF analysis in preeclampsia.


The aim of this study was to determine the possible role of amniotic fluid pH and electrolytes for prediction of neonatal morbidities in preeclamptic mother infants.


This was a prospective controlled cohort study. During C-section, 1 ml of AF was aspirated before incision of membranes. AF pH and electrolytes were analyzed by blood gas machine and biochemistry laboratory concurrently. Maternal and neonatal demographic features and clinical outcomes, presence of respiratory morbidities were all recorded.


AF pH, Na and gestational age were found to be independent risk factors for preeclampsia. Subgroup analysis revealed that in early onset preeclampsia (EOP) group mechanical ventilation duration, duration of 02 therapy, sepsis and IUGR were higher than healthy infants born before 32 GW. Also, in EOP group AF pH and K were higher compared with the healthy group.


To our best of knowledge, this is the first study that suggests the possible role of AF analysis for prediction of neonatal morbidities in preeclamptic mother infants. However, more studies including larger number of infants are required to confirm the role of AF analysis to support our data.


Örs R. 1, Çimen D. 2

Konya Medova Hospital, Neonatology, Konya-Turkey 1

Konya Medova Hospital, Pediatric Cardiology, Konya-Turkey 2


PDA is a common problem especially in extremely low birth weight infants. Indomethacin and ibuprofen are used as medical treatment for PDA closure. However, these medications may cause some side effects, both of them may not use in PDA treatment due to severe clinical problems of babies. Surgical closure is applied in newborns where it is an obstacle or failure to administer medical treatment. However, some complications can be seen during or after surgical closure.


To evaluate the safety and efficacy of paracetamol treatment in medical closure of PDA


Sixteen preterm infants with hemodynamically significant PDA who were hospitalized in our hospital in our newborn intensive care unit between September 2018 and June 2019 were evaluated retrospectively. Patients with ductus diameter > 1.5 mm and / or ratio of left atrial aorta (LA / Ao)> 1.5 were found to have hemodynamically significant PDA. One course of paracetamol treatment was administered as 60 mg / kg / day (4 doses, 3 days) in all cases. The patients who had a still open duct after one course of paracetamol were treated with the second dose of the same dose. Liver enzymes (ALT, AST) and total bilirubin levels were measured to evaluate hepatotoxicity.


Sixteen preterm babies between 25 and 33 weeks of gestation were included in the study. It didn’t open again. No side effects developed during treatment.


Although this study includes small number babies, we think that IV paracetamol treatment can be used as the first choice for medical closure of PDA. Because it is cheap, easily accessible, effective and has few side effects. However, randomized controlled trials are needed to confirm and generalize these results.


Okulu E. 1, Erdeve Ö. 1, Arslan Z. 2, Demirel N. 3, Kaya H. 4, Gökçe İ. 4, Ertuğrul S. 5, Çetinkaya M. 6, Büyükkale G. 6, Atasay B. 1, Özlü F. 7, Şimşek H. 7, Çelik Y. 8, Özkan H. 9, Köksal N. 9, Akcan B. 10, Türkmen M. 10, Çelik K. 11, Armangil D. 12, Bülbül A. 13, Tekgündüz K. 14, Öncel M. 15, Tüzün F. 16, Ergenekon E. 17, Ergin H. 18, Arsan S. 1

Ankara University School of Medicine, Department of Pediatrics, Division of Neonatology, Ankara-Turkey 1

University of Health Sciences, Etlik Zubeyde Hanim Women’s Health Teaching and Research Hospital, Department of Neonatology, Ankara-Turkey 2

Yildirim Beyazit University School of Medicine, Department of Pediatrics, Division of Neonatology, Ankara-Turkey 3

Inonu University School of Medicine, Department of Pediatrics, Division of Neonatology, Malatya-Turkey 4

Dicle University School of Medicine, Department of Pediatrics, Division of Neonatology, Diyarbakir-Turkey 5

University of Health Sciences, Kanuni Sultan Suleyman Training and Research Hospital, Department of Neonatology, Istanbul-Turkey 6

Cukurova University School of Medicine, Department of Pediatrics, Division of Neonatology, Adana-Turkey 7

Mersin University School of Medicine, Department of Pediatrics, Division of Neonatology, Mersin-Turkey 8

Uludag University School of Medicine, Department of Pediatrics, Division of Neonatology, Bursa-Turkey 9

Adnan Menderes University School of Medicine, Department of Pediatrics, Division of Neonatology, Aydin-Turkey 10

Diyarbakir Gazi Yasargil Training and Research Hospital, Neonatal Intensive Care Unit, Diyarbakir-Turkey 11

Koru Hospital, Neonatal Intensive Care Unit, Ankara-Turkey 12

University of Health Sciences, Sisli Etfal Hamidiye Training and Research Hospital, Department of Neonatology, Istanbul-Turkey 13

Atatürk University School of Medicine, Department of Pediatrics, Division of Neonatology, Erzurum-Turkey 14

Izmir Katip Celebi University School of Medicine, Department of Pediatrics, Division of Neonatology, Izmir-Turkey 15

Dokuz Eylul University School of Medicine, Department of Pediatrics, Division of Neonatology, Izmir-Turkey 16

Gazi University School of Medicine, Department of Pediatrics, Division of Neonatology, Ankara-Turkey 17

Pamukkale University School of Medicine,Department of Pediatrics, Division of Neonatology, Denizli-Turkey 18


Regarding the management of patent ductus arteriosus (PDA) in preterm infants, no consensus has been reached on which PDA to treat, when to treat, or how to treat. A prospective, multicenter (24 units) trial was conducted to compare the impacts of conservative approach and medical treatment options on ductal closure, surgical ligation, prematurity related morbidities and mortality in Turkey.


Infants with 24 0/7-28 6/7 weeks of gestation were enrolled and their PDA management data were recorded through an online registry system via electronic case report forms.


Among 1193 enrolled infants (mean gestational age of 26.7±1.4 wk and mean birthweight of 926±243 g), 33% (n=397) had no PDA, whereas 21% (n=252) and 46% (n=544) had small or moderate-to-large PDA, respectively. 24% (n=130) of infants with hemodinamically significant PDA were managed conservatively in contrast to 76% (n=414) who received treatment at a mean age of 4±2.6 days. Preferred treatment options were ibuprofen (iv;36%, oral;31%), and paracetamol (iv;26%, oral;7%). 62% (n=80) of conservatively managed infants did not require any rescue treatment during their hospitalization. The rates of late-onset-sepsis, necrotizing enterocolitis (NEC), retinopathy of prematurity, bronchopulmonary dysplasia and surgical ligation were similar between conservatively managed and medically treated infants who lived longer than 7 days (p>0.05), whereas infants who were medically treated had a higher mortality rate (p=0.005). Infants who were treated with oral paracetamol had a higher rate of NEC in comparison to other treatment options (p=0.04).


In preterm infants born <29 weeks of gestation with moderate-to-large PDAs, medical treatment did not reduce surgical ligations or prematurity related morbidities, but was associated with a higher rate of mortality.


Okay I. 1

El Bebek Gul Bebek Dernegi, Istanbul-Turkey 1

Many studies show that early contact such as visiting, touching, holding and skin to skin contact with the infant have many positive outcomes, e.g. better oxygen saturation levels, lower heart rates, pain relieving etc. However, when a preterm infant is hospitalized in the neonatal intensive care unit (NICU), mother and infant are often separated and not able to bond and build up a relationship as strong and quick as parents and infants outside NICUs.

In our study, we aimed to find out, if mothers in Turkey have the opportunity to be in contact with their infant either with regular visits, touch or kangaroo care. We conducted an online questionnaire during December 2018 and January 2019 and received 222 replies from mothers, whose infants were born between 24th and 35th gestational week and had been in NICUs due to premature birth either in public, private or university hospitals.

We showed that 16.4% of mothers were not allowed to visit their babies in the NICUs every day of the week. 35.2% of mothers could visit their babies only for less than 20 minutes per day. 16% of the mothers were not allowed touch their babies, and 35% of the mothers were not allowed to hold their babies during the first month or longer after their birth. 10% were permitted to hold their babies for the first time 2 month or later after birth. Only 14% were allowed to touch their babies the day they were born.

The higher the infant’s birth week, the earlier their mothers were allowed to touch or hold them. For example, none of the mothers of infants born in 24th or 25th week were allowed to hold them earlier than 20 days after birth, whereas 29% of mothers with infants born in 34th to 35th week were permitted to hold them within the first three days. 86% of mothers we not allowed to see their babies whenever they want. 50% of mothers reported that skin to skin contact was not possible while their infant was in the NICU.

The data shows that the opportunities for parents to bond with their preterm infants in NICUs are highly insufficient in Turkey. We demand more opportunities for more frequent contact of mother and infant, including longer visiting hours, early and often touching and regular skin to skin contact starting from the first days after birth. This will enhance the physiological and neurological development of the baby and the psychological well-being of the parents.


Mitsiakos G. 1, Gialamprinou D. 1, Chatzigrigoriou F. 2, Karagkiozi A. 2, Chatziioannidis I. 1, Papacharalampous E. 1, Karagianni P. 1, Soubasi V. 1

Aristotle University of Thessaloniki, “Papageorgiou” Hospital, Second Neonatal Department, Thessaloniki-Greece 1

Aristotle University of Thessaloniki, “Papageorgiou” Hospital, First Department of Obstetrics and Gynaecology, Thessaloniki-Greece 2


Pregnant female refugees who have immigrated to Greece as a result of civil war in mild east countries are giving birth mostly in public hospitals. In context of family medicine, they should be screened in scheduled appointments in the prenatal period, however as still do not attend official screening registries and health management in camps and community health units. As in most cases the prenatal monitoring has been disrupted, the risk of delivery complications and neonatal morbidities still remains high.


Descriptive study in neonatal refugee population for purpose of evaluating the delivery complications and neonatal morbidity and mortality


In this prospective study, data were obtained for refugee live births that occurred in our hospital, between September 1, 2016 and December 31, 2018. Data for 137 neonates were analysed for gestational age, delivery type, prematurity, somatometric features. For 34 refugee neonates who hospitalised in NICU furthermore analysis for maternal morbidities, neonatal morbidity and mortality rates as well as for simple correlations was conducted.


Overall, 137 refugees with median gestational age 39 weeks (2 IQR) were included and 34 neonates (24.8%) with median postmenstrual age 259 days (21 IQR) were admitted to NICU from which 22 (64.7%) were premature (<37w pma). Cesarean section was undertaken for 47 (34.1%) of all refugee live births and for 13 (38.2%) of the hospitalised in NICU neonates while the median for hospitalization was 4 days (2.5 IQR). Median neonatal birth weight was higher among non-hospitalised (3140 g, 610 IQR) than mean birth weight among hospitalised refugees (2533.27g, 729.87 SD) while from the later 4 (11.8%) were IUGR. Gestational hypertension was recorded for 3 (8.8%), gestational diabetes for 5 (14.7%), pre-eclampsia for 2(5.9%), chorioamnionitis for 2 (5.9%), PROM for 7 (20.6%) neonates admitted in the NICU. Neonatal morbidity in NICU was recorded as RDS for 8 (23.5%) neonates, from which prenatal steroid administration performed for 5 (14.7%), as jaundice for 20 (58.8%) and infection for 15 (44.1%). Maternal morbidity in an overall percentage of 29.4% was correlated with prematurity in 70% (CI 95%, 1.3-68.2, P 0.01, OR 8.17), RDS in 40% (CI 95%, 0.45-23.5, P 0.19, OR 3.2, no statistical significance) and infection (suspected and confirmed sepsis) in 60% (CI 95%, 0.43-15.2, P 0.27, OR 2.4, no statistical significance) of the hospitalised neonates. The neonatal mortality was recorded as a percentage of 2.9% (one death due to major complications).


Maternal and neonatal morbidities remain in high proportion for refugees. Caesarean rates are fairly higher than these reported in USA (32.8%) and in Europe (25%). Prematurity and IUGR constitute the main reason for admission to NICU and in association with maternal morbidity we approximately assume that these correlations could be the impact of nutritional inadequacies and poor prenatal care among pregnant refugee women in Greece. The low neonatal mortality rate could be attributed to high quality health care was achieved in NICU.


Kayki G. 1, Celik H. 1, Ayaz E. 2, Tandircioglu U. 1, Oguz B. 2, Yigit S. 1, Yurdakok M. 1

Hacettepe University, Neonatology, Ankara-Turkey 1

Hacettepe University, Radiology, Ankara-Turkey 2

Methylxanthines are used for reducing apnea of prematurity (1). The mechanism is not completely understood, but it is thought to increase chemoreceptor responsiveness to CO2 in central nervous system (2, 3). Besides, effect of methylxanthines on diaphragmatic contractility has also been found in experimental studies (4). A study of premature newborns has showed caffeine increase diaphragmatic activity and tidal volume (5). But there is limited data about caffeine direct effect on diaphragma.


We aimed to show the direct effect of caffeine on diaphragmatic contractility.


The babies under 32 weeks with respiratory support were enrolled in this study if caffeine treatment was decided to receive. Evaluation of muscle contraction was made by ultrasound before and 30 minutes after caffeine loading dose. Right and left sides of diaphragma thickness were measured by two clinicians on B mode ultrasound by anterior subcostal view. The velocity before and after caffeine administration was calculated, dividing excursion frequency (parameter) for inspiratory time, respectively. Movement of the diaphragm at inspiratory and expiratory phases was also observed on M mode and the difference between the two phases was measured.


There isn’t any statistically significant difference in both sides diaphragma thicknesses before and 30 minutes after caffeine loading dose. The changes between expiratory and inspiratory movement on M mode examination were not also improved. The outcome (bpd, death) was not found related with any measurement.


This study does not support the direct effect of caffeine on diaphragma, but more studies are needed to prove it.


Tandircioglu U. 1, Kayki G. 1, Celik H. 1, Yigit S. 1

Hacettepe University, Neonatology, Ankara-Turkey 1


Respiratory distress is reported in nearly 80% of babies born at 28 weeks’ gestation increasing to 90% at 24 weeks’ gestation. Fifteen percent of term infants and twenty nine percent of late preterm infants also have respiratory distress. Chest X-ray is commonly used as first line imaging method to diagnose the reason of respiratory distress in NICUs. Lung ultrasound is a new diagnostic tool for lung imaging, and this method has been used more common recently in NICUs.

We aimed to determine the decrease in the number of chest X-rays in newborns with respiratory distress, with the use of lung ultrasonography.


We designed a prospective observational study. A total of 21 newborns with respiratory distress were included in the study. We used bed side ultrasound as the first line technic for lung imaging. X-ray were taken in cases with increasing respiratory distress in spite of treatment according to diagnosis depending on USG findings. We calculated decreased number of chest X ray for every patient and evaluated the estimated decrease in radiation exposure.


21 preterm and term neonates with median 36 weeks (29-40) gestational age and birth weight 2640 gr (660-4100) were enrolled in the study. Fourteen (66%) of these babies were male, 95% (n=20) were born by cesarean section. Seven of them diagnosed as respiratory distress syndrome (white lung, pleural line abnormalities), 9 patients as transient tachypnea of the newborn (double lung point) and, 5 babies as congenital pneumonia (consolidations with irregular borders and air bronchograms, associated with pleural line abnormalities) by lung USG. Lung ultrasonography were performed 47 times for all study group but chest X-rays were performed a total of only 26 times simultaneously. In 4 patients, who were evaluated with only ultrasonography, X-ray were not performed.


Lung ultrasonography screening is a first line imaging technique for newborns with respiratory distress in our NICU. We observed that usage of lung ultrasonography decreased the number of chest X-ray and radiation exposure in newborns with respiratory distress.


Tandircioglu U. 1, Guzoglu N. 2, Gucuyener K. 3, Aliefendioglu D. 2

Hacettepe University, Neonatology, Ankara-Turkey 1

Kirikkale University, Neonatology, Kirikkale-Turkey 2

Gazi University, Pediatric Neurology, Ankara-Turkey 3


Amplitude-integrated EEG (aEEG) presents a valuable tool for functional brain maturation of preterm infants. However the effect of enlightenment on functional brain maturation of premature babies hasn’t been investigated. We aimed to do this with aEEG.


33 babies,30-35 gestational weeks, are involved in the study. They were randomly distributed into three groups in which different lighting protocols were applied. In group1,the babies’ incubators were covered for 24 hours. In group2 the babies’ incubators were open for 24 hours. In group3 the babies’ incubators were covered for 12 hours and open for another 12 hours. The babies are evaluated with aEEG recordings done on the third (first measurement) and tenth days (second measurement) along with the Burdjalov scoring. Anaysis of aEEG recordings was performed, based on sleep-wake cycles (SWC), upper and lower margin amplitude, narrow and broadband of SWC and bandwidth of SWC.


At first,the narrow band lower amplitudes in group one were higher than those of the other groups (p:0,042), but the difference was not significant in the second measurement (p:0,110). The Burdjalov scores were higher in group1 and group3 on tenth days, though not statistically significant (p:0,871). When the babies were re-evaluated according to the gestational weeks, the Burdjalov scores of the two groups under 34 weeks(30-31 weeks, 32-33 weeks) were similar, whereas 34-35 weeks were higher when compared to those of the two groups.


The difference observed between groups in terms of narrow band lower amplitude in the first measurement, may reflect the effect of intrauterine environment rather than enlightenment at the same gestational age; because it was made on the third day. However the fact that all groups have similar results on day 10 suggests that other factors in the intensive care setting may diminish the effect of enlightenment. Burdjalov scores are associated with maturation, and high scores found in the 34-35 week group suggest that the 34-week maturation might be a threshold for SWC and development in our group sample.


Can Ş. 1, Okulu E. 2, Atasay B. 2, Kraja E. 2, Arsan S. 2, Erdeve Ö. 2

Ankara University School of Medicine, Department of Pediatrics, Ankara-Turkey 1

Ankara University School of Medicine, Department of Pediatrics, Division of Neonatology, Ankara Turkey 2


Preterm birth is the most important cause of perinatal mortality and morbidities. The survival of preterm infants has been increased with the expansion of neonatal intensive care units (NICUs) and technical equipments, the formation of teams and introduction of less invasive treatments. Premature infants face to serious problems in their postnatal lives due to their different physiological and anatomical features.

In this study, we aimed to compare the mortality and morbidities of preterm infants born at 240/7-316/7 weeks in last 4-years period with the 4-years period 20 years ago (1997-2000).


Infants born at 240/7 to 316/7 weeks or transferred to our NICU at first week of life between January 2014 and December 2017 were evaluated retrospectively. The results were compared with the results of 20-years ago. Infants who were transferred after first week of life or had congenital major anomaly were excluded.


During the last 4 year period, 227 among 321 preterm infants admitted to our NICU were enrolled. The mean gestational age and birth weight were 29±2 weeks and 1158±372 g, respectively. Majority of infants were AGA (78%) and was born via cesarean section (89%). Sixty-eight percent of mothers received antenatal corticosteroids. The survival rate was 84% and the mean duration of hospitalization was 35.5±23.5 days. The incidences of respiratory distress syndrome (received surfactant), patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH) (≥ Grade 3) and bronchopulmonary dysplasia (BPD) (moderate-severe), retinopathy of prematurity (ROP) and nosocomial sepsis (culture proven) were 44%, 21%, 12%, 7.2%, 7.2%, 7% and 21%, respectively. Sixty percent of infants with PDA received medical treatment whereas 40% managed conservatively. The incidence of rehospitalization was 13%, and the most common cause was apnea of prematurity. Thirty-five percent of infants received RSV immunoprophylaxis. When the results were compared to 1997-2000 period; NICU admissions have increased twice, the mean gestational age of infants was lower, but the incidence of cesarean section was still high. The incidence of surfactant use was increased by time whereas the incidence of NEC was lower and the conservative management for PDA was more preferred in 2014-2017 periods. On the other hand, the incidences of nosocomial sepsis, ROP, BPD and the rate of survival were similar in both periods.


Time period comparison helped us to update our knowledge about the preterm infants admitted to our NICU. Results demonstrated that although more conservative strategies have been used by time, no any change was observed in main morbidities due to increased survival rate of more preterm infants.


Papathoma E. 1, Stamouli K. 1, Gavrili S. 1, Kovlatzi A. 1, Papadopoulos G. 1, Kyriakopoulou M. 1, Dania K. 1, Sevastiadou S. 1

General Hospital of Athens “Alexandra”, Nicu, Athens-Greece 1


Neonatal mortality is an important index for the evaluation of the perinatal healthcare system. Although rapid advances in perinatal and neonatal care during the past few years contributed in decreasing the neonatal mortality rate worldwide, it remains a matter where more improvements could be implemented. The present study aims to determine in-hospital mortality rates and the factors related in a single unit.


This study involves retrospective analysis of collected data of infants who died in the NICU of the General Hospital of Athens “Alexandra”, a Level III NICU with an on-site delivery service, between January 1, 2013 and December 31, 2018. Infants born at ≥22 weeks estimated gestational age who were born alive were included. Stillborn infants and infants who died in the delivery room were excluded. Variables that were recorded were: gestational age, birth weight, sex, singleton and multiple birth, age at death, principal cause of death, circumstances of death.


A total of 2.549 neonates were admitted in NICU during the study period, while 108 of them died. Of those who died, 63 (58.3%) were male and 45 were female (41.7%). Neonatal hospital mortality rates for the years 2013, 2014, 2015, 2016, 2017 and 2018 were 6.9%, 3.7%, 6%, 3.2%, 3.2% and 3.4% respectively. 46 (42.6%) neonates died during night shift, from 8pm to 7am. 55 (50.9%) neonates died during the first 24 hours of life. Prematurity, low birth weight, respiratory distress syndrome, cardiorespiratory arrest, congenital anomalies and sepsis accounted for most of neonatal deaths. 40-70.5% of neonates who died weighted between 400-1000gr and 64.2-82.6% weighted <=1.500gr. Only 9.2%(n=10) had a birth weight <= 2.500 gr. 23.5-57.1% of neonates were <=26 weeks.


The neonatal mortality rates in our NICU are in accordance with mortality rates in other developed countries. Prematurity and low birth weight are the two most frequent causes of death, which could be attributable to the large number of preterm births in our hospital as it is worldwide Males were more likely to die than females and most neonates died during the first week of life, which is in accordance with results in other NICU’s worldwide. Local data should be used to inform and monitor the implementation of interventions to improve newborn health.


Solomonia N. 1, Kandelaki E. 2, Kherkheulidze M. 2, Kavlashvili N. 2

M. Iashvili Children Hospital, Neonatology, Tbilisi-Georgia 1

M. Iashvili Children Hospital, Pediatrics, Tbilisi-Georgia 2


The developments in perinatal care has led to increase in survival and also morbidity in preterm and high risk neonates. These cohort need to be followed up on regular base to ensure growth and developmental outcome, for early identification of delays and initiation of adequate stimulation and interventions. M. Iashvilis Children’s Central Hospital in Tbilisi, Georgia initiated first follow-up clinic for high risk neonates, discharged from NICU of same hospital. Our goal was to assess developmental outcome. On first stage of survey we performed general observation, without grouping patients by problems. Main goal is to reveal possibility of elaboration of national protocol for NICU discharged infants follow-up, establish clear criteria for interventional programs and new services for high risk infants to ensure the best possible outcomes.


Prospective observational study over 2 year period was set up for neonates discharged from NICU In 2014 – 2018 period. Cohort of 237 neonates was assessed and still is under surveillance. Follow up clinic elaborates specific protocol for this purpose based on resources and needs of patients.

Enrollment criteria’s were: Birth weight < 1800 gr, gestational age < 35 weeks , Small for date (<3rd percentile) and large for date (>97th percentile), Perinatal asphyxia – Apgar score 3 or less at 5 min and/or hypoxic ischemic encephalopathy, Mechanical ventilation for more than 24 hours, seizures, infections – meningitis and/or culture positive sepsis. Major morbidities such as CLD, IVH, PVL, Hyperbilirubinemia > 20mg/dL or requirement of exchange transfusion. major malformations, IEM / other genetic disorders.

Assessment was performed at 6, 9, 12, 18 and 24 month corrected or chronological age. Main tool for assessment was Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III).


From 237 high risk newborns assessed at age 6 month ( chronological or corrected) – 27 % had moderate to severe global developmental problems ( in 2 and more areas of development), 31.5% represented mild to moderate global developmental delays. At age 24 month developmental global delay was observed in 7% of cohort and delay in one area was stated in 27% of observed children. Up to 56% of children from delayed cohort were not offered interventional services in PHC facilities were they undergo immunization process and health check ups. Immunization schedule was not fulfilled according national schedule in 61 % of cases due to “possible complications linked to patient’s risks”.


More in depth separation of the cohort is needed to understand specific problems for main morbidity groups and elaborate separate plans for follow up. The results represented problems in national health care system due to inability to deal with high risk infants health issues. Possible best option can be fully associated these groups with NICU follow up clinics to ensure continuum of care and quality of service they need to receive. Main hypotheses to be tested in future must be: are outcomes better in case of high risk infants 2 years period observation in NICU follow up programs compared with PHC facilities for general


İmrahor İlyas S. 1, Acunaş B. 1, Güzey I. 2, Aladağ Çiftdemir N. 1, Vatansever Ü. 1, Duran R.1, Uçar Ö. 2

Trakya University Faculty of Medicine, Division of Neonatology, Pediatric Department, Edirne-Turkey 1

Trakya University Faculty Engineering, Department of Computer Engineering, Edirne-Turkey 2


Following recent recommendations, the oxygen saturation (SpO2) target range for preterm infants was changed from 85 %-95% to our NICU. Our objective was to compare the compliance rates to the SpO2 target ranges between pre and post implementation periods and determine its consequences on the incidences of major morbidities such as intraventricular haemorrhage (IVH), necrotising enterocolitis (NEC), bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP) etc.


A pre-post implementation (retrospective-prospective) study was performed in our NICU evaluating infants ≤ 32 weeks of gestation before (Group 1) and after (Group 2) changing the target ranges. Infants with major abnormality and severe cardiovascular disease. were excluded. SpO2 values were collected by using seconds based times series pulse oximetry data of NICU Central Monitoring System Database (collected by Mindray iMec Patient Monitors) till discharge. Oxygen was manually adjusted. Hypoxaemic (SpO2 < 80%;<%85; <%90); hyperoxic (SpO2> 95%: >98%) and within target range events (SpO2 90-95%) were analysed as well as rates of major morbidities.


Data were analysed for 68 infants (30 before and 38 after the range was changed). The study groups were very similar in terms of demographic, antenatal and natal features. When the infants were receiving oxygen as well as during room air, the frequency of hyperoxic (>95%) events and mean SpO2 levels were significantly lower and within range events were significantly higher in the after change group (p<0.01for all). However, hypoxic episodes (<80%) when receiving oxygen was significantly higher in Group 2(p=0,03). The incidence of NEC and the duration of hospital stay was significantly lower in Group 2 when compared to Group 1. (p=0,022 and 0,003 respectively). Although a tendency toward decreasing frequency was observed in mortality, BPD and ROP rates in the after change group, they did not reach significance.


Compliance with the new oxygen saturation target ranges in very preterm infants in our NICU seems to be relatively good and beneficial in terms of reducing some of the morbidities. This beneficial effect can be further improved by increasing the compliance.


Leblebici U. 1, Turkyilmaz C. 1, Atalay Y. 1, Hirfanoglu İ. 1, Ergenekon E. 1, Önal E. 1, Özcan E. 2, Aksu M. 3, Koc E. 1

Gazi University Faculty of Medicine, Neonatology, Ankara-Turkey 1

Mersin City Hospital, Neonatology, Mersin-Turkey 2

Başkent University Faculty of Medicine, Neonatology, Ankara-Turkey 3

The recognizing and managing acid base and oxygenation disorders in neonates have a significant effect on mortality and morbidity. In addition, identifying any acid base disorder and understanding its etiology are vital for effective treatment. The gold standard test for detecting any acid-base disturbance is arterial blood gas measurement in neonatal intensive care unit NICU patients. The disadvantage of blood gas measurement is that it is a painful and invasive method. Nowadays, noninvasive transcutaneous methods are also on the agenda for the evaluation of oxygenation in NICU.

Aim of this issue is to discuss the correlation of an alternative method which is noninvasive transcutaneous measurement with invasive arterial blood gas sampling in newborns. This study was generated in Gazi University Hospital NICU over 72 neonates which are 20 VLBW, 22 LBW and 30 normal birth weights.

Neonates are classified and evaluated according to their birth weights, gestational age, way of birth, perinatal risk factors, and intrauterine growth standards, diagnosis of sepsis and needs of transfusion, inotropic drug, respiratory support and phototherapy. Neonates between postnatal 1to 5 days were included into study. Blood sample is taken via umbilical artery catheterization or peripheral artery catheterization. Blood gas and transcutaneous partial oxygen and carbon dioxide levels (TcPO2 and TcPCO2) are measured at the same time. The level of agreement between PO2 and PCO2 measured by TCM4 CombiM Monitor, agreement was illustrated by Bland – Altman scattered plots and ICC statistic method. In general arterial blood sampling and transcutaneous results are found correlated. All groups except inotropic drug used neonates results are between %95 limits of agreement. During application and measurement there was no major side effect. The arterial blood gas and TcPO2 and TcPCO2 results of the patients classified according to their birth weight, type of delivery were discovered to be in concordance. The results of arterial blood gas and TcPO2 and TcPCO2 were determined to be in concordance in hypocapnic, normocapnic, hypercapnic infants and normotensive, hypotensive, hypertensive cases. The results of arterial blood gas and TcPO2 and TcPCO2 were found to be consistent in the group with or without PRBC transfusion. The results of arterial blood gas and TcPO2 and TcPCO2 were found to be compatible in the group with or without respiratory support. According to the prenatal risk factors, arterial blood gas and TcPO2 and TcPCO2 results were determined to be in concordance.

As the result of this study, similar results are found with premature and mature neonates. As controversy, in literature there are studies were found unagreement in hyper/hypocapnic patient groups. In patients with and without sepsis, arterial blood gas and TcPO2 and TcPCO2 results were discovered to be in concordance

As a conclusion; transcutaneous carbon dioxide and oxygen monitoring is safe, useful, valid and non-invasive alternative method can be applied in NICU.

Neonatology – Bronchopulmonary dysplasia


Ruiz Lopez R. 1, Ayala-Yáñez R. 1, Ibarrola-Buen Abbad E. 1

Abc Medical Center I.a.p., Obstetrics & Gynecology, Mexico City-Mexico 1

This is the case of a 32 year old pregnant woman diagnosed during a second trimester ultrasound with a fetus presenting a congenital cystic adenomatoid malformation type 1 with macrocystic disease, hydrops, and mediastinal shift to the left, ascites, and polyhydramnios. Weekly ultrasounds and corticosteroid therapy for pulmonary maturation and indomethacin 25mg every 8h was prescribed. At 33 weeks she was admitted due to preterm labor. She underwent a C-section and delivered a 2,900g male, with respiratory distress, severe pulmonary hypertension and generalized cyanosis, requiring intubation and ventilatory support. An echocardiogram revealed no other cardiac malformations. A thoracic x-ray showed complete compromise of the right lung and 90% of the left with pulmonary hypoplasia. High frequency ventilation was initiated, with no clinical response, and the neonate died three hours after birth.

Cystic adenomatoid malformations are developmental malformations of the lower respiratory tract and the most frequent (25%) among all subtypes of congenital pulmonary malformations, with a variable history resulting in hydrops (40%) or regression (15% of the cases).

Almost 100% of lung cysts can be detected at routine 18-20-week ultrasound or during the ethyological evaluation for polyhydramnios or fetal hydrops.

Complications in utero include mediastinum deviation, superior vena cava, or esophageal compression, leading to hydrops, hydramnios, and pulmonary hypoplasia. In our case, diagnosis was made at 22.1 weeks of gestation, based on postnatal classification as CCAM type one, though lesions ranged from 2-3 cm in diameter, compatible with bilateral macrocystic disease. Ultrasonography reported multiple cystic lesions in both lungs, along with polyhydramnios and hydrops. Prenatally, congenital cystic adenomatoid malformation (CCAM), is classified as macrocystic (<5mm, 26% incidence) or microcystic (>5mm diameter, 74% incidence). Congenital pulmonary airway malformation volume ratio (CVR) is a sonographic indicator for risk of hydrops. A CVR <1.6 suggests a low risk for hydrops in the absence of a dominant large cyst, as opposed to a CVR > 1.6 with a dominant large cyst which translates a high risk for hydrops. Postnatally, CCAM is classified in five types due to various parameters.

The CVR was not reported and weekly follow up was performed, despite the diagnosis of polyhydramnios and hydrops no surgical intervention was made.

Ultrasonography and clinical presentation were compatible with CCAM type three, where polyhydramnios and hydrops are common, as well as progressive respiratory distress, all present in this case. Without prenatal intervention, bilateral disease and hydrops are indicators of poor outcome, risk of perinatal death approaches 100%.

Several interventions for CCAM are available, including amniocentesis, steroid therapy, thoracoamniotic shunts and laser ablation among others. Approach depends on the type of anomaly, macro versus microcystic disease, steroids being the only medical treatment reported to reverse hydrops and improve outcome, though in this particular case showed no benefit.

In conclusion, the diagnosis presented was not compatible and didn’t show the prognosis reported in 95% of the cases for congenital pulmonary airway malformation type one, which didn´t allow for further intervention.

Neonatology – Lung injury and long-term lung function


Okur N. 1, Bezirganoglu H. 1

Zekai Tahir Burak Women, Neonatology, Ankara-Turkey 1


Many recent studies suggest that vitamin D deficiency has a detrimental impact on lung development in neonatal period, but the mechanism of this association has not been clearly understood. The aim of this study was to investigate the effect of vitamin D deficiency on surfactant synthesis and whether it has a role on lung maturation.


Umbilical cord blood samples and gastric aspirates were immediately obtained in the delivery room from the infants, of ≥34 weeks’ gestation. Family consent was taken. Vitamin D level was measured from umbilical cord blood and lamellar body counts(LBC) from gastric aspirate. All babies were monitored from birth and Silverman scoring was performed every 30 minutes. Infants with a score of ≥4 were admitted to the neonatal intensive care unit (NICU). Infants were divided into two groups: admitted to NICU because of respiratory problems and not admitted to NICU. Vitamin D level and lamellar body counts were compared in two groups.


46 babies in the NICU group and 27 babies in the control group were analyzed. Mean gestational ages (36.3 ± 1.4 in the NICU group and 37.9 ± 1.3 weeks in the control group) and mean birth weights (2761 ± 491 and 3138 ± 419 g, respectively) were significantly lower in the NICU group. (p <0.01). Lamellar body counts (109 × 103 ± 20 × 103 and 191 × 103 ± 27 × 103 / μl, p <0.001) and vitamin D levels (7.9 ± 1.1 and 14.3 ± 0.8 ng / ml, p = 0.017) were both lower in the NICU group. No significant relationship was found between the lamellar body counts and vitamin D levels (r = –0.031, p = 0.79).


Vitamin D deficiency in pregnancy has detrimental consequences on placental development. It may be a cause of preterm birth that leads to development of respiratory distress syndrome. Measuring LBC from amniotic fluid, tracheal aspirate or gastric fluid can be used to determine surfactant level which is related lung maturation. Since lung maturation and lamellar body counts are directly proportional with gestational weeks, we aimed to select infants of ≥34 weeks gestation in which lung maturation is relatively mature. In this study, vitamin D and LBC were found to be lower in infants with respiratory distress supporting vitamin D’s role in lung development. Maternal vitamin D deficiency may have a negative role on surfactant synthesis in infants.


Alyamac Dizdar E. 1, Bozkaya D. 1, Sarı F. 1, Beser E. 1, Tayman C. 1, Oguz S. 1

University of Health Sciences, Ankara Zekai Tahir Burak Women’s Health, Health Application and Research Center, Neonatal Intensive Care Unit, Ankara-Turkey 1


Measurement of lung function helps in diagnosis, monitoring and treatment of respiratory diseases but conventional techniques such as spirometry are not possible in newborn babies. Structured Light Plethysmography (SLP) is a novel, non-contact, bed side respiratory assessment technique. It provides non-invasive tidal breathing measurement in patients difficult to cooperate such as newborns.


To determine the normal values for tidal breathing parameters measured by Structured Light Plethysmography (SLP) in term and late preterm newborns without respiratory pathology.


Infants between 2-5 days of life without having any respiratory symptoms were eligible for this observational study. Infants with all known disorders likely to cause tachypnea, major congenital anomalies, sepsis, hypoglycemia and perinatal asphyxia were excluded. Study infants were divided into 2 groups according to gestational age as term and late preterm infants. Five minutes of tidal breathing was recorded using SLP (Thora-3Di, Pneuma Care Ltd) in each infant. Various tidal breathing parameters including timing indices; respiratory rate (RR), inspiratory time (tI), expiratory time (tE), total breath time (tTot), flow-based parameters; time to reach peak tidal expiratory flow over tE (tPTEF/tE), time to reach peak tidal inspiratory flow over tI (tPTIF/tI), tidal inspiratory flow at 50% of inspiratory volume divided by tidal expiratory flow at 50% of expiratory volume (IE50) and regional parameters; left–right hemi-thoracic asynchrony in degree (HTA), thoraco-abdominal asynchrony in degree (TAA), relative contribution of the thorax to each breath in percentage (rCT) were obtained from every detected breath.


A total of 57 infants underwent SLP measurements in the study. Evaluable recordings from 42 term and 11 late preterm infants were analyzed after exclusions. Median (IQR) gestational age and birthweight of the infants were 38 (37-39) and 3195 (2790–3585) respectively. Median (IQR) values for timing indices in whole study infants were presented as follows: RR 49 (43-58), tI 0.51 (0.50-0.60), tE 0.67 (0.53-0.77), tTot 1.23 (1.03-1.40). Flow based parameters in study infants calculated as median (IQR) were as follows: IE50 1.29 (1.13-1.53), tPTEF/tE 0.44 (0.38-0.52), tPTIF/tI 0.44 (0.40-0.47). Regional parameters as median (IQR) were rCT 38.67 (28.21-43.60), rCRHTX 18.78 (14.56-22.19), rCLHTX 20.32 (13.94-22.89), HTA 6.92 (5.35-9.04), TAA 17.96 (12.98-36.44) in the study population.

There were no differences in tidal breathing parameters except a regional parameter, ‘hemi-thoracic asynchrony’ between term and late preterm infants. HTA was significantly lower in term neonates than late preterms.


SLP was found to be feasible to obtain measures of tidal breathing parameters in newborns and it could be performed successfully even in the first days of life.

Neonatology – Neonatal Nutrition


Ikeda N. 1, Awata K. 2, Murano Y. 3, Ohkawa N. 2, Shoji H. 3, Kantake M. 2, Shimizu T. 3

Kamisu Saisekai Hospital, Pediatrics, Ibaraki-Japan 1

Juntendo University Shizuoka Hospital, Neonatology, Shizuoka-Japan 2

Juntendo University Faculty Of Medicine, Pediatirics, Tokyo Japan 3


Hypoxic–ischaemic encephalopathy (HIE) may lead to dysfunction of heart, lung, kidney, brain and intestine. In Japan, therapeutic hypothermia (TH) is now used as a standard treatment for moderate to severe neonatal HIE. However, guidelines for enteral feeding during and after TH in patients with HIE have not been evaluated. Our concern was that delayed enteral feeding would provide harmful effects to enterobacterial flora. Therefore, this study aimed to examine the effects of probiotics on infants with HIE treated with TH.


This retrospective cohort study was conducted at the neonatal intensive care unit (NICU) at Juntendo University Shizuoka Hospital, Shizuoka, Japan. Infants with HIE treated with TH, admitted to the unit from May 2012 to June 2018, were included in this study. The inclusion criteria included gestational age at birth to be ≧ 36 weeks and birth weight to be ≧ 1800 g. All infants started enteral feeding after TH on day 4. The collected data included the clinical course, body weight measured over time and duration of NICU stay. Results between the probiotic group (group P: enteral feeding started with probiotics, B. brave, 5 × 109 CFU/day) and no probiotic group (group NP: enteral feeding started without probiotics) were compared.


The two groups included 10 infants each. Significant difference was not found between the groups in terms of mean gestational age at birth, birth weight, perinatal Objective and severity of HIE. Moreover, the start time of enteral feeding after birth, day of reaching full enteral feeding (150 mL/kg/day), day on which appropriate body weight was achieved, duration of hospital stay and weight increment per day did not differ significantly between the two groups. However, infants in group P with median body weight were significantly heavier at the time of discharge than those in group NP (p < 0.05).


In this study, we examined the effect of probiotics on enteral feeding and body weight gain in infants with HIE who were treated with TH. Significant effects were not found on the day when full enteral feeding was achieved and the duration of hospital stay, but the results of this study suggested that daily supplementation of probiotics helps such infants to gain weight. Further studies are necessary to clarify the effects of probiotics on infants with HIE after TH treatment.


Sokou R. 1, Grivea G. 2, Konstantinidi A. 1, Antonogeorgos G. 1, Kokori F. 3, Varhalama E. 3, Gounari E. 4, Panogiotounakou P. 1, Gounaris A. 2

Nikaia General Hospital Agios Panteleimon, Piraeus, Nicu, Piraeus-Greece 1

University Hospital of Larissa, Nicu, Larissa-Greece 2

Nikaia General Hospital Agios Panteleimon, Piraeus, Radiology Department, Piraeus-Greece 3

Children’s Hospital, Pediatric Departmroyal Alexandra Ent, Brighton-United Kingdom 4


To evaluate gastric emptying time during continuous and intermittent milk feeds in very premature neonates, based on antral cross-sectional area (ACSA) measurements.


A randomized prospective clinical trial with crossover design was conducted with 31 preterm neonates with gestational age (GA)<30 weeks, hospitalized in our NICU over a one year period. Gastric emptying time was assessed twice in every neonate: during intermittent (group A) and continuous feeding (group B) by measuring ACSA changes with ultrasound (U/S) during a 2-hours observation period, at 7 specific time points: every 10 minutes for the first half hour and thereafter every 30 minutes; the last one in 120 minutes after the milk feed administration.


All study neonates had mean birth weight (± SD) of 982 (± 28) grams and a mean GA (± SD) of 28.3 (± 1.5) weeks. In 11 neonates during continuous feeding we haven’t measured gastric emptying, as ACSA didn’t reached the half of the initial value which is necessary for the measurement. Statistically significant difference was found with regards to the mean gastric emptying time between group A and group B [37.8±15 minutes vs 57.7±29 minutes (P=0.0032)]. In the last U/S measurement (at 120 min), group A had mean ACSA value 0.1cm2 and group B had 0.8cm2, and this difference was statistically significant (p<0.001). Median ACSA value measured at 120min, was expressed as percentage, of ACSA value measured immediately after administering feeding milk and was found 3% (range 0-25%) for group A and 50% (range 15-80%) for group B. No complications or signs of feeding intolerance were recorded for the neonates of both groups.


In very preterm neonates, gastric emptying time seems to depend on the mode of oral feeding method. Our study results show that gastric emptying time is shorter when feeding these neonates intermittently. It is noteworthy, in neonates who were fed with the continuous feeding mode, no gastrointestinal complications were noted despite the fact that gastric residual reached the 80% of gastric feeding volume according to ACSA values calculated. Further studies are necessary to verify our findings as similar results may suggest changes in the nutritional practices of this very susceptible neonatal population.


Konstantinidi A. 1, Grivea G. 2, Sokou R. 1, Antonogeorgos G. 1, Varhalama E. 3, Kokori F. 3, Gounari E. 4, Baltogianni M. 5, Gounaris A. 2

Nikaia General Hospital Agios Panteleimon, Nicu, Piraeus-Greece 1

University Hospital of Larissa, Nicu, Larissa-Greece 2

Nikaia General Hospital Agios Panteleimon, Radiology Department, Piraeus-Greece 3

Royal Alexandra Children’s Hospital, Pediatric Department, Brighton-United Kingdom 4

University Hospital Of Ioannina, Nicu, Ioannina-Greece 5


Primary objective of our study was to investigate the effect of caffeine on the gastric emptying time of very low birth weight (VLBW) neonates. Secondary objectives were a) to assess the effect of caffeine on gastric emptying time in very preterm neonates in association with their birth weight (BW) and b) to evaluate the occurrence of gastrointestinal complications during caffeine treatment.


This randomized cross-over clinical trial was conducted during over a 6 months period at a tertiary-level 26 bed NICU in Greece. We studied 22 preterm neonates appropriate for gestational age with BW less than 1500gr and the need for caffeine treatment after excluding neonates with congenital anomalies, intrauterine growth retardation (IUGR) or necrotizing enterocolitis (NEC) stage II or III. Gastric emptying time was checked twice for each neonate, with ultrasound assessment of changes in antral cross sectional area (ACSA). All neonates were sequentially allocated to the caffeine group and the control group (without caffeine treatment). Complications from the gastrointestinal tract were documented throughout the study.


All study neonates had mean BW (±SD) 1077 (±229) g and mean gestational age (GA) (±SD) 28.6 (±2.1). The mean gastric emptying time (SD) between caffeine treatment group [41.7 (4.4) min] and control group [31.5 (3.1) min] had not significant statistical difference (P=0.065). However in the neonates with BW 1000-1500g, the gastric emptying time was significant longer during caffeine treatment [53.1 (±5.8) min] as compared to the gastric emptying time during no caffeine treatment [32.6 (±3.9) min] (P=0.003). More gastrointestinal complications were recorded (6 versus 1) during caffeine treatment, but the difference was not statistically significant (P=0.09).


Our study showed that VLBW neonates who received caffeine had no significant delay in the gastric emptying time, nor statistically significant difference in the number and the severity of the gastrointestinal complications during the first weeks of life. Despite these findings, the effect of caffeine treatment on gastric emptying time seems to be in association with BW, as in our neonates with BW 1000-1500g a delay of gastric emptying time was observed. It is obvious that further and larger studies are needed to confirm our interesting findings.


Baysal B. 1, Tuzun F. 1, Engur D. 2, Ozbal S. 3, Ergur B. 3, Iscan B. 1, Yucesoy E. 1, Duman N.1, Ozkan H. 1, Kumral A. 1

Dokuz Eylul University School of Medicine, Neonatology, Izmir-Turkey 1

Izmir Health Sciences University Tepecik Education and Research Hospital, Neonatology, Izmir-Turkey 2

Dokuz Eylul University School of Medicine, Department of Basic Medical Sciences, Izmir Turkey 3


Cholestasis is a common disease of the liver in premature infants and no specific preventive treatment is currently available. Fucose, one of the monosaccharide building blocks of human milk oligosaccharides, may prevent cholestatic hepatic injury by various mechanisms. The aim of this study was to investigate the protective effect of fucose treatment after endotoxin induced cholestasis in a rat model.


Wistar rat pups were divided into four groups as: Group I, control group; Group II, fucose-supplemented group; Group III, lipopolysaccharide (LPS)-administered group and Group IV, LPS – exposed and fucose-supplemented group. Fucose was administered via intraperitoneal (i.p.) injection every other day between 5ththrough 17th days. LPS was administered on the 19th day to establish endotoxin-induced cholestasis model. On postnatal day 21, biochemical analysis was performed, and animals were sacrificed to evaluate liver cell damage and apoptosis by immunohistochemical assessments.


Fucose supplementation significantly improved the biochemical parameters that deteriorated in LPS administered group, significantly increased the expression of bile salt export pump, reduced the number of apoptotic cell death and greatly prevented LPS-induced cholestatic hepatic injury.


Given our results, fucose may be useful in reducing hepatic injury and possessing clinical relevance for the preventive treatment of inflammation induced cholestatic injury in newborns.


Pavicic Bosnjak A. 1

University Hospital Sveti Duh, Department of Obstetrics and Gynecology Medical School University of Zagreb, Zagreb-Croatia 1


Breastfeeding is the optimal way of premature infants’ feeding as it contributes to their growth, development and overall health outcomes. The Baby Friendly Hospital Initative for Neonatal Wards (the Neo-BFHI) is a program developed by the Nordic and Quebec Working Group focused on breastfeeding support for preterm and ill infants. The Neo-BFHI includes Three Guiding Principles, the expanded BFHI’s Ten Steps and compliance with the International Code of Marketing of Breast-milk Substitutes (Code). The Neo-BFHI was launched in Croatia in 2013 as well in many other countries. Recently, the results of the first international study measuring compliance with the Neo-BFHI policies and practices in neonatal wards were published which allow to identify the challenges for the Neo-BFHI implementation on the country level. The aim is to present the Croatian results reported in the first international study measuring compliance with Neo-BFHI policies and practices.


A cross-sectional survey in 36 countries was carried out in 2017. All thirteen Croatian neonatal intensive care units (NICUs) participated in the study (response rate 100%), of which 5 units were level 2 and 8 level 3. Out of 13 NICUs, 11 were in hospitals designated as Baby-friendly. Compliance was measured with the Neo-BFHI’s Self-Assessment questionnaire which included a set of indicators for the14 components of the Neo-BFHI (the three Guiding Principles, Ten Steps and the Code). Croatian data was extracted from a benchmark report. Results were reported as a country overall score and scores obtained on 14 components. Country scores for the level 2 and level 3 NICUs were compared.


The median Croatian overall score was 77, which was the same as the median international overall score. When compared with the international scores for each of the 14 components of the Neo-BFHI, the lowest scores in Croatia were obtained for Guiding Principle (GP) 2 about family-centered care (67 vs. 82), Step 4 about kangaroo care (50 vs. 80) and Step 7 about rooming-in (33 vs. 67). Level 3 NICUs achieved less favorable scores on those 3 components compared to level 2 NICUs. In the majority (77%) of Croatian NICUs the estimated daily duration of kangaroo care was less than 4 hours. Sixty nine percent of our NICUs reported a free 24/7 maternal visiting policy while 85% were restrictive regarding paternal visiting. The country scores obtained on GP 1 and Steps 1, 2, 5, 6, 8 and 10 were above the international scores. Compliance with the Code was high.


Croatian NICUs achieved relatively high compliance with the Neo-BFHI policies and practices. However, more efforts are required to increase the involvement of parents in care for their infants and to better support breastfeeding in neonatal wards. A benchmark report prepared for each neonatal ward presenting the results for their ward, their country and international, will help each unit to identify the obstacles in the Neo-BFHI implementation and plan how to fully integrate the BFHI into their unit.

Neonatology – Nutrition of the Very Preterm


Çelen R. 1, Taş Arslan F. 1, Soylu H. 2

Selcuk University Faculty of Nursing, Pediatric Nursing Department, Konya-Turkey 1

Selcuk University Faculty of Medicine, Department of Neonatology, Konya-Turkey 2


The purpose of this randomized trial is to test the effect of Safe Individualized Nipple-Feeding Competence (SINC) feeding protocol on preterm infants’ weight gain, the transition to oral feeding and the length of hospitalization.


This was single-blinded, parallel group randomized controlled trial. The trial was conducted in the Selcuk University neonatal intensive care unit in Konya. Data were collected February 2018-March 2019 from 76 infants. 76 preterm neonates (28–33 weeks gestation) were randomly assigned to the intervention (n= 37) and control groups (n=39). The intervention group received SINC feeding protocol and the control group received standart feeding method. Primary outcomes are weight gain, the transition to oral feeding and the length of hospitalization from birth to discharge. The data were assessed by Pearson χ2 analyses or Fisher’s exact test and by independent t test and Mann-Whitney U test.


There were no significant differences in our primary outcomes at first oral feeding (mean difference: 2.12 days 95% CI: –0.59 to 0.31), the transition to full oral feeding (mean difference: –0.07 days 95% CI: –0.39 to 0.51 days) and the length of hospitalization (mean difference 3.4 days 95% CI: –0.48 to 0.42 days) (p > 0.05). There was better weight gain in the intervention group (p < 0.001).


Evidence based feeding practices improve outcomes in preterm infants. These provide empowering nursing and improving the quality of care.

Trial registration: Identifier: NCT03371927

Neonatology – Neonatal Brain Injury and Neuroprotection


Campbell G. 1, McGregor R. 1, Matthews A. 1, Krishnan G. 1

Wishaw General Hospital, Neonatology, Glasgow-United Kingdom 1


To assess and compare compliance and completion rates of neuroprotective measures over the years 2016-2018. Preterm neonates and those with low birthweight are at greater risk of early neurological damage leading to long-term sequelae. There are a myriad of factors that contribute which are often subdivided into neuroprotective factors and neurodevelopmental factors. This audit focused on neuroprotective factors.


Retrospective audit comparing three years of data from 2016 to 2018

Data was collected using the online database BadgerNet and Clinical Portal. Included all patients who were ≤ 29 weeks gestational age or birthweight of <1.5kg. Data was collected on the following: antenatal steroids, antenatal magnesium sulphate, admission temperature, delayed cord clamping, early caffeine citrate use, hypocarbia and prevalence of intraventricular haemorrhage.


Since introduction of neuroprotective measures the overall prevalence of intraventricular haemorrhage has reduced. Prevalence of a full course of antenatal steroids has increased by 18% alongside use of magnesium sulphate, which has increased by 10%. Delayed cord clamping has increased by 27%. Abnormal admission temperature (<36.5 or >37.5) has decreased by 12%. Hypocarbia has decreased by 7%. Early caffeine use is maintained at 92%.


Overall, the rate of adherence to known neuroprotective factors is increasing and this has been reflected in a decrease in the prevalence of intraventricular haemorrhage. This is encouraging given that there is also a trend of babies being born earlier and at a lower birth weight. Further work is needed to include neurodevelopmental factors and data on the long term sequelae of these patients.


Griffin C. 1, Martil C. 1, Queiroz L. 1, Rebello C. 1, Zacarias R. 1, Gomes A. 1

Albert Einstein Jewish Hospital, Neonatal Unit, São Paulo-Brazil 1


Minimal manipulation refers to a care grouping in which the newborn is seen as the care center, which leads caregivers to act together, prioritizing the need for newborns 1. Caring for newborns in a Neonatal ICU demonstrates the coexistence with the fragility of living / surviving in the light of complexity 2.


To verify the impact of the application of the Protocol of minimal manipulation in the control of Intraventricular Hemorrhage in the Neonatal Intensive Care Unit of a private Institution of the State of São Paulo.


Minimal manipulation protocol was developed in the Neonatal Intensive Care Unit of the Jewish Albert Einstein Hospital in the period of October 2017. Inclusion criteria: newborns with gestational age ≤ 29 6/7 weeks and/or ≤ 1,500g. Strict minimum manipulation was maintained in the first 72 hours of life and could be extended up to the 7th day of life 3-5. The release of the change of decubitus is allowed from the 7th day of life. First Ultrasound of Cranial Fontanelles between the 3rd and 7th day of life of the newborn, to verify hemorrhage 6,7. There was an explanation of the content for the multidisciplinary team and family of the newborn, fixed support material in the unit and fixed identifier in the incubator for visualization of the newborn participants of the protocol.




There was a positive impact on the application of the Protocol, even though it did not demonstrate a significant decrease in cases of Intraventricular Cerebral hemorrhage. There was a decrease between grade I and III. The incidence of intraventricular cerebral hemorrhages decreased from 40.6% (CI 95%: 29.5%-52.8%) In 2016 to 39.5% (95% CI: 26.4%-54.4%) at 2018. Grade III and IV Hemorrhages showed a decrease from 84.4% to 83.7%. Considering the non-measurable results on the implementation of the Protocol, we can observe the involvement of the nursing team that conducted the protocol orientation and there was great adherence to the multidisciplinary team and the newborn’s family. The awareness of the multidisciplinary team regarding the importance of minimal manipulation. The support material that was essential support for conducting the implementation of the Protocol. The identifier fixed in the incubators for visualization reinforced the orientation of the multiprofessional team and the family of newborns.


Baysal B. 1, Micili S. 2, Engur D. 3, Tuzun F. 1, Akokay P. 2, Iscan B. 1, Yucesoy E. 1, Ergur B.2, Keskin P. 4, Yilmaz O. 5, Duman N. 1, Ozkan H. 1, Kumral A. 1

Dokuz Eylul University School of Medicine, Neonatology, Izmir-Turkey 1

Dokuz Eylul University School of Medicine, Department of Basic Medical Sciences, Izmir-Turkey 2

Izmir Health Sciences University Tepecik Education and Research Hospital, Neonatology, Izmir Turkey 3

Dokuz Eylul University School of Medicine, Department of Biostatistics and Informatics, Izmir-Turkey 4

Dokuz Eylul University School of Medicine, Vocational School of Health Services, Izmir-Turkey 5


Fetal growth restriction (FGR) describes the state when a fetus is unable to achieve genetically pre-determined potential of growth due to several pathologies. Postnatal management of FGR requires close monitoring of the nutritional status of these infants, however, whether negative effects of FGR can be alleviated by postnatal diet and the ideal postnatal diet to achieve the best neurodevelopmental outcome in the presence of FGR remains unclear. Our aim is to investigate the ideal postnatal diet for the best neurodevelopmental outcome in an animal model of FGR.


Female Wistar rats were fed a diet containing either 10% (low protein, LP) or 20% protein (standart protein, SP) diet starting after breeding and were maintained on their respective diets throughout pregnancy. In order to establish an intrauterine growth restriction model both groups received 300 μg/kg intraperitoneal lipopolysaccharide (LPS) on embryonic days (E) 18 and E19 in addition to dietary protein restriction.

After birth, rats were further assigned into three groups and fed a diet containing either, LP, SP or 50% protein (high protein, HP). Neuro-behavioral development of offsprings were evaluated on postnatal day (PN) 30. Pups were sacrificed on PN 35 and hippocampus, dentate gyrus and prefrontal cortex were evaluated histologically.


Antenatal LP group displayed lower birth weight and lower brain weight in the offspring as well as lower neurobehavioral scores compared with antenatal SP group. Histologic examination revealed increased apoptosis in antenatal LP group when compared with antenatal SP group. Postnatal SP and HP diet in antenatal LP group lowered apoptosis and increased neuronal density in dentate gyrus when compared with postnatal LP group. Postnatal SP diet in antenatal LP group significantly improved speed and total distance scores in water maze test when compared with postnatal LP and HP groups.


Brain injury due to FGR can be alleviated by postnatal SP diet. Postnatal HP diet was not associated with better histologic outcome in the prefrontal cortex and dentate gyrus in antenatal LP group. Moreover, in antenatal SP group, postnatal HP support resulted in unfavorable histologic results in the hippocampus, prefrontal cortex and dentate gyrus compared to postnatal SP diet. Although, postnatal HP support was associated with a successful catch-up growth in short term, better neurodevelopmental scores in the offsprings were achieved by postnatal SP diet rather than postnatal HP support.


Alp Ünkar Z. 1

Beykoz Government Hospital, Pediatrics – Neonatology, Istanbul-Turkey 1

The aim of this retrospective research was to vocalize numerically that the amount of serum total bilirubin (STB) levels of jaundiced newborns who are referred to our hospital from other clinics increase significantly and reach dangerous levels while waiting in the emergency rooms (ERs) and during transport.

Computer files of the patients accepted to our neonatal intensive care unit (NICU) between January 2017 and June 2019 were scanned, demographic data and laboratory results were recorded. Patients who were hospitalized for hyperbilirubinemia but turned out to have neonatal sepsis or those who developed hyperbilirubinemia during their period of hospitalization for another reason were excluded.

1077 patients were accepted for unconjugated hyperbilirubinemia, 523 (48.6%) of these were either from our own out-patient clinics or ER and 554 (51.4%) were accepted from centers all around the city. 593 were males (%55.1) and 484 were females (44.9%). Fifty newborns (4.6%) were hospitalized within the first 24 hours of life. There were only 2 patients, both from our clinic, with TSB levels >30 mg/dl, who were both referred to tertiary clinics for exchange transfusion. 208 newborns had STB levels ≥20 mg/dl, and among these 13 had TSB ≥25 mg/dl. Patients were evaluated separately as those from our clinic and referred patients. The first STB measured which was used as phototherapy indication and STB level with which the patient was accepted to NICU were compared. In both groups, increases in STB values as the patients went through the hospitalization procedures were statistically significant (both p<0.001). When the differences between the first and second measurements were compared among the groups, the rise in the STB levels of the transport group was significantly higher than that of our out-patient group (p<0.001). TSB levels of 87 patients had increased more than 20% during hospitalization process and among these 76 patients (87.4%) were referred from another hospital.

The time it takes for patients from our clinic to be diagnosed with hyperbilirubinemia and accepted to NICU is fairly uniform; however same cannot be told for those being referred from other clinics, the period being as long as 6-8 hours for some. These patients wait in the ER for the Provincial Health Directorate Transfer Unit to find a suitable NICU, an ambulance to pick them up and deliver them to their destination, during which (with the exception of one or two centers) nothing is being done to lower the initial STB level, contrarily increasing the risk of acute bilirubin encephalopathy and kernicterus. This “study” has many flaws; however, the main objective is to draw attention to the period wasted while waiting for transfer to the referred unit and the increasing STB levels which were never before verbalized as statistical numbers.

The use of modalities to allow newborns with hyperbilirubinemia receive phototherapy while waiting for and during transport (e.g. portable LED phototherapy devices, biliblankets, etc.) should be made widespread as the first step of neuroprotection. Campaigns (national and worldwide) for hyperbilirubinemia awareness should be initiated.


Yeşiladalı M. 1, Api O. 2, Ceyhan M. 2

Yeditepe University Hospital, Obstetrics and Gynecology, Istanbul-Turkey 1

American Hospital, Obstetrics and Gynecology, Istanbul-Turkey 2


To study any possible effects of maternal progesterone therapy on important proteins and receptors in fetal brain tissue of rats.

Materials and Methods

Fifteen female Speaque-Dawley rats were used in this study, which were divided in three groups. 17-α-OH progesterone caproate 7mg/kg, i.m. was applied once a week to Group A, from first day of pregnancy. Micronised progesteron 4mg/kg p.o. was daily applied to Group B, from first day of pregnancy. Group C was control group and olive oil was given daily from first day of pregnancy. After 21 days pregnancy period, 152 newborn rats were born by vaginal birth. 60 of them, including 4 from each mother, were taken study and decapitated from first day of their birth. Their brain tissues were obtained and ER, PR, MBP, PLP, OLIG2, PDGFR were studied by immunohistochemistry.


Groups A and B had significantly more expression of ER, MBP, PLP, OLIG2; and less expression of PDGFR; compared to Group C. None of the groups had PR expression.


There are very few studies concerning the effect of maternal progesteron therapy on fetal organ systems. Our study revealed significant effects of progesterone therapy on fetal brain receptors and proteins, which have particular roles on embryogenesis and brain tissue development. In the light of these results, long term effects of maternal progesterone therapy on fetus remains to be studied; including possible effects on metabolism, cognitive functions, sexual behaviour, neuron migration and differentiation and increased myelination. Maternal progesterone therapy causes statistically significant changes on expressions of several proteins and receptors in brain, which have important roles in central nervous system development.


Metallinou D. 1, Karampas G. 2, Lykeridou K. 3, Iacovidou N. 4, Rizos D. 5

“Alexandra” General Hospital, Nicu, Athens-Greece 1

2nd Department of Obstetrics and Gynecology, “Areatieio” University Hospital, Obstetrics & Gynecology, Athens-Greece 2

University of West Attica, Midwifery, Athens-Greece 3

2nd Department of Obstetrics and Gynecology, “Areatieio” University Hospital, Neonatal Division, Athens-Greece 4

2nd Department of Obstetrics and Gynecology, “Areatieio” University Hospital, Hormone Laboratory, Athens-Greece 5


Preterm birth (< 37 weeks gestation) is a significant public health problem worldwide. Consequences of prematurity are numerous, with the preterm neonatal brain injury (NBI) being one of the most severe. The underlying mechanism of NBI involves an initial insult to the vulnerable, developing fetal brain that is usually either of hypoxic–ischemic, hemorrhagic or infectious in nature and activates a cascade of events leading to further brain injury. Neonatal brain injury increases the risk for serious long-term neurodevelopmental impairment, including motor, cognitive, neurologic and sensory disability. Intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL) and hypoxic-ischemic encephalopathy (HIE) are subtypes of brain injury which can affect infants born at any gestational age, however, infants born <34 weeks gestation are more prone to IVH and PVL. We sought to determine whether neonatal glial fibrillary acidic protein (GFAP) levels on the first 3 days of life could identify in preterm infants (<34 weeks gestation) NBI.


This is a prospective longitudinal case-control study of all liveborn, nonanomalous preterm (<34w) neonates who were born at a single tertiary hospital and were admitted to the NICU from November 2016 – January 2018. Neonates with major congenital malformations, chromosomal or genetic abnormalities were excluded from the study. For GFAP, the residual unused portion of serum from daily routine clinical laboratory tests was used during the first 3 days of life. Most of these samples were obtained from peripheral or umbilical vessels. Residual serum was aliquoted and stored at –35 C until assayed. After neonatal discharge, we reviewed the results of head scans from ultrasound or magnetic resonance imaging. Preterm infants with NBI were then compared with normal ones at the same gestational age within 1 week, similar birthweight and mode of delivery, matching in a 1:1 fashion. Head imaging scans were all performed in the same hospital and were evaluated by 2 pediatric radiologists. Results: During our study, 29 cases with NBI with gestational age 29.6±3.0 weeks and birth weight of 1225±475gr were compared with 29 control infants (gestational age: 29.9±2.5 weeks; birth weight: 1303±428gr). The incidence of caesarean delivery was 91.4% in both groups. The lowest detection limit (0.05ng/ml) of the kit used was set as reference for the statistical analysis. The frequency of samples with GFAP level more than 0.05ng/ml was higher on day 1 (X2-test, p=0.01), day 2 (X2-test, p=0.04) and day 3 (X2-test, p=0.05) in the NBI group.


Level of GFAP differs during the first 3 days of life between normal and neonates that will later develop NBI. The ability to predict NBI with a blood test for GFAP shortly after birth opens the possibility for rapid identification of infants for early intervention and provides a benchmark for the determination of future neuroprotective strategies.


Chatzııoannıdıs I. 1, Mıtsıakos G. 1, Koukoulıas D. 1, Karagıannı P. 1, Tsakalıdıs C. 1, Kyrıakıdou M. 1, Gıalamprınou D. 1, Papacharalampous E. 1, Babacheva E. 1, Soubası V. 1

Aristotle University of Thessaloniki, “Papageorgiou” Hospital, Second Neonatal Department, Thessaloniki-Greece 1


Late Preterm Infants (LPIs) are at increased risk for morbidity and mortality. Small for gestational age (SGA) refers to restricted size at birth. Although SGA preterms are prone to neurodevelopmental delay, only few studies have reports on neurological outcome during the first years of life, with differing results. High-risk infant follow up programs provide early identification and referral for treatment of neurodevelopmental delays/impairment.


The aim of this cohort study was to compare SGA/LPIs with AGA/LPIs neurological/neuromotor outcome within first year of life corrected age (CA), and investigate their optimality scores.


The Hammersmith Infant Neurological Examination (HINE) was performed in a cohort study of 35 LPIs follow up in the NICU at 6 months period time. The infants were examined at 3,6 and 12 months CA respectively and scored with the optimality score system including 26 items assessing cranial nerve function, posture, movements, tone and reflexes.


SGA/LPIs at 3-6 to 12 months had a global score of 55 (51-58) to 61 (56-66) much lower than AGA although non statistically significant. There were also no statistically significant differences for all subscores for all time periods. All SGA/LPIs had suboptimal scores while for AGA ranged from 84.2% to 71.4% at 3-6mo and 12 months respectively.


SGA/LPIs have poor neurological outcome at 3-12 mo corrected age, suggesting for closer follow up and early intervention programs. Larger, prospective studies focusing on SGA/LPIs are needed to assess neurological outcome and their association to neurodevelopmental impairment throughout follow up.


Sezik M. 1, Ozmen O. 2, Koker A. 3, Asci H. 4, Savran M. 4, Yalcin S. 1, Guler S. 3, Sidekli O.3, Konuk E. 5, Quliyeva F. 5

Suleyman Demirel University Faculty of Medicine, Department of Obstetrics and Gynecology, Isparta-Turkey 1

Mehmet Akif Ersoy University Faculty of Veterinary Medicine, Department of Pathology, Burdur-Turkey 2

Mehmet Akif Ersoy University Faculty of Veterinary Medicine, Department of Veterinary Obstetrics and Gynecology, Burdur Turkey 3

Suleyman Demirel University Faculty of Medicine, Department of Medical Pharmacology, Isparta-Turkey 4

Akdeniz University Faculty of Medicine, Department of Histology and Embryology, Antalya-Turkey 5


Magnesium sulfate is currently the standard antenatal treatment for neuroprotection in early-preterm fetuses. However, its exact mechanism of action on the fetal preterm brain is not clear. We aimed to investigate the region-specific effects of magnesium sulfate on caspase-3, caspase-8, and tumor necrosis factor-alpha (TNF-alpha) expressions in the preterm goat fetus brain, using an endotoxin-induced experimental chorioamnionitis model.


With (n=5) or without (n=5) maternal granulocyte colony-stimulating factor (50 microg for 5 days) followed by high-dose (20 mg) intra-amniotic endotoxin, magnesium sulfate was administered at doses of 0.14 g/kg loading and 0.035 g/kg maternal bodyweight maintenance every 4 h for a 24-hour-period, corresponding to a cumulative maternal dose of 0.35 g/kg bodyweight. Preterm delivery was induced by cesarean section at 0.80 gestation. Brain tissues of the kids from 9 areas (frontal cortex, parietal cortex, occipital cortex, cerebellum, thalamus, corpus callosum, periventricular white matter (PWM), pons, and medulla spinalis) were then harvested. Immunohistochemistry and Western Blot were used to evaluate the specimens for apoptosis and TNF-alpha expressions.


Compared to non-endotoxin controls, immunohistochemical TNF-alpha positive cell counts were significantly decreased (p<0.05) in the occipital cortex, cerebellum, corpus callosum, and PWM. With Western Blot, however, there were significant (p<0.05) decrements in TNF-alpha expressions only in the frontal cortex and PWM. Caspase-3 immunostaining was significantly lower (p<0.05) in all of the 9 brain regions, whereas caspase-8 staining was decreased (p<0.05) only in the PWM and corpus callosum, compared to controls.


The neuroprotective effects of magnesium sulfate on preterm fetal brain are complex and seem to involve region-specific inhibition of TNF-alpha and apoptosis. Inhibitory effects were consistently shown at the PWM, emphasizing the critical role of this area in inflammation-mediated preterm fetal brain injury.

Supported by a grant from the Scientific and Technological Research Council of Turkey (research project no, 116S413).

Neonatology – Hemodynamic monitoring of the sick neonate


Dincer E. 1, Gönen İ. 1, Bornaun H. 2, Yaşa B. 1, Babayiğit A. 1, Sağlam Ö. 1, Çetinkaya M. 1

Kanuni Sultan Süleyman Research and Training Hospital, Neonatology, Istanbul-Turkey 1

Kanuni Sultan Süleyman Research and Training Hospital, Pediatric Cardiology, Istanbul Turkey 2


Eye-drops containing 2.5% phenylephrine and 0.5% benzalkonium chloride are used prior to ophthalmologic examinations for retinopathy of prematurity (ROP). These eye-drops which have parasympatholytic and sympathetic effects, has potential to cause side effects as well as desired mydriatic effect.

Besides the local side effects of these drops, such as paleness of the skin and allergic reactions, they are reported to cause severe side effects such as tachycardia, increased blood pressure, feeding intolerance, respiratory distress, and even possible necrotizing enterocolitis development in two cases in the literature.


In this study; we aimed to observe the cardiovascular effects of these two mydriatic drugs via autonomic nervous system.


Between December 2018 and January 2019, 20 patients hospitalized and went under ophthalmologic examination in our unit were included. Vital signs (heart rate, respiratory rate, SpO2, blood pressure arterial values), cerebral and mesenteric tissue saturation of the patients were recorded before ROP screening and after the application of mydriatic eye drops (2.5% phenylephrine and 0.5% Benzalkonium chloride).

Left ventricular functions of the patients were evaluated by echocardiography before the application and 30 minutes after the drops were applied 3 times with 15 minutes intervals and the data were compared statistically.


Heart rate was significantly increased after application of the drops (p = 0.024). There was no significant difference between the NIRS values, and no differences were found in the echocardiographic evaluation before and after the administration.


These drugs, which have the potential to cause serious side effects from their impact on the autonomic nervous system if they are included in the systemic circulation, have been shown to increase heart rate and blood pressure arterial values in previous studies, but their effects have not been evaluated with echocardiography and NIRS so far.

In this study, although there was an increase in heart rate in accordance with the literature, arterial blood pressure values were not increased and mesenteric and cerebral tissue saturations were not affected. Also no significant effect of the drops was observed in echocardiography findings.

It was thought that, maneuvers such as pressure on the nasolacrimal canal and wiping out the excess amount of the drop limit the formation of side effects by preventing the passage of the drops into the systemic circulation. The increase in heart rate was thought to be due to pain itself caused by application of the drops rather than the effect of systemic passage.


In this study it has been firstly shown that mydriatic eye drops have no significant effect on cardiac functions, cerebral and mesenteric hemodynamics. But also studies with a higher number of patients are needed.


Griffin C. 1, Pamponet J. 1, Bella V. 1, Gonçalves P. 1, Zacharias R. 1

Albert Einstein Jewish Hospital, Neonatal Unit, São Paulo-Brazil 1

The high level of complexity of Neonatal Intensive Care Units requires the presence of a specialized team that broadly addresses the aspects of the child and his family during the period of hospitalization. (1) Early death of a child breaks with the life cycle logic and its sudden form can make the development of the loss even more difficult and intolerant for parents. (2) With the loss of a newborn, parents need to complete their bond with the infant and gradually distance themselves from it so that they can attend to their needs and family life, progressing through the grieving process. (3) Even with all the feelings of sadness and anguish experienced, there is also fulfillment, since the team did its best to care for the newborn and his/her family. (4) The objective is to report the holistic approach to grief in the Neonatal Intensive Care Unit at a private institution in the city of São Paulo in June 2019. The study reports a case of a family that went through the grieving process and was attended with a holistic approach by the multidisciplinary team. Newborn with diagnosis of Left Heart Hypoplastic Syndrome, with Restrictive Atrial Canal. Third child of German mother, and Brazilian father. Newborn in the 2nd day of life, Immediately Operatory Procedure of selective pulmonary artery banding and stent implantation in the Arterial Canal. Procedure with difficulty of adjustment of the bandages with need of rebanding twice, and implant of stent of 7mm. After 2 hours of the procedure, newborn presented bradycardia Cardiac Frequency 50bpm with Oxygen Saturation of 32%. Initiated neonatal resuscitation maneuvers. A telephone call was made to the parents to return to the neonatal unit. Upon entering the unit, the mother found newborn during the resuscitation process. The doctor informed her about the conditions of the newborn and immediately the mother interrupted the procedure and removed the newborn from the doctor hands. With the baby in her lap asked for help to remove all devices. Slowly with the help of the nursing and medical staff, the devices were removed, one by one, by the mother. She asked to change the baby’s diaper and let it nestle into her lap. The baby remained with her in her arms until removal to the mortuary. As the protocol of the institution provides for routines defined for the event, there was cultural adaptation and activities for the maternal embrace at the time of loss. The team was understanding and with humanized care for a better experience for the patient and family. The moment of neonatal grief is still a challenge for the neonatal team and confronts the cultural identity of the parents. The performance of the multidisciplinary team was essential, especially for the mother of the baby, who was outside her country of origin. The parents were embraced and had privacy, their needs met, their individuality respected, in a holistic and humanized environment.

Neonatology – Neonatal resuscitation


Halder N. 1, Choudhuri A. 2, Gupta A. 2, Raychowdhury R. 3, Sarkar A. 4, Pal R. 4, Nag S. 5, Das S. 5

Glangwili General Hospital, Obstetrics and Gynaecology, Carmarthen-United Kingdom 1

Rkmsp Hospital, Paediatrics, Kolkata-India 2

Rkmsp Hospital, Ent, Kolkata-India 3

Rkmsp Hospital, Anaesthetics, Kolkata-India 4

Rkmsp Hospital, Oral And Maxillofacial Surgery, Kolkata-India 5

Pierre Robin Sequence or Syndrome (PRS) is a rare congenital craniofacial deformity cluster that equally affects males and females with a prevalence of 1:8,500 –14,000 births. It is characterised by micrognathia (hypoplastic mandible), glossoptosis (posteriorly placed / rotated tongue) that is often associated with a perinatal emergency due to airway obstruction. Cleft palate is found in about 90% cases of PRS. Other concerns include failure to thrive and speech difficulties. Unfortunately, the diagnosis of PRS still remains mostly clinical only after birth.


26-year-old primigravida was delivered by an emergency Caesarean Section due to fetal distress at term in a private nursing home in the outskirts of the city, following a straightforward pregnancy with normal antenatal scans. A 2.45Kg baby boy showed no signs of birth asphyxia however developed respiratory distress within few minutes of delivery and hence was transferred to a tertiary hospital. At admission, the baby had stridor, suprasternal and subcostal retraction, cyanosis and oxygen saturation was 67% on air. Symptoms improved when nursed in prone position with saturations of 95%. PRS was diagnosed due to micrognathia, retrognathia, microstomia with cleft of the soft palate and uvula. Mum failed to breast feed on repeated attempts due to tongue fall-back resulting in reduced saturation. Nasogastric tube was inserted and expressed breast milk was fed. Septic screen was negative, echocardiogram and ultrasound brain were normal. Respiratory distress worsened at 1 month and 2 days of age when chest X-ray showed bilateral patchy lung opacities suggestive of aspiration pneumonia. CPAP and antibiotics were initiated. Baby was thereafter intubated and kept on ventilatory support for 5-days due to clinical deterioration. Direct laryngoscopy under anaesthesia during EUA revealed normal trachea with no tracheomalacia or tracheoesophageal fistula.

Baby is to be nursed in lateral or prone position. Stay-suture on tongue to avoid fall-back risks further aspiration due to limited tongue movement as it affects deglutination. Palatoplasty for cleft closure is planned at 9 months of age. Bilateral Distraction-Osteogenesis (DO) taking advantage of the mandibular growth can be considered at 6 years of age. Close monitoring of the pattern of Facial Growth will be done with X-ray lateral Cephalometry. If necessary, Orthodontic treatment will be offered. If the retro and micrognathic mandible does not correct itself adequately, then advancement of the mandible by Bilateral Sagittal Split Osteotomy along with correction of the chin position may be considered after growth completion ie, after 18 years of age.

Suspect PRS in micro or retrognathia and / or polyhydramnios on antenatal ultrasound with prompt referral to Fetal Medicine Unit (FMU) for further detailed imaging, management plan and counselling. Diagnostic limitation of antenatal ultrasound in detecting craniofacial malformations leaves both parents and clinicians unprepared for such emergency after birth. Mortality in PRS remains high at 30% due to such unforeseen emergency and urgent MDT involvement from senior clinicians is essential and life-saving.


Bıkoulı E. 1, Pıras M. 2, Faa G. 3, Papaloıs A. 4, Xanthos T. 5, Iacovıdou N. 6, Salakos C. 7

National and Kapodistrian University of Athens, Neonatal Department, Athens-Greece 1

University Pf Cagliari, Division of Pathological, Cagliary-Italy 2

University of Cagliary, Department of Surgical Sciences, Cagliary-Italy 3

Elpen, Experimenta; Educational Research Centre, Athens-Greece 4

European University Cyprus, Department of Physiology, Nicosia Greece 5

National and Kapodistrian University of Athens, Department of Neonatology, Athens-Greece6

National and Kapodistrian University of Athens, Deparetment of Pediatric Surgery, Athens-Greece 7


Little data is currently available regarding the effect of perinatal asphyxia on the ovarian histology and function. The current study aims at investigating the impact of asphyxia during the early perinatal period on the structure of ovaries through histology/ pathology and biochemistry indices.


35 Landrace/ Large White female piglets, aged 1-4 days old will finally be the study subjects of the present research protocol. So far, 22 experiments have been performed and the study is still in progress. The piglets are allocated in 4 groups (A, B, C, N). Group A, B and C will consist of 11 piglets each, which will share common initial steps of preparation and stabilization. Group N includes 2 piglets undergoing minimal procedures before harvesting the ovaries. Following the initial steps, group A piglets will have their ovaries surgically removed under general anesthesia (control group), with no further intervention. Group B piglets will undergo asphyxia and have their ovaries removed at the time of cardiovascular compromise. Group C piglets will undergo asphyxia and after cardiovascular compromise will be resuscitated as per the neonatal life support guidelines (ILCOR 2015). The latter will have their ovaries removed after a period of stabilization. Ovaries are kept in formalin solution 4% and sections are stained with H-E for histology. Blood and urine samples are also obtained at predefined time points.


The quantification of the pathological findings and the statistical analysis of the data are currently under evaluation as the study is still in progress. The histological indices examined are the presence of balloon cells, apoptosis, stroma cells and vacuolization of the oocytes. Preliminary results indicate the presence of all types of lesions in all sample groups at different extent and proportions. More specifically, balloon cells appear to be more prominent in group C samples (5/6, 83%) but also present in group A (3/7, 43%) and less common in group B (1/7, 14%). Apoptotic cells are present in groups A, B and C at a similar ratio whereas abundant stroma cells were noted in 5/7 (71%) of group A and B samples and 3/6 (50%) of group C samples. Finally, presence of vacuoles in the oocytes was noted in the majority of the samples of all groups but the extent of the lesions appears to be different between the groups with marked vacuolization being noted in 2/7 (28.5%) of group A, 4/7 (57%) of group B and 1/6 (16.7%) of group C samples.


The preliminary results available so far indicate that asphyxia in the early postnatal period potentially alters the histology of ovaries reflecting a degree of hypoxia-induced damage that could hypothetically have long-term complications and implication on the reproductive ability of perinatal asphyxia victims. Moreover, histological lesions appear to be more prominent in group B compared to group C samples, indicating that effective resuscitation might reverse some of the damage caused by asphyxia. More results are awaited, both histological and biochemical to lead to further conclusions.


Yılmaz Yeğit C. 1, Ince Z. 2, Yaşa B. 2, Saraç Sivrikoz T. 3, Coban A. 2

Istanbul University, Istanbul Faculty of Medicine, Department of Pediatrics, Istanbul-Turkey1 Istanbul University, Istanbul Faculty of Medicine, Department of Neonatology, Istanbul Turkey 2

Istanbul University, Istanbul Faculty of Medicine, Department of Perinatology, Istanbul-Turkey 3


Rhesus mediated hemolytic disease is still a major public health problem, especially in developing countries. The aim of this retrospective study is to evaluate the demographic and clinical characteristics of the newborn infants with Rh hemolytic disease (Rh D), morbidity and mortality rates and treatment modalities in a ten year period.


The study included 260 newborn babies with positive direct Coombs test and/or a history of antenatal transfusion, whose mothers were evaluated at least once in our perinatology clinic antenatally between January 2007 – December 2016. All the babies were admitted to our Neonatal Intensive Care Unit. Prenatal, natal and postnatal data were acquired from the patient records and the digital database of our hospital. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia recommendations were accepted for the postnatal management of the newborn infants.


The mean gestational age of the patients were 36.9±2.7 weeks (24.9 – 41.1weeks), 126 babies (48.8 %) were male and 107 patients (41.2%) were born prematurely. The majority of the mothers was multigravida (n=224, 87.2%), almost half of the women had more than three pregnancies (n=121, 47.1 %) and 76.3% (n=196) of them were multiparous. The history of anti-D prophylaxis in previous pregnancies was obtained from the mothers and out of 191 mothers with a reliable history 51.3% (n=98) had not received anti-D prophylaxis. Intrauterine transfusion rate was 31.7 % (n=82). Twenty three of the newborns (8.8%) were hydropic at birth. Exchange transfusion was performed in 15% (n=40) of the newborns, 51.2 % of the newborns (n=133) had received phototherapy only and 33.5% of the patients (n=87) did not need either phototherapy or exchange transfusion. The mortality rate was 3.8%, 9 out of ten patients who died were hydropic.


Rhesus hemolytic disease is an ongoing problem in our country like other developing countries because of high rate of multiparity, low rate of anti-D immunglobulin prophylaxis and inappropriate antenatal care. The multiparity rate was high and almost half of the pregnant women had not received anti-D prophylaxis. Although it is a preventable disease in the presence of appropriate antenatal follow up and care facilities Rhesus hemolytic disease is still an important cause of neonatal mortality and morbidity.


Palistsiou S. 1, Boutsikou T. 2, Volaki P. 3, Bikouli D. 3, Kontogeorgou A. 4, Xanthos T. 5, Iacovidou N. 3

National and Kapodistrian University of Athens Greece, 2nd Deppartmetn of Obstetrics and Gynecology, Athens-Greece 1

Department of Neonatology, Department of Neonatology, Athens-Greece 2

National and Kapodistrian University of Athens Greece, Department of Neonatology, Athens-Greece 3

National and Kapodistrian University of Athens Greece, Department of Neonatologya, Athens-Greece 4

European University of Cyprus, Faculty of Medicine, Nicosia-Cyprus 5


In Greece Neonatal Life Support course (NLS) is organized by the Hellenic Society for Cardiorespiratory Resuscitation (HSCPR), based on the guidelines of the European Resuscitation Council (ERC). It aims at training in resuscitation healthcare professionals involved in perinatal care of the newborn. It is a one-day , 10-hour duration seminar and provides theoretical knowledge and technical skills to which they are tested in order to be certified. It is known from other life support seminars that theoretical knowledge and technical skills decline over time, but there are no data for the NLS seminar. Moreover, investigation of the levels of stress the seminar causes to the trainees and association as to how this may affect their performance during the seminar or in the ensuing period has not been reported.


To study the degree of theoretical knowledge and skill retention of newly certified NLS providers at 3 and 6 months after the seminar, and the investigation of the levels of stress the seminar causes to the trainees and association to how this may affect their performance during the seminar or in the ensuing period


68 newly certified NLS providers volunteered to participate after signing informed consent. Demographic data were recorded, the STAI I & II questionnaires were answered and theoretical knowledge and technical skills (airway opening, bag-mask ventilation, chest compressions) were evaluated on the day of the seminar, at 3 and 6 months later without preparation.


Significant difference was observed in the score of the written test (median at the end of the seminar was 86.0, at 3 and 6mths it was 80.0 p<.001). Regarding technical skills, at 3mths 100% of the study population performed correctly the first 5 lung inflation breaths of the algorithm for airway management and the 2-handed chest compression technique. At 6mths 100% of the participants still performed correctly the 5 lung inflation breaths. As to the selection of the 500ml self-inflating bag-and-mask for lung inflation, 80.5% and 90.2% at 3 and 6 mths respectively, did not perform correctly. In STAI I (evaluates anxiety from a specific situation) the median score was 41.0 in the baseline test, and 37.0 at 3 and 6mths with this difference being statistically significant (p=.042). In STAI II (evaluates anxiety as a personality trait) the median score was 37.0 at all times (p=.534)


The theoretical knowledge declines over time. In technical skills, the degree of retention varies. The stress level on individuals who are involved in neonatal resuscitation is increased during the seminar but decreases at 3 and 6 months. The idiosyncratic stress does not change between training and checking intervals.


Yasa B. 1, Gonen I. 1, Dincer E. 1, Babayigit A. 1, Saglam O. 1, Cetinkaya M. 1

Kanuni Sultan Suleyman Training and Research Hospital, Neonatology, Istanbul-Turkey 1


Delayed umbilical cord clamping for at least 30 seconds results with better neurological and hematological outcomes in term infants Umbilical cord milking has suggested being an alternative for delayed clamping. This study aimed to evaluate the effects of different umbilical cord milking techniques on hematological parameters in term neonates.


A total of 150 term neonates were included to this randomized controlled trial. Neonates were randomized to 5 groups of early cord clamping, delayed cord clamping for 60 seconds and 3 times / 4 times / 5 times umbilical cord milking. The newborn infant was hold at introitus level in vaginal deliveries and at mother’s leg level in cesarean deliveries. The umbilical cord was clamped 25 cm away from umbilicus. Hematological changes at 24th hours of life were the primary outcome and the development of hyperbilirubinemia, polycythemia or respiratory distress was assessed as the secondary outcomes.


The median gestational age and birth weights of neonates were 39 (37-40) weeks and 3280 (2140-4850) grams respectively. There were no significant differences in terms of umbilical cord hemoglobin (Hb) and hematocrit (Hct) levels (p>0.05) but Hb and Hct levels at 24th hours of life were significantly lower in early cord clamping group (p<0.05). Hb and Hct levels at 24th hour were significantly higher in delayed cord clamping and 4 times umbilical cord milking groups (p<0.05). All the hematological values were detailed in Table 1. There were no differences between groups in terms of hyperbilirubinemia, polycythemia and respiratory distress development.


To the best of our knowledge, this is the first study that evaluates different umbilical cord milking techniques on hematological parameters. Umbilical cord milking seems to be an effective alternative for delayed umbilical cord clamping that is independent from different techniques. Umbilical cord milking may be associated with better hematological parameters than early cord clamping.

Neonatology – Early origins of adult disease


Masuyama H. 1, Mitsui T. 1, Tamada S. 1, Maki J. 1, Tani K. 1, Eto E. 1, Hayata K. 1

Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Obstetrics and Gynecology, Okayama-Japan 1

The links between obesity in parents and their offspring and the role of genes and a shared environment are not completely understood. Adipocytokines such as leptin and adiponectin play important roles in glucose and lipid metabolism. Therefore, we examined whether the offspring from dams exposed to a high fat diet (HFD) during pregnancy (OH mice) exhibited hypertension, insulin resistance and hyperlipidemia along with epigenetic changes in the expression of adipocytokine genes. OH mice were significantly heavier than the offspring of dams exposed to a control diet during pregnancy (OC mice) from 14 weeks of age following an increased caloric intake from 8 weeks. OH mice exhibited higher blood pressure and worse glucose tolerance than the OC mice at 24 weeks. Total triglyceride and leptin levels were significantly higher and the adiponectin level was significantly lower in OH compared with OC mice at 12 weeks of age. This was associated with changes in leptin and adiponectin expression in white adipose tissue. There were lower acetylation and higher methylation levels of histone H3 at lysine 9 of the promoter of adiponectin in adipose tissues of OH mice at 2 weeks of age as well as at 12 and 24 weeks of age compared with OC mice. In contrast, methylation of histone 4 at lysine 20 in the leptin promoter was significantly higher in OH compared with OC mice. Thus, exposure to an HFD in utero might cause a metabolic syndrome-like phenomenon through epigenetic modifications of adipocytokine, adiponectin and leptin gene expressions.


Murano Y. 1, Shoji H. 2, Ikeda N. 2, Ohkawa N. 2, Hayashi K. 2, Shimizu T. 2, Guilmor S. 3

Toshima Hospital, Pediatrics, Tokyo-Japan 1

Juntendo Hospital, Pediatrics, Tokyo-Japan 2

St.luke International Hospital, Public Health, Tokyo-Japan 3


Since Barker et al. reported in 1986 that low birth weight infants are at risk of future cardiovascular diseases, many diseases have been reported to have an association with being born with low birth weight and are now established as components of the Development origin of health and disease (DOHaD) theory. Because of progress in neonatology, more immature infants are surviving their infant periods and mortality of them is decreasing. Although, this trend is associated with long-term negative health and development outcome, there are few reports about the possible future health consequences of their extremely premature birth. Previous studies mostly studied infants whose gestational age (GA) was over 30 weeks and few patients with less than 29 weeks of GA are included. Moreover, many studies do not analyze intrauterine growth restriction (IUGR), who has more effect on future development, separately.


To estimate body composition in preterm infants born less than 29 weeks of GA


Data source is Neonatal Research Network Japan (NRNJ) data, which includes 24244 infants born between GA 23-29 weeks and/or under 1500 grams. We analyzed BMI by GA, with interaction for IUGR, separately by gender and presence of multiple pregnancy, adjusting for complications during pregnancy and hospital stay (pregnancy induced hypertension (PIH), chronic lung disease (CLD), late circulatory collapse (LCC) intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC)), using a linear regression model.


A total of 19510 infants were born between 23 to 28 weeks of GA and eligible for this study. In single pregnancy, the effect of both IUGR and GA, and their interaction, and IVH were seen in BMI score at 18 and 36 months in boys. There were effects of IUGR and GA and their interaction and IVH, LCC in BMI at 18 and 36 months were seen in girls. However, in multiple pregnancies, there were no effect of IUGR in BMI at 18 and 36 months in both boys and girls. Among them, there were effects of GA and IVH in BMI both at 18 and 36 months.


It is no longer reasonable to discuss body composition without both gestational age and presence of IUGR in infants born at 23 to 28 weeks of GA. Moreover, presence of IVH is associated with reduced BMI in infants born at 23 to 28 weeks of GA.


This study revealed that in preterm infants born under 28 weeks of GA, GA is an important factor in future BMI, and presence of IUGR is important in single pregnancy infants.


Sifakis S. 1, Karzi V. 2, Katsikantami I. 2, Tzatzarakis M. 2, Velegrakis A. 3, Vakonaki E. 2, Stavroulaki A. 2, Xezonaki P. 1, Rizos A. 4, Tsatsakis A. 2

Mitera Maternity Hospital, , Heraklion-Greece 1

Medical School, University of Crete, Laboratory of Toxicology and Forensic Sciences, Heraklion-Greece 2

Venizeleio General Hospital, Department of Obstetrics and Gynecology, Heraklion-Greece 3 University of Crete and Foundation for Research and Technology – Hellas (forth-iesl), Department of Chemistry, Heraklion-Greece 4


In modern life, humans are exposed continuously to a wide variety of chemicals. The scientific community focuses on investigating the possible health impacts of this constant exposure. In this study we assess the prenatal exposure to endocrine disruptors, which are present in several everyday products, and correlate it with the health impacts of pregnant women and subsequently their infants.


Hair and amniotic fluid samples were collected during 1st or 2nd trimester of pregnancy. The participants also completed questionnaires concerning maternal and infants somatometric characteristics, lifestyle habits and health status. The samples were analyzed so as to estimate the burden of pregnant women to phthalate metabolites (mEP, miBP, mnBP, mBzP, mEHP, mEHHP, mEOHP), bisphenol A (BPA), bisphenol S (BPS), parabens (methyl-, ethyl-, butyl-, benzyl paraben) and triclosan.


Frequent use of cosmetics during or before pregnancy was associated with higher levels of phthalates metabolites in hair (p<0.05). At the same time, frequent use of makeup and hairspray, was also correlated with higher concentration levels of parabens in both hair (p=0.028 & 0.036) and amniotic fluid (p=0.020 for makeup products) as well as BPA in amniotic fluid (p=0.032 & 0.068). Statistical analysis of questionnaires’ data and experimental results indicated strong associations between mEHP concentrations in hair and low birth weight (p=0.021), while exposure to BPS was associated with increased body mass index of the participants (p=0.036). Finally, positive correlation was observed between benzyl paraben levels in hair and infants height (p=0.026).


Our results indicate that use of everyday products expose humans to a wide range of chemicals which pose risks for their health. Further studies need to be conducted in order to clarify these health impacts.


Tsekoura E. 1

Asklepieion General Hospital Paediatrics, Developmental, Athens-Greece 1


Neurodevelopmental outcome of extremely and very preterm neonates beyond early life remains a public health issue of major interest. A high percentage of these children, when they reach school age, will have Autistic Spectrum Disorders (ASDs), Attention Deficit Hyperactivity Disorder (ADHD), Specific Learning Difficulties (SLDs) and other Behavioral Disorders such as internalizing and externalizing disorder. Perinatal infection, head scan anomalies and ART techniques considered perinatal risk factors of adverse outcome.


We aimed to detect the incidence of neurodevelopmental disorders observed in a group of extremely and very preterm children up to school age, and analyze associated risk factors such as perinatal infection, head scan anomalies and ART techniques.


We retrospectively analyzed medical records of preterm children <=29 wks GA up to 23 wks GA, from the data base system of our preterm follow up program as they were referred from private and NHS NICUs. We focused on the incidence of ADHD, ASD, SLDs and motor disturbances in relation to perinatal infection, head scan anomalies, ART techniques.


In total we included n=66 preterm children with GA <=29 wks. Mean age at evaluation was 70.85 months (SD 38.656 months). Autistic Spectrum Disorder diagnosed in 15.15%, ADHD in 48.48%, Specific Learning Difficulties in 33.33%, CP in 10.6% and Mental Retardation in 10.6%. Perinatal infection reported in 40.7 % of cases with adverse outcome and in 41.66 % of cases with no abnormal outcome. ART history reported in 80% (4/5) of children with typical ASD. Head scan anomalies of any severity had 42.42% of which 42.86% were subtle lesions. Abnormal head scan overall had 50% of cases with normal development and 40.7% of children with adverse outcome. Children with normal development walked at an earlier stage (14 months) compared to all children with abnormal outcome (17 months).


At school age 18.18% of preterm neonates <=29 wks GA will have no neurodevelopmental disabilities, while 81.81% will have a degree of ADHD and/ or SLDs. Perinatal infection in recorded in equal percentages in children with and without abnormality. ART techniques reported more frequently in typical ASD cases. Head scan cannot be used as a strong biomarker for outcome, regarding ADHD and SLDs cases, since half children with normal development had head scan anomalies, while 40% and 60% of children with ADHD and SLDs respectively had normal head scans. Generally gross motor immaturity, characterized as delayed age of independent walking, could be used as biomarker strongly associated with adverse outcome.

Published Online: 2019-09-07
Published in Print: 2019-09-25

© 2019 Walter de Gruyter GmbH, Berlin/Boston

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