1.
Lung ultrasound and computed tomographic findings in pregnant woman with COVID‐19
Kalafat, E.; Yaprak, E.; Cinar, G. ...
Ultrasound in obstetrics & gynecology,
June 2020, 2020-06-00, 20200601, Volume:
55, Issue:
6
Journal Article
ABSTRACT
Imaging modalities play a crucial role in the management of suspected COVID‐19 patients. Before reverse transcription polymerase chain reaction (RT‐PCR) test results are positive, 60–93% of ...
patients have positive chest computed tomographic (CT) findings consistent with COVID‐19. We report a case of positive lung ultrasound findings consistent with COVID‐19 in a woman with an initially negative RT‐PCR result. The lung ultrasound‐imaging findings were present between the negative and subsequent positive RT‐PCR tests and correlated with CT findings. The point‐of‐care lung‐ultrasound examination was easy to perform and, as such, could play an important role in the triage of women with suspected COVID‐19. The neonatal swabs, cord blood and placental swab RT‐PCR tests were negative for SARS‐CoV‐2, a finding consistent with the published literature suggesting no vertical transmission of this virus in pregnant women. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
more
2.
3.
Incidence of postpartum hypertension within 2 years of a pregnancy complicated by pre‐eclampsia: a systematic review and meta‐analysis
Giorgione, V; Ridder, A; Kalafat, E ...
BJOG,
February 2021, 2021-02-00, 20210201, Volume:
128, Issue:
3
Journal Article
Background
Women with a history of hypertensive disorders of pregnancy (HDP) are at increased long‐term risk of cardiovascular disease. However, there has been increasing evidence on the same risks ...
in the months following birth.
Objectives
This review aims to estimate the incidence of hypertension in the first 2 years after HDP.
Search strategy
MEDLINE, Embase and Cochrane databases were systematically searched in October 2019.
Selection criteria
Observational studies comparing hypertension rate following HDP and normotensive pregnancies up to 2 years.
Data collection and analysis
A meta‐analysis to calculate the odds ratio (OR) with a 95% confidence interval (CI) and a sub‐group analysis excluding women with chronic hypertension were performed.
Main results
Hypertension was diagnosed within the first 2 years following pregnancy in 468/1646 (28.4%) and 584/6395 (9.1%) of the HDP and control groups, respectively (OR 6.28; 95% CI 4.18–9.43; I2 = 56%). The risk of hypertension in HDP group was significantly higher in the first 6 months following delivery (OR 18.33; 95% CI 1.35–249.48; I2 = 84%) than at 6–12 months (OR 4.36; 95% CI 2.81–6.76; I2 = 56%) or between 1–2 years postpartum (OR 7.24; 95% CI 4.44–11.80; I2 = 9%). A sub‐group analysis demonstrated a similar increase in the risk of developing postpartum hypertension after HDP (OR 5.75; 95% CI 3.92–8.44; I2 = 49%) and pre‐eclampsia (OR 6.83; 95% CI 4.25–10.96; I2 = 53%).
Conclusions
The augmented risk of hypertension after HDP is highest in the early postpartum period, suggesting that diagnosis and targeted interventions to improve maternal cardiovascular health may need to be commenced in the immediate postpartum period.
Tweetable
The risk of hypertension within 2 years of birth is six‐fold higher in women who experienced pre‐eclampsia.
Tweetable
The risk of hypertension within 2 years of birth is six‐fold higher in women who experienced pre‐eclampsia.
This article includes Author Insights, a video available at https://vimeo.com/rcog/authorinsights16545
more
4.
Significance of placental cord insertion site in twin pregnancy
Kalafat, E.; Thilaganathan, B.; Papageorghiou, A. ...
Ultrasound in obstetrics & gynecology,
September 2018, 2018-Sep, 2018-09-00, 20180901, Volume:
52, Issue:
3
Journal Article
ABSTRACT
Objective
To investigate the association between abnormal cord insertion and the development of twin‐specific complications, including birth‐weight discordance, selective fetal growth ...
restriction (sFGR) and twin‐to‐twin transfusion syndrome (TTTS).
Methods
This was a single center retrospective cohort study of twin pregnancies. Abnormal cord insertion was defined as either marginal (umbilical cord attachment site less than 2 cm to the nearest margin of the placental disc) or velamentous (cord attached to the membrane before reaching the placental disc with clear evidence of vessels traversing the membranes to connect with the placental disc), as described in placental pathology reports. Twins with major structural or chromosomal abnormalities and monochorionic monoamniotic twins were not included in the study. Information on the pregnancies, ultrasound findings, prenatal investigations and interventions was obtained from the electronic ultrasound database, while data on placental histopathological findings, pregnancy outcome, mode of delivery, birth weight, gestational age at delivery and admission to the neonatal intensive care unit were obtained from maternity records. Categorical variables were compared using the chi‐square or Fisher's exact test, while continuous variables were compared using the Student's t‐test, ANOVA for multiple comparisons and the Kruskal–Wallis test.
Results
Of the 497 twin pregnancies included in the analysis, 351 (70.6%) were dichorionic and 146 (29.4%) were monochorionic. The incidence of birth‐weight discordance of 25% or more was significantly higher in pregnancies with velamentous and those with marginal cord insertions compared to those with normal cord insertion (24.0%, 15.3% vs 7.6%, P < 0.001 and P = 0.020, respectively). In pregnancies with birth‐weight discordance of 25% or more, the smaller twins had significantly higher prevalence of velamentous (13.8%) and marginal (34.2%) cord insertions compared with the larger twins (1.8% and 18.5%, respectively, P < 0.001). The smaller twins of the monochorionic diamniotic pregnancies showed an even higher prevalence of velamentous (29.5%) and marginal (40.9%) cord insertions compared with the larger twins (2.3% and 31.5%, respectively, P < 0.001). Compared with the normal cord insertion group, only velamentous insertion was associated significantly with the risk of sFGR (odds ratio (OR), 9.24 (95% CI, 2.05–58.84), P < 0.001) and birth‐weight discordance of 20% or more (OR, 4.34 (95% CI, 1.36–14.61), P = 0.007) and 25% or more (OR, 6.81 (95% CI, 1.67–34.12), P = 0.003) in monochorionic twin pregnancies. There was no significant association between velamentous cord insertion and TTTS (P = 0.591), or between marginal cord insertion and the development of sFGR (P = 0.233), birth‐weight discordance of 25% or more (P = 0.114) or TTTS (P = 0.487). Subgroup analysis of dichorionic twins showed that abnormal cord insertion was not associated with the risk of birth‐weight discordance (P = 0.999), sFGR (P = 0.308), composite neonatal adverse outcome (P = 0.637) or intrauterine death (P = 0.349).
Conclusion
Monochorionic twins with velamentous cord insertion are at increased risk of birth‐weight discordance and sFGR. Sonographic delineation of placental cord insertion could be of value in the antenatal stratification of twin pregnancies. Prospective studies are required to assess the value and predictive accuracy of this potential screening marker. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
more
5.
6.
Metformin for prevention of hypertensive disorders of pregnancy in women with gestational diabetes or obesity: systematic review and meta‐analysis of randomized trials
Kalafat, E.; Sukur, Y. E.; Abdi, A. ...
Ultrasound in obstetrics & gynecology,
December 2018, 2018-Dec, 2018-12-00, 20181201, Volume:
52, Issue:
6
Journal Article
ABSTRACT
Objective
Metformin has been reported to reduce the risk of pre‐eclampsia. It is also known to influence soluble fms‐like tyrosine kinase‐1 level, which correlates significantly with the ...
gestational age at onset and severity of pre‐eclampsia. The main aim of this systematic review and meta‐analysis of randomized trials was to determine whether metformin use is associated with the incidence of hypertensive disorders of pregnancy (HDP).
Methods
MEDLINE (1947 to September 2017), Scopus (1970 to September 2017) and the Cochrane Library (inception to September 2017) were searched for relevant citations in the English language. Only randomized controlled trials on metformin use, reporting the incidence of pre‐eclampsia or pregnancy‐induced hypertension, were included. Studies on populations with a high probability of metformin use prior to randomization (those with type II diabetes or polycystic ovary syndrome) were excluded. Random‐effects models with the Mantel–Haenszel method were used for subgroup analyses. Bayesian random‐effects meta‐regression was used to summarize the evidence.
Results
In total, 3337 citations matched the search criteria. After evaluating 2536 s and performing full‐text review of 52 studies, 15 were included in the review. In women with gestational diabetes, metformin use was associated with a reduced risk of pregnancy‐induced hypertension when compared with insulin (relative risk (RR), 0.56; 95% CI, 0.37–0.85; I2 = 0%; 1260 women) and a non‐significantly reduced risk of pre‐eclampsia (RR, 0.83; 95% CI, 0.60–1.14; I2 = 0%; 1724 women). In obese women, when compared with placebo, metformin use was associated with a non‐significant reduction in risk of pre‐eclampsia (RR, 0.74; 95% CI, 0.09–6.28; I2 = 86%; 840 women). In women with gestational diabetes, metformin use was also associated with a non‐significant reduction in risk of any HDP (RR, 0.71; 95% CI, 0.41–1.25; I2 = 0%; 556 women) when compared with glyburide. When studies were combined using Bayesian random‐effects meta‐regression, with treatment type as a covariate, the posterior probabilities of metformin having a beneficial effect on the prevention of pre‐eclampsia, pregnancy‐induced hypertension and any HDP were 92.7%, 92.8% and 99.2%, respectively, when compared with any other treatment or placebo.
Conclusions
There is a high probability that metformin use is associated with reduced HDP incidence when compared with other treatments or placebo. The small number of studies included in the analysis, the low quality of evidence and the clinical heterogeneity preclude generalization of these results to broader populations. Given the clinical importance of this topic and the magnitude of effect observed in this meta‐analysis, further prospective trials are urgently needed. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
RESUMEN
La metformina para la prevención de los trastornos hipertensivos del embarazo en mujeres con diabetes gestacional u obesidad: revisión sistemática y metaanálisis de ensayos aleatorizados
Objectivo
Se ha informado que la metformina reduce el riesgo de preeclampsia. También se sabe que influye en el nivel de la tirosina quinasa 1 soluble similar a la fms, que está correlacionada significativamente con la edad gestacional al comienzo de la preeclampsia y su gravedad. El objetivo principal de esta revisión sistemática y del metaanálisis de los ensayos aleatorizados fue determinar si el uso de metformina está asociado con la incidencia de trastornos hipertensivos del embarazo (THE).
Se realizaron búsquedas en MEDLINE (desde 1947 a septiembre de 2017), Scopus (desde 1970 a septiembre de 2017) y en la Cochrane Library (desde el inicio hasta septiembre de 2017) para encontrar citas bibliográficas relevantes en inglés. Sólo se incluyeron ensayos controlados aleatorizados sobre el uso de metformina que informaron sobre la prevalencia de la preeclampsia o la hipertensión inducida por el embarazo. Se excluyeron los estudios sobre poblaciones con una alta probabilidad de uso de metformina antes de la aleatorización (poblaciones con diabetes mellitus o síndrome de ovario poliquístico). Para los análisis de subgrupos se utilizaron modelos de efectos aleatorios mediante el método de Mantel‐Haenszel. Se utilizó la metarregresión de efectos aleatorios bayesiana para resumir las pruebas.
Resultados
En total, 3337 citas bibliográficas cumplieron los criterios de búsqueda. Después de evaluar 2536 resúmenes y realizar una revisión del texto completo de 52 estudios, se incluyeron 15 en la revisión. En las mujeres con diabetes gestacional, el uso de metformina se asoció con un menor riesgo de hipertensión inducida por el embarazo en comparación con la insulina (riesgo relativo (RR), 0,56; IC 95%: 0,37–0,85; I2 =0%; 1260 mujeres) y un riesgo de preeclampsia no reducido significativamente (RR, 0,83; IC 95%: 0,60–1,14; I2 =0%; 1724 mujeres). En las mujeres obesas, en comparación con el placebo, el uso de metformina se asoció con una reducción no significativa del riesgo de preeclampsia (RR, 0,74; IC 95%: 0,09–6,28; I2 =86%; 840 mujeres). En las mujeres con diabetes gestacional, el uso de metformina se asoció también con una reducción no significativa del riesgo de cualquier THE (RR, 0,71; IC 95%: 0,41–1,25; I2 =0%; 556 mujeres) en comparación con la glibenclamida. Cuando los estudios se combinaron mediante la metarregresión de efectos aleatorios bayesiana, con el tipo de tratamiento como covariable, las probabilidades posteriores de que la metformina tuviera un efecto beneficioso sobre la prevención de la preeclampsia, la hipertensión inducida por el embarazo y cualquier THE fueron del 92,7%, 92,8% y 99,2%, respectivamente, en comparación con cualquier otro tratamiento o placebo.
Conclusiones
Existe una alta probabilidad de que el uso de la metformina esté asociado con una menor incidencia de los THE, en comparación con otros tratamientos o placebos. El pequeño número de estudios incluidos en el análisis, la baja calidad de la evidencia y la heterogeneidad clínica impiden la generalización de estos resultados a poblaciones más amplias. Dada la importancia clínica de este tema y la magnitud del efecto observado en este metaanálisis, hacen falta urgentemente ensayos adicionales. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
摘要
妊娠期糖尿病或肥胖孕妇中二甲双胍预防妊娠期高血压疾病:随机试验的系统评价和meta分析
目的
已有研究报道二甲双胍能够降低子痫前期的风险,还能影响可溶性fms样酪氨酸激酶1的水平,其与子痫前期的发病孕周和严重程度明显相关。本文对随机试验进行了系统评价和meta分析,主要目的是检测二甲双胍是否与妊娠期高血压疾病(hypertensive disorders of pregnancy,HDP)的发病率有关。
方法
检索MEDLINE(1947年至2017年9月)、Scopus(1970年至2017年9月)、Cochrane Library(建库至2017年9月),查找相关文献,语种为英文。仅纳入应用二甲双胍、报道子痫前期或妊娠期高血压发病率的随机对照试验。排除随机分组前很可能服用二甲双胍的人群(2型糖尿病或多囊卵巢综合征患者)的研究。采用随机效应模型,应用Mantel‐Haenszel方法进行亚组分析。采用Bayesian随机效应meta回归总结证据。
结果
共3337篇文献符合检索条件。评价2536条摘要并浏览52项研究的全文,本篇综述纳入15项研究。在妊娠期糖尿病孕妇中,与使用胰岛素相比,使用二甲双胍能够降低妊娠期高血压风险相对危险度relative risk,RR,0.56;95% CI,0.37~0.85;I2=0%;1260例孕妇,但子痫前期风险未明显降低(RR,0.83;95% CI,0.60~1.14;I2=0%;1724例孕妇)。肥胖孕妇中,与使用安慰剂相比,使用二甲双胍子痫前期风险未明显降低(RR,0.74;95% CI,0.09~6.28;I2=86%;840例孕妇)。妊娠期糖尿病孕妇中,与使用格列本脲相比,使用二甲双胍也未使HDP风险明显降低(RR,0.71;95% CI,0.41~1.25;I2=0%;556例孕妇)。采用Bayesian随机效应meta回归将研究合并,将治疗类型作为一个协变量,与其他治疗或安慰剂相比,二甲双胍对预防子痫前期、妊娠期高血压以及HDP有益的后验概率分别为92.7%、92.8%和99.2%。
结论
与其他治疗或安慰相比,二甲双胍很可能与HDP发病率降低有关。分析中纳入研究数量较少、证据质量较低以及临床异质性,使得这些结果不能普遍用于更广泛的人群。由于这一论题对于临床十分重要以及本篇meta分析中所见的影响程度,急需进行进一步的前瞻性试验。
This article's has been translated into Spanish and Chinese. Follow the links from the to view the translations.
more
7.
Prediction of adverse pregnancy outcome in monochorionic diamniotic twin pregnancy complicated by selective fetal growth restriction
Monaghan, C.; Kalafat, E.; Binder, J. ...
Ultrasound in obstetrics & gynecology,
February 2019, 2019-02-00, 20190201, Volume:
53, Issue:
2
Journal Article
ABSTRACT
Objective
To identify key factors associated with adverse perinatal outcome in monochorionic diamniotic twin pregnancy complicated by selective fetal growth restriction (sFGR).
Methods
This ...
was a retrospective cohort study of all monochorionic diamniotic twin pregnancies diagnosed with sFGR at ≥ 16 weeks' gestation, in a single tertiary referral center between March 2000 and May 2015. The presence of coexisting twin–twin transfusion syndrome (TTTS) was noted. Fetal biometry and Doppler indices, including those of the umbilical artery (UA) and ductus venosus (DV), were recorded at the time of diagnosis. The type of sFGR was diagnosed according to the pattern of end‐diastolic flow in the UA of the smaller twin. DV pulsatility indices for veins (DV‐PIV) were converted to Z‐scores and estimated fetal weight values to centiles, to correct for gestational age (GA). Cox proportional hazards model was used to examine for independent predictors of adverse perinatal outcome, which was defined according to survival and included both intrauterine fetal demise and neonatal death of the FGR twin.
Results
We analyzed 104 pregnancies, of which 66 (63.5%) were diagnosed with Type‐I and 38 (36.5%) with Type‐II sFGR at initial presentation. In pregnancies complicated by Type‐II sFGR, the diagnosis of sFGR was made earlier than in those complicated by Type‐I sFGR (mediam GA, 19.6 vs 21.5 weeks; P = 0.012), and Type‐II sFGR was associated with increased risk of adverse perinatal outcome (intrauterine demise of the smaller twin, 34.2% vs 10.6%; P = 0.004). Twin pregnancies complicated by sFGR resulting in perinatal demise had a significantly earlier diagnosis (P = 0.002) and lower birth‐weight centile of the smaller twin (P < 0.01), those with Type‐I sFGR had earlier GA at delivery (P = 0.007) and those with Type‐II sFGR had higher DV‐PIV Z‐score of the smaller twin (P = 0.003), when compared with pregnancies resulting in live birth. Coexisting TTTS had no significant impact on the perinatal outcome of pregnancies diagnosed with either Type‐I or Type‐II sFGR (P > 0.05 for both). Earlier GA at diagnosis (hazard ratio (HR), 0.70 (95% CI, 0.56–0.88); P = 0.002), Type‐II sFGR (HR, 3.53 (95% CI, 1.37–9.07); P = 0.008) and higher DV‐PIV Z‐score (HR, 1.36 (95% CI, 1.12–1.65); P = 0.001) were significantly associated with increased risk of adverse perinatal outcome of the smaller twin.
Conclusions
Pregnancies complicated by Type‐II sFGR are diagnosed significantly earlier and are associated with increased risk of adverse perinatal outcome compared with those with Type‐I sFGR. Coexisting TTTS has no significant impact on the perinatal outcome of pregnancies diagnosed with either Type‐I or Type‐II sFGR. Earlier GA at diagnosis, Type‐II sFGR and higher DV‐PIV Z‐score are associated significantly with increased risk of adverse perinatal outcome of the smaller twin. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
more
8.
9.
10.
Should angiogenic markers be included in diagnostic criteria of superimposed pre‐eclampsia in women with chronic hypertension?
Binder, J.; Kalafat, E.; Palmrich, P. ...
Ultrasound in obstetrics & gynecology,
February 2022, 2022-Feb, 2022-02-00, 20220201, Volume:
59, Issue:
2
Journal Article
ABSTRACT
Objective
Although the most recent guidance from the International Society for the Study of Hypertension in Pregnancy (ISSHP) has highlighted the role of angiogenic marker assessment in the ...
diagnosis of pre‐eclampsia (PE) in women with chronic hypertension, the ISSHP has withheld recommending its implementation due to the limited available evidence in this group of women. Therefore, we aimed to investigate the value of soluble fms‐like tyrosine kinase‐1 (sFlt‐1) and placental growth factor (PlGF) assessment in women with chronic hypertension and suspected superimposed PE.
Methods
This was a retrospective analysis of prospectively collected data recorded in an electronic database between January 2013 and October 2019. Women with chronic hypertension and singleton pregnancy who had suspected superimposed PE were included. Superimposed PE was suspected in women presenting with worsening hypertension, epigastric pain, new‐onset edema, dyspnea or neurological symptoms. The exclusion criteria were delivery within 1 week after assessment for reasons other than PE, chronic kidney disease, history of cardiac disease, fetal aneuploidy, genetic syndrome or major structural anomaly and missing pregnancy outcome. Maternal serum angiogenic markers (sFlt‐1, PlGF and sFlt‐1/PlGF ratio) were measured. The primary outcome was the utility of angiogenic markers in the prediction of superimposed PE. Predictive accuracy was assessed for superimposed PE diagnosed at different timepoints, including within 1 week after assessment and any time before birth. The secondary outcome was comparison of adverse maternal and perinatal outcomes between women with superimposed PE diagnosed according to the traditional ISSHP criteria and those diagnosed according to extended criteria including angiogenic markers. The predictive accuracy of each angiogenic marker was assessed using receiver‐operating‐characteristics‐curve analysis. Area under the curve (AUC) values were compared using De Long's test. A sensitivity analysis was planned for gestational age at assessment. The association of various variables with composite adverse maternal and perinatal outcomes was assessed using binomial regression.
Results
The study included 142 pregnant women with chronic hypertension and suspected superimposed PE, of whom 25 (17.6%) developed PE within 1 week after assessment, 52 (36.6%) developed PE at any timepoint before birth and 90 (63.4%) delivered without PE. Maternal serum angiogenic imbalance was associated significantly with superimposed PE diagnosed according to the ISSHP criteria within 1 week or at any time after assessment (P < 0.001 for both). The predictive accuracy of maternal serum sFlt‐1/PlGF ratio for superimposed PE diagnosed within 1 week after assessment was superior to that of maternal serum PlGF level (AUC, 0.91 vs 0.86; P = 0.032). The addition of angiogenic imbalance to the traditional ISSHP diagnostic criteria was associated with an increase in the detection rate (35.1% increase; 95% credible interval (CrI), 16.6–53.6%) and positive (9.6% increase; 95% CrI, 0.0–20.6%) and negative (3.1% increase; 95% CrI, 1.3–4.9%) predictive values for composite adverse maternal outcome, with high posterior probabilities of an increase in each predictive accuracy parameter (> 99.9%, 95.6% and > 99.9%, respectively), without a meaningful decrease in specificity. The addition of angiogenic imbalance improved the detection rate for composite adverse perinatal outcome (20.6% increase; 95% CrI, 0.0–42.2%), with a high posterior probability (96.9%). There was a corresponding drop in specificity (5.7% decrease; 95% CrI, −2.3% to 13.6%), with a posterior probability of 91.8%.
Conclusions
In women with chronic hypertension and suspected superimposed PE, addition of maternal serum angiogenic markers to the traditional diagnostic criteria for superimposed PE improved significantly the sensitivity for the prediction of both maternal and perinatal adverse outcomes. Implementation of angiogenic marker assessment in the evaluation of pregnant women with chronic hypertension should therefore be considered. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
more
PDF
