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Papers by stefania fieni

Research paper thumbnail of Antepartum amnioinfusion: a review

The Journal of Maternal-Fetal & Neonatal Medicine, 2003

Antepartum amnioinfusion is a relatively recent procedure introduced with fetal medicine techniqu... more Antepartum amnioinfusion is a relatively recent procedure introduced with fetal medicine techniques. It is usually indicated for severe oligohydramnios in order to avoid the related complications such as pulmonary hypoplasia, the deforming effects of oligohydramnios, variable fetal heart rate decelerations and intraventricular hemorrhage. Antepartum amnioinfusion is also employed to improve ultrasound visualization in cases with oligohydramnios. Our objective was to evaluate the benefits and complications related to this procedure which is still less commonly used compared to intrapartum amnioinfusion, and whose risks are therefore not well established. Reports of study designs identified from searches of MEDLINE, PUBMED, the Cochrane Collaboration, specialized databases and bibliographies of review articles were identified. Studies in women who underwent amnioinfusion between 1987 and 2002 were included. Amnioinfusion seems to offer several benefits, in terms of both prenatal diagnosis and favorable perinatal outcome. Most clinical experiences report that amnioinfusion is safe, both for the mother and for the fetus. However, randomized control-group studies subdivided on the basis of the cause of oligohydramnios (e.g. premature rupture of membranes, fetal growth restriction, obstructive uropathy and renal agenesis) could help to determine the advantages and risks linked to this procedure. Prospective randomized studies should therefore be encouraged, to clarify any possible doubts regarding the procedure, before it can be introduced into routine practice in the management of oligohydramnios.

Research paper thumbnail of P226: Normalization of middle cerebral artery flow velocity before fetal death: what is its real meaning?

Ultrasound in Obstetrics and Gynecology, 2003

Poster abstracts Methods: The hepatic and umbilical venous systems were examined in 390 fetuses i... more Poster abstracts Methods: The hepatic and umbilical venous systems were examined in 390 fetuses in a prospective study using two dimensional (2D) ultrasonography, color, and spectral Doppler. Fetuses suspected to have ductus venosus anomalies were additionally examined with 3D power Doppler ultrasonography. Results: Eight fetuses with venous abnormalities (absent ductus venosus n = 4, direct connection between the umbilical vein and the right atrium n = 2, and direct connection between the umbilical vein and the inferior vena cava n = 2) were detected among the 310 (Incidence 2.6%) in which the venous system could be visualized. Three-dimensional power Doppler accurately showed the course of the umbilical vein, its relationship to the porto-systemic circulation, and whether a ductus venosus was present or absent. Conclusions: 3D power Doppler ultrasonography has the potential to improve the diagnostic accuracy and differentiation between distinct types of malformations of the fetal porto-systemic and umbilical venous system.

Research paper thumbnail of Amniotic fluid index versus largest vertical pocket in the prediction of perinatal outcome in post-term pregnancies

Acta bio-medica : Atenei Parmensis, 2004

We studied a cohort of 41 singleton pregnancies induced at term with prostaglandins and, when nec... more We studied a cohort of 41 singleton pregnancies induced at term with prostaglandins and, when necessary, oxytocin. We evaluated with ultrasound the amniotic fluid index (AFI) and the largest vertical pocket (LVP), at least 2 days before the delivery, to compare the sonographic measurement of amniotic fluid with fetal distress and perinatal outcome. We analysed the incidence of fetal distress using intrapartum monitoring of fetal heart rate, considering the absence of variability, the presence of persistent severe variable and/or late decelerations. The oligohydramnios group, indipendently by ultrasound index, showed the same incidence of abnormal FHR, and rate of Cesarean section for fetal distress as the group with normal amniotic fluid. In conclusion there is no significant difference between the group of patients with oligohydramnios and the one with normal amniotic fluid regarding the perinatal outcome in induced labor.

Research paper thumbnail of Amnioreduction for treatment of severe polyhydramnios

Acta bio-medica : Atenei Parmensis, 2004

Between January 2000 and March 2003 we studied the pregnancies complicated by polyhydramnios in 1... more Between January 2000 and March 2003 we studied the pregnancies complicated by polyhydramnios in 10 patients. The objective was that of evaluating the efficacy of amnioreduction in improving the principal complications given by polyhydramnios such as maternal dyspnea and uterine activity. Our results showed that this procedure resolve maternal symptoms in all the cases but there is no significant reduction in uterine activity.

Research paper thumbnail of Twin-twin transfusion syndrome: a review of treatment option

Acta bio-medica : Atenei Parmensis, 2004

The twin-twin transfusion syndrome (TTTS) is a complication of monozygotic-monochorionic twinning... more The twin-twin transfusion syndrome (TTTS) is a complication of monozygotic-monochorionic twinning and is a direct result of transplacental communication between the circulations of twins. When acute TTTS occurs in the second trimester, the perinatal mortality can be as high as 95% in the absence of treatment. For this reason, several aggressive, even desperate treatment modalities have been attempted including selective fetocide, umbilical cord ligation, maternal digoxin therapy. None have gained wide acceptance. Serial drainage amniocentesis or amnioreduction is actually the most widely used therapy. More recently, laser ablation under fetoscopic guidance of placental vessel has been reported in an attempt to improve survival. The objective of this review was to evaluate the impact of treatment modalities in TTTS. Reports of prospective and retrospective trials and other study designs in English identified from searches of MEDLINE, EMBASE, specialized databases, bibliographies of r...

Research paper thumbnail of Early complications of prenatal invasive diagnostics: perspective analysis

Acta bio-medica : Atenei Parmensis, 2004

In this retrospective analysis we studied 1489 women who underwent prenatal invasive diagnostic p... more In this retrospective analysis we studied 1489 women who underwent prenatal invasive diagnostic procedures between January 2000 and December 2002. We examine the influence of risk factors and the incidence of early complications following amniocentesis and chorion villus sampling, in particular the incidence of fetal loss. The study group included 438 women who underwent CVS and 1051 underwent amniocentesis. For each woman we studied anamnestic risk factors (recurrent pregnancy losses, fibroids, twin birth, uterine hematic loss), intraoperative risk factors (repetition of the insertion, transplacental sample, hematic liquid, early bleeding) and postoperative risk factors (pelvic pain, hematic losses, liquid losses, spastic pain, fever). In our data the miscarriage incidence was 1% for CVS and 1.7% for amniocentesis. Our results showed that in relation to CVS, the presence of fibroids gives an OR of miscarriage of 68 (95% C.I.=6.50-659.78; p=0.000). In relation to amniocentesis, the ...

Research paper thumbnail of Amniotic fluid dynamics

Acta bio-medica : Atenei Parmensis, 2004

Amniotic fluid was once considered to be a stagnant pool, approximately circulating with a turnov... more Amniotic fluid was once considered to be a stagnant pool, approximately circulating with a turnover time of one day. Adequate amniotic fluid volume is maintained by a balance of fetal fluid production (lung liquid and urine) and resorption (swallowing and intramembranous flow). Even though different hypotheses have been advanced on the mechanisms regulating this turnover, the inflow and outflow mechanism that keeps amniotic fluid volume within the normal range is not entirely clear. Regulatory mechanisms act at three levels: placental control of water and solute transfer; regulation of inflows and outflows from the fetus; and, maternal effect on fetal fluid balance. Amniotic fluid is 98-99% water. The chemical composition of its substances varies with gestational age. When fetal urine begins to enter the amniotic sac, amniotic osmolarity decreases slightly compared with fetal blood. After keratinization of the fetal skin, amniotic fluid osmolarity decreases further with advancing ge...

Research paper thumbnail of Prelabour rupture of the membranes: recent evidence

Acta bio-medica : Atenei Parmensis, 2004

Premature rupture of the membranes (PROM) complicates 10% of all gestations and 2-4% of preterm p... more Premature rupture of the membranes (PROM) complicates 10% of all gestations and 2-4% of preterm pregnancy. Our success in preventing preterm PROM and preterm birth is hampered by our limited knowledge of its etiology. PROM remains the single most identifiable cause of preterm delivery and the major contributor to perinatal morbidity and mortality. Its clinical management continues to be controversial. The management dilemma associated with preterm PROM (PPROM) involves a balance between expectant management and intervention, taking into consideration the risks of infection with the increased duration of membrane rupture. Recent evidence on the use of antibiotics and amnioinfusion, together with advances in the prediction, diagnosis and estimation of risk based upon occupational factors and genetics have provided additional therapeutic tools in our approach to the problem of PPROM. While PPROM at very early gestation is a serious complication and a major management dilemma often asso...

Research paper thumbnail of Sonographic assessment of amniotic fluid volume between 11 and 24 weeks of gestation: construction of reference intervals related to gestational age

Ultrasound in Obstetrics and Gynecology, 2001

Objective At present, most of the methods for sonographic assessment of amniotic fluid volume are... more Objective At present, most of the methods for sonographic assessment of amniotic fluid volume are unreliable in the second trimester of pregnancy, or else they do not present nomograms related to gestational age. Design The aim of this prospective cross-sectional study was to construct normal reference ranges of four ultrasound parameters for the evaluation of amniotic fluid volume which could be applied in the second trimester. For these parameters we calculated normal curve limits suitable for use in clinical practice. Subjects From a population of normal pregnant women between the 12th and the 24th weeks of gestation undergoing a routine ultrasound examination during 1997 at our institute, 273 were found to be suitable for the study, after the exclusion of all cases which presented any feto-maternal pathology or complications up to the 24th week. Methods The largest 'amniotic pocket' in a vertical direction, free of small fetal parts and umbilical cord, was measured: the maximum vertical and transverse diameters were measured on the same scan; the mean diameter and the product of the two diameters were calculated. The 'mean amniotic fluid diameter', the 'two-diameter pocket', the 'largest vertical pocket' and the 'largest transverse pocket' were the four sonographic parameters considered. Results The four parameters correlated well with gestational week and with the biparietal diameter; the normal reference intervals and normal curve were then calculated. All these parameters were found to have good intra-and interoperative reproducibility. Conclusions We conclude that the use of an ultrasound semiquantitative method based on the measurement of a single amniotic fluid pocket and involving normal reference intervals according to gestational age could improve the early diagnosis of amniotic fluid variations during the second trimester, although this has yet to be confirmed by extensive clinical trials.

Research paper thumbnail of P14.84: Fetal pyelectasis and prediction of post-natal renal abnormalities

Ultrasound in Obstetrics and Gynecology, 2004

To examine the underlying pathology in male fetuses with sonographic evidence of severe and isola... more To examine the underlying pathology in male fetuses with sonographic evidence of severe and isolated LUTO. Methods: Detailed postmortem examination was carried out after termination of pregnancy in 24 male fetuses presenting before 25 weeks of gestation with ultrasound evidence of isolated severe low urinary tract obstruction. Results: Gender was male in all cases. There was megacystis and hyperechogenic kidneys in all cases. There was anhydramnios/oligohydramnios and pelvicalyceal dilatation in 20 and 15 cases respectively. Prenatal diagnosis of the underlying condition was erroneous in 2/3 of the cases. Urethral atresia was never suspected antenatally. Examination of the urethra demonstrated atresia in 6 cases, severe stenosis in 8 cases, posterior urethral valves in 9 cases and an apparently normal urethra in one. Renal dysplasia was found in all cases but one. Urethral atresia was the most common urethral anomaly at 12-17 weeks. Hydronephrosis was more frequent in cases with PUV (8/9) and urethral stenosis (6/8) than with urethral atresia (1/6). In LUTO presenting before 25 weeks hyperechogenic kidneys was predictive of renal dysplasia in 95% of the cases. The association of a bladder larger diameter of more than 40 mm and hydronephrosis in a male fetus before 25 weeks was predictive of PUV with a PPV and NPV of 44% and 100% respectively. Absence of hydronephrosis and a bladder larger diameter of less (or equal) than 40 mm were predictive of urethral atresia or stenosis with a PPV and NPV of 83% and 57% respectively. Conclusion: LUTO presenting with megacystis in a male fetus in the first and second trimester can correspond to urethral atresia or stenosis more often than posterior urethral valves. Since the formers carry a poor prognosis size of the bladder and the presence of hydronephrosis could be the most discriminant association to improve prenatal counselling.

Research paper thumbnail of Mid-trimester amniocentesis and antibiotic prophylaxis

Prenatal Diagnosis, 2007

Assuming that the rate of fetal loss after amniocentesis may be reduced in patients receiving ant... more Assuming that the rate of fetal loss after amniocentesis may be reduced in patients receiving antibiotic prophylaxis, we conducted a retrospective study on untreated versus treated patients receiving prophylactic antibiotics (amoxicillin/clavulanic-acid or azithromycin) and evaluated the fetal loss rate within the 22nd week of gestation, also with respect to the risk of spontaneous abortion, both preexisting and related to mid-trimester amniocentesis. Spontaneous abortion occurred in 22 cases out of 1744 (1.26%). The incidence of spontaneous abortion was 1.3% among patients treated with antibiotic prophylaxis and 1.2% among untreated patients. Between patients with risk factors that predated amniocentesis, the spontaneous fetal loss rate was 9.2% in untreated patients versus 2.3% in patients treated (p = 0.10). In patients with procedure-related risk factors at amniocentesis, the spontaneous abortion rate was, respectively, 2.2 and 1.2% (p = 0.72). Our data demonstrate that antibiotic prophylaxis does not reduce the risk of spontaneous abortion within the 22nd week of gestation. Compared with untreated patients, patients treated with amoxicillin showed the lower fetal loss rate (1.16 vs 0.31%), but the difference was not statistically significant (odds ratio (OR) = 3.68, p = 0.32). The same was true for patients with preexisting risks (OR = 4.25, p = 0.10).

Research paper thumbnail of Very-Early-Onset Discordant Growth in Monochorionic Twin Pregnancy

Obstetrics & Gynecology, 2004

Research paper thumbnail of Clinical Management of Paroxysmal Nocturnal Hemoglobinuria in Pregnancy: A Case Report and Updated Review

Obstetrical & Gynecological Survey, 2006

Because women with paroxysmal nocturnal hemoglobinuria (PNH) are especially vulnerable to thrombo... more Because women with paroxysmal nocturnal hemoglobinuria (PNH) are especially vulnerable to thromboembolic phenomena, pregnancy is a time of increased risk for both mother and fetus. However, pregnancies in affected women are rare; only case reports and small studies have been reported so far. We present the case of a 20-year-old woman with PNH who, while undergoing medical tests in preparation for a bone marrow transplant, was discovered to be pregnant. We also review the obstetric literature on pregnancy complicated by PNH, which indicates that both maternal and fetal mortality is exceptionally high (11.6% and 7.2%) with the major cause of maternal mortality being thromboembolism. Major maternal complications are more frequent postpartum (30.2%) than antepartum or intrapartum (16.3%). Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that paroxysmal nocturnal hemoglobinuria (PNH) during pregnancy increases adverse events for both the mother and the fetus, state that maternal and fetal mortality are both high, and explain that the major complications occur in the postpartum period. The authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to this educational activity. The authors have disclosed that eculizumab has not been approved by the U.S. Food and Drug Administration. Lippincott Continuing Medical Education Institute, Inc. has identified and resolved all faculty conflicts of interest regarding this educational activity.

Research paper thumbnail of Prenatal Diagnosis of Isolated Limb Defects: An Updated Review

Fetal Diagnosis and Therapy, 2005

Abnormalities of bone segments, either isolated or in combination with others, may affect any sin... more Abnormalities of bone segments, either isolated or in combination with others, may affect any single bone. Given the relatively low incidence of such defects and the relevance of the clinical issues involved, it could be useful to evaluate all the diagnostic and procedural aspects that should be considered at prenatal diagnosis, when obstetricians are confronted with an event that is certainly unfamiliar to most of them: a fetus with an isolated limb defect. In fact, with comparatively infrequent abnormalities investigators often tend to neglect some diagnostic aspects that could be useful both in terms of prenatal counseling and of optimum management of the affected fetus. Therefore, a multidisciplinary approach is required that supplements ultrasound diagnostics with additional tests and examinations, even of the invasive type, depending on the complexity of the condition. This updated review may represent a useful tool to reach the stated objectives.

Research paper thumbnail of Changes in interleukin-6 and IGF system and their relationships in placenta and cord blood in newborns with fetal growth restriction compared with controls

European Journal of Endocrinology, 2006

Objectives: The IGF system is central to fetal growth. Recently, the relationships between cytoki... more Objectives: The IGF system is central to fetal growth. Recently, the relationships between cytokines and the IGF system have been shown in specific tissues. It is unknown whether these occur in the placenta. The aim of this study was to assess whether interleukin-6 (IL-6) modulated the IGF system. Methods: Whole villous tissue and cord serum were collected from fetal growth restriction (FGR) neonates diagnosed before birth with altered Doppler velocimetry and controls. Sixteen FGR and 20 controls, born after week 32 of gestation from elective Caesarean sections, were compared. Total RNA was extracted from the placenta samples, reverse transcribed, and real-time quantitative reverse transcriptase (RT)-PCR was performed to quantify cDNA for IGF-I, IGF-II, IGF binding protein (IGFBP)-1, IGFBP-2, and IL-6. The same proteins were assayed in placenta lysates and cord serum using specific commercial kits and western immunoblotting. Results: FGR subjects had significantly more IGFBPs-1 and ...

Research paper thumbnail of Diagnostic accuracy of IOTA ultrasound morphology in the hands of less experienced sonographers

The Australian and New Zealand Journal of Obstetrics and Gynaecology, 2008

The purpose of our study was to evaluate the ability of the International Ovarian Tumor Analysis ... more The purpose of our study was to evaluate the ability of the International Ovarian Tumor Analysis (IOTA) classification and its impact on the identification of benign and malignant adnexal masses by less experienced sonographers. Methods: One hundred and five patients undergoing elective surgical treatment for single adnexal masses at the University of Parma were enrolled. After the final diagnosis, we had the ultrasound recordings reviewed retrospectively by a group of three residents, and the features of each adnexal mass were evaluated according to the morphological score reported by the IOTA Group. Results: Based solely on the qualitative classification of the IOTA Group unilocular cysts were associated with a high, significant probability of a benign lesion (odds ratio (OR) = 12.6 (95% CI, 1.61-99.10), P < 0.001). This probability remained high also with multilocular cysts (OR = 7.9 (95% CI, 1.00-62.38), P < 0.05). By contrast, multilocular-solid cysts were significantly associated with the probability of malignancy (OR = 6.4 (95% CI, 1.81-22.70), P < 0.001), as were solid masses (OR = 5.5 (95% CI, 1.48-20.92), P < 0.05). None of the five ultrasound categories of lesions could be significantly correlated with borderline masses. Conclusions: A simple qualitative classification based solely on the recognition of five different ultrasound categories may be enough to guide the physician to an accurate identification of the nature of the mass. Our findings confirm the diagnostic reliability of the IOTA Group classification by less experienced sonographers. This system is especially helpful because it is capable of discriminating between ovarian masses without further tests and clinical examinations.

Research paper thumbnail of Diagnostic accuracy of fetal renal pelvis anteroposterior diameter as a predictor of significant postnatal nephrouropathy: Second versus third trimester of pregnancy

American Journal of Obstetrics and Gynecology, 2006

Fetal hydronephrosis Ultrasound Prenatal diagnosis Neonatal outcome Receiver operating characteri... more Fetal hydronephrosis Ultrasound Prenatal diagnosis Neonatal outcome Receiver operating characteristic curve Objective: The objective of the study was to determine the most effective fetal renal pelvis anteroposterior diameter thresholds and the best gestational age in predicting significant neonatal nephrouropathy and neonatal nephrouropathy requiring surgery. Study design: Eighty-three newborns with prenatal ultrasound evidence of unilateral or bilateral fetal renal pelvis dilatation (anteroposterior diameter 4 mm or more) before the 26th week of gestation were systematically and prospectively investigated prenatally and postnatally. Results: Receiver operating characteristic curve analysis showed that third-trimester anteroposterior diameter cutoffs were more reliable than second-trimester cutoffs in predicting significant neonatal nephrouropathy, the best threshold being 8 mm. No significant differences were found between the 2 trimesters in the screening of fetuses at risk of neonatal nephrouropathy requiring surgery. Conclusion: Significant neonatal nephrouropathy is better predicted at the third trimester, the best threshold being 8 mm, but the screening of patients at greater risk of surgery is also possible during the second trimester. An anteroposterior diameter of 11 mm or more, with an odds ratio of 128.33 (95% confidence interval 11.68 to 1408.98), is a very effective cutoff and a reliable prognostic indicator of neonatal nephrouropathy requiring surgery, even before the 26th week.

Research paper thumbnail of 722: Is FHR baseline > 150 bpm associated with a higher risk of an adverse outcome?

American Journal of Obstetrics and Gynecology, 2020

with access to a cell phone with text ability. Enrollees were given an OmronÒ 3 series bp710n BP ... more with access to a cell phone with text ability. Enrollees were given an OmronÒ 3 series bp710n BP cuff, instructed on use, and sent two reminder text messages to check BP 2x/ day for 10 days after hospital discharge. All BPs were recorded on a web-based platform available for provider review. BPs that exceeded SBP >160 or DBP >100 mm Hg prompted a provider text with BP result. After day 10 participants completed a survey on the program. We measured the proportions of eligible and enrolled women, those who measured BP, and survey responses. RESULTS: 199 (65%) of 305 potentially eligible women enrolled. 190 (96%) of 199 women recorded at least one BP. 131 (66%) recorded a BP within the first 3-4 days, 167 (84%) within 7-10 days, and 124 (62%) recorded a BP during both times. 70 (35%) had at least one BP > 160/100; 31 (16%) were started on oral antihypertensive treatment; and within 2 weeks of discharge, 10 (5%) women had a hospital readmission for hypertension. 98 (49%) of women completed the survey. Almost all thought it was easy to read and receive texts. 92 (94%) agreed that 'Texts helped to pay attention to BP' , and 91 (93%) agreed 'I would recommend this program to a friend or family member'. Results by each site are shown in the table. CONCLUSION: Postpartum women are willing and able to use the Heart Safe Motherhood Program. This text-based home BP monitoring may improve compliance with close BP surveillance, identify those who would benefit from a clinic visit, and avoid the burden of a clinic visit among the majority of women who remain normotensive. The impact of the Heart Safe Motherhood Program on severe postpartum morbidity should be evaluated.

Research paper thumbnail of Achieving an appropriate cesarean birth (CB) rate and analyzing the changes using the Robson Ten‐Group Classification System (TGCS): Lessons from a Tertiary Care Hospital in Italy

Birth, 2022

BACKGROUND To describe the interventions that were implemented at a Tertiary University Hospital ... more BACKGROUND To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes. STUDY DESIGN An analysis of the contemporaneously collected data from all deliveries that occurred from 2014 to 2018. Major obstetric and neonatal outcomes were analyzed and grouped according to the Ten-Group Classification System (TGCS). RESULTS A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported. CONCLUSIONS A reduction in CB rate may be safely achieved through implementing a multifaceted strategy.

Research paper thumbnail of Hyperechoic amniotic membranes in patients with preterm premature rupture of membranes (p-PROM) and pregnancy outcome

Journal of Perinatal Medicine, 2020

Objectives The early identification of women with preterm premature rupture of membranes (p-PROM)... more Objectives The early identification of women with preterm premature rupture of membranes (p-PROM) who are at higher risk of imminent delivery remains challenging. The aim of our study was to evaluate if an increased echogenicity of the amniotic membranes may represent a sonographic marker of impending delivery in women with p-PROM. Methods This was a prospective study including women with singleton pregnancies and diagnosis of p-PROM between 22 and 37 gestational weeks. A sonographic examination was performed within 24 h from the hospital admission and the appearance of the amniotic membranes close to the internal os was specifically evaluated. The membranes were defined as hyperechoic when their echogenicity was similar to that of the fetal bones or normoechoic in the other cases. The primary aim of the study was to compare the admission to spontaneous onset of labor interval and the pregnancy outcome between the cases of p-PROM with and without hyperechoic membranes. Results Overa...

Research paper thumbnail of Antepartum amnioinfusion: a review

The Journal of Maternal-Fetal & Neonatal Medicine, 2003

Antepartum amnioinfusion is a relatively recent procedure introduced with fetal medicine techniqu... more Antepartum amnioinfusion is a relatively recent procedure introduced with fetal medicine techniques. It is usually indicated for severe oligohydramnios in order to avoid the related complications such as pulmonary hypoplasia, the deforming effects of oligohydramnios, variable fetal heart rate decelerations and intraventricular hemorrhage. Antepartum amnioinfusion is also employed to improve ultrasound visualization in cases with oligohydramnios. Our objective was to evaluate the benefits and complications related to this procedure which is still less commonly used compared to intrapartum amnioinfusion, and whose risks are therefore not well established. Reports of study designs identified from searches of MEDLINE, PUBMED, the Cochrane Collaboration, specialized databases and bibliographies of review articles were identified. Studies in women who underwent amnioinfusion between 1987 and 2002 were included. Amnioinfusion seems to offer several benefits, in terms of both prenatal diagnosis and favorable perinatal outcome. Most clinical experiences report that amnioinfusion is safe, both for the mother and for the fetus. However, randomized control-group studies subdivided on the basis of the cause of oligohydramnios (e.g. premature rupture of membranes, fetal growth restriction, obstructive uropathy and renal agenesis) could help to determine the advantages and risks linked to this procedure. Prospective randomized studies should therefore be encouraged, to clarify any possible doubts regarding the procedure, before it can be introduced into routine practice in the management of oligohydramnios.

Research paper thumbnail of P226: Normalization of middle cerebral artery flow velocity before fetal death: what is its real meaning?

Ultrasound in Obstetrics and Gynecology, 2003

Poster abstracts Methods: The hepatic and umbilical venous systems were examined in 390 fetuses i... more Poster abstracts Methods: The hepatic and umbilical venous systems were examined in 390 fetuses in a prospective study using two dimensional (2D) ultrasonography, color, and spectral Doppler. Fetuses suspected to have ductus venosus anomalies were additionally examined with 3D power Doppler ultrasonography. Results: Eight fetuses with venous abnormalities (absent ductus venosus n = 4, direct connection between the umbilical vein and the right atrium n = 2, and direct connection between the umbilical vein and the inferior vena cava n = 2) were detected among the 310 (Incidence 2.6%) in which the venous system could be visualized. Three-dimensional power Doppler accurately showed the course of the umbilical vein, its relationship to the porto-systemic circulation, and whether a ductus venosus was present or absent. Conclusions: 3D power Doppler ultrasonography has the potential to improve the diagnostic accuracy and differentiation between distinct types of malformations of the fetal porto-systemic and umbilical venous system.

Research paper thumbnail of Amniotic fluid index versus largest vertical pocket in the prediction of perinatal outcome in post-term pregnancies

Acta bio-medica : Atenei Parmensis, 2004

We studied a cohort of 41 singleton pregnancies induced at term with prostaglandins and, when nec... more We studied a cohort of 41 singleton pregnancies induced at term with prostaglandins and, when necessary, oxytocin. We evaluated with ultrasound the amniotic fluid index (AFI) and the largest vertical pocket (LVP), at least 2 days before the delivery, to compare the sonographic measurement of amniotic fluid with fetal distress and perinatal outcome. We analysed the incidence of fetal distress using intrapartum monitoring of fetal heart rate, considering the absence of variability, the presence of persistent severe variable and/or late decelerations. The oligohydramnios group, indipendently by ultrasound index, showed the same incidence of abnormal FHR, and rate of Cesarean section for fetal distress as the group with normal amniotic fluid. In conclusion there is no significant difference between the group of patients with oligohydramnios and the one with normal amniotic fluid regarding the perinatal outcome in induced labor.

Research paper thumbnail of Amnioreduction for treatment of severe polyhydramnios

Acta bio-medica : Atenei Parmensis, 2004

Between January 2000 and March 2003 we studied the pregnancies complicated by polyhydramnios in 1... more Between January 2000 and March 2003 we studied the pregnancies complicated by polyhydramnios in 10 patients. The objective was that of evaluating the efficacy of amnioreduction in improving the principal complications given by polyhydramnios such as maternal dyspnea and uterine activity. Our results showed that this procedure resolve maternal symptoms in all the cases but there is no significant reduction in uterine activity.

Research paper thumbnail of Twin-twin transfusion syndrome: a review of treatment option

Acta bio-medica : Atenei Parmensis, 2004

The twin-twin transfusion syndrome (TTTS) is a complication of monozygotic-monochorionic twinning... more The twin-twin transfusion syndrome (TTTS) is a complication of monozygotic-monochorionic twinning and is a direct result of transplacental communication between the circulations of twins. When acute TTTS occurs in the second trimester, the perinatal mortality can be as high as 95% in the absence of treatment. For this reason, several aggressive, even desperate treatment modalities have been attempted including selective fetocide, umbilical cord ligation, maternal digoxin therapy. None have gained wide acceptance. Serial drainage amniocentesis or amnioreduction is actually the most widely used therapy. More recently, laser ablation under fetoscopic guidance of placental vessel has been reported in an attempt to improve survival. The objective of this review was to evaluate the impact of treatment modalities in TTTS. Reports of prospective and retrospective trials and other study designs in English identified from searches of MEDLINE, EMBASE, specialized databases, bibliographies of r...

Research paper thumbnail of Early complications of prenatal invasive diagnostics: perspective analysis

Acta bio-medica : Atenei Parmensis, 2004

In this retrospective analysis we studied 1489 women who underwent prenatal invasive diagnostic p... more In this retrospective analysis we studied 1489 women who underwent prenatal invasive diagnostic procedures between January 2000 and December 2002. We examine the influence of risk factors and the incidence of early complications following amniocentesis and chorion villus sampling, in particular the incidence of fetal loss. The study group included 438 women who underwent CVS and 1051 underwent amniocentesis. For each woman we studied anamnestic risk factors (recurrent pregnancy losses, fibroids, twin birth, uterine hematic loss), intraoperative risk factors (repetition of the insertion, transplacental sample, hematic liquid, early bleeding) and postoperative risk factors (pelvic pain, hematic losses, liquid losses, spastic pain, fever). In our data the miscarriage incidence was 1% for CVS and 1.7% for amniocentesis. Our results showed that in relation to CVS, the presence of fibroids gives an OR of miscarriage of 68 (95% C.I.=6.50-659.78; p=0.000). In relation to amniocentesis, the ...

Research paper thumbnail of Amniotic fluid dynamics

Acta bio-medica : Atenei Parmensis, 2004

Amniotic fluid was once considered to be a stagnant pool, approximately circulating with a turnov... more Amniotic fluid was once considered to be a stagnant pool, approximately circulating with a turnover time of one day. Adequate amniotic fluid volume is maintained by a balance of fetal fluid production (lung liquid and urine) and resorption (swallowing and intramembranous flow). Even though different hypotheses have been advanced on the mechanisms regulating this turnover, the inflow and outflow mechanism that keeps amniotic fluid volume within the normal range is not entirely clear. Regulatory mechanisms act at three levels: placental control of water and solute transfer; regulation of inflows and outflows from the fetus; and, maternal effect on fetal fluid balance. Amniotic fluid is 98-99% water. The chemical composition of its substances varies with gestational age. When fetal urine begins to enter the amniotic sac, amniotic osmolarity decreases slightly compared with fetal blood. After keratinization of the fetal skin, amniotic fluid osmolarity decreases further with advancing ge...

Research paper thumbnail of Prelabour rupture of the membranes: recent evidence

Acta bio-medica : Atenei Parmensis, 2004

Premature rupture of the membranes (PROM) complicates 10% of all gestations and 2-4% of preterm p... more Premature rupture of the membranes (PROM) complicates 10% of all gestations and 2-4% of preterm pregnancy. Our success in preventing preterm PROM and preterm birth is hampered by our limited knowledge of its etiology. PROM remains the single most identifiable cause of preterm delivery and the major contributor to perinatal morbidity and mortality. Its clinical management continues to be controversial. The management dilemma associated with preterm PROM (PPROM) involves a balance between expectant management and intervention, taking into consideration the risks of infection with the increased duration of membrane rupture. Recent evidence on the use of antibiotics and amnioinfusion, together with advances in the prediction, diagnosis and estimation of risk based upon occupational factors and genetics have provided additional therapeutic tools in our approach to the problem of PPROM. While PPROM at very early gestation is a serious complication and a major management dilemma often asso...

Research paper thumbnail of Sonographic assessment of amniotic fluid volume between 11 and 24 weeks of gestation: construction of reference intervals related to gestational age

Ultrasound in Obstetrics and Gynecology, 2001

Objective At present, most of the methods for sonographic assessment of amniotic fluid volume are... more Objective At present, most of the methods for sonographic assessment of amniotic fluid volume are unreliable in the second trimester of pregnancy, or else they do not present nomograms related to gestational age. Design The aim of this prospective cross-sectional study was to construct normal reference ranges of four ultrasound parameters for the evaluation of amniotic fluid volume which could be applied in the second trimester. For these parameters we calculated normal curve limits suitable for use in clinical practice. Subjects From a population of normal pregnant women between the 12th and the 24th weeks of gestation undergoing a routine ultrasound examination during 1997 at our institute, 273 were found to be suitable for the study, after the exclusion of all cases which presented any feto-maternal pathology or complications up to the 24th week. Methods The largest 'amniotic pocket' in a vertical direction, free of small fetal parts and umbilical cord, was measured: the maximum vertical and transverse diameters were measured on the same scan; the mean diameter and the product of the two diameters were calculated. The 'mean amniotic fluid diameter', the 'two-diameter pocket', the 'largest vertical pocket' and the 'largest transverse pocket' were the four sonographic parameters considered. Results The four parameters correlated well with gestational week and with the biparietal diameter; the normal reference intervals and normal curve were then calculated. All these parameters were found to have good intra-and interoperative reproducibility. Conclusions We conclude that the use of an ultrasound semiquantitative method based on the measurement of a single amniotic fluid pocket and involving normal reference intervals according to gestational age could improve the early diagnosis of amniotic fluid variations during the second trimester, although this has yet to be confirmed by extensive clinical trials.

Research paper thumbnail of P14.84: Fetal pyelectasis and prediction of post-natal renal abnormalities

Ultrasound in Obstetrics and Gynecology, 2004

To examine the underlying pathology in male fetuses with sonographic evidence of severe and isola... more To examine the underlying pathology in male fetuses with sonographic evidence of severe and isolated LUTO. Methods: Detailed postmortem examination was carried out after termination of pregnancy in 24 male fetuses presenting before 25 weeks of gestation with ultrasound evidence of isolated severe low urinary tract obstruction. Results: Gender was male in all cases. There was megacystis and hyperechogenic kidneys in all cases. There was anhydramnios/oligohydramnios and pelvicalyceal dilatation in 20 and 15 cases respectively. Prenatal diagnosis of the underlying condition was erroneous in 2/3 of the cases. Urethral atresia was never suspected antenatally. Examination of the urethra demonstrated atresia in 6 cases, severe stenosis in 8 cases, posterior urethral valves in 9 cases and an apparently normal urethra in one. Renal dysplasia was found in all cases but one. Urethral atresia was the most common urethral anomaly at 12-17 weeks. Hydronephrosis was more frequent in cases with PUV (8/9) and urethral stenosis (6/8) than with urethral atresia (1/6). In LUTO presenting before 25 weeks hyperechogenic kidneys was predictive of renal dysplasia in 95% of the cases. The association of a bladder larger diameter of more than 40 mm and hydronephrosis in a male fetus before 25 weeks was predictive of PUV with a PPV and NPV of 44% and 100% respectively. Absence of hydronephrosis and a bladder larger diameter of less (or equal) than 40 mm were predictive of urethral atresia or stenosis with a PPV and NPV of 83% and 57% respectively. Conclusion: LUTO presenting with megacystis in a male fetus in the first and second trimester can correspond to urethral atresia or stenosis more often than posterior urethral valves. Since the formers carry a poor prognosis size of the bladder and the presence of hydronephrosis could be the most discriminant association to improve prenatal counselling.

Research paper thumbnail of Mid-trimester amniocentesis and antibiotic prophylaxis

Prenatal Diagnosis, 2007

Assuming that the rate of fetal loss after amniocentesis may be reduced in patients receiving ant... more Assuming that the rate of fetal loss after amniocentesis may be reduced in patients receiving antibiotic prophylaxis, we conducted a retrospective study on untreated versus treated patients receiving prophylactic antibiotics (amoxicillin/clavulanic-acid or azithromycin) and evaluated the fetal loss rate within the 22nd week of gestation, also with respect to the risk of spontaneous abortion, both preexisting and related to mid-trimester amniocentesis. Spontaneous abortion occurred in 22 cases out of 1744 (1.26%). The incidence of spontaneous abortion was 1.3% among patients treated with antibiotic prophylaxis and 1.2% among untreated patients. Between patients with risk factors that predated amniocentesis, the spontaneous fetal loss rate was 9.2% in untreated patients versus 2.3% in patients treated (p = 0.10). In patients with procedure-related risk factors at amniocentesis, the spontaneous abortion rate was, respectively, 2.2 and 1.2% (p = 0.72). Our data demonstrate that antibiotic prophylaxis does not reduce the risk of spontaneous abortion within the 22nd week of gestation. Compared with untreated patients, patients treated with amoxicillin showed the lower fetal loss rate (1.16 vs 0.31%), but the difference was not statistically significant (odds ratio (OR) = 3.68, p = 0.32). The same was true for patients with preexisting risks (OR = 4.25, p = 0.10).

Research paper thumbnail of Very-Early-Onset Discordant Growth in Monochorionic Twin Pregnancy

Obstetrics & Gynecology, 2004

Research paper thumbnail of Clinical Management of Paroxysmal Nocturnal Hemoglobinuria in Pregnancy: A Case Report and Updated Review

Obstetrical & Gynecological Survey, 2006

Because women with paroxysmal nocturnal hemoglobinuria (PNH) are especially vulnerable to thrombo... more Because women with paroxysmal nocturnal hemoglobinuria (PNH) are especially vulnerable to thromboembolic phenomena, pregnancy is a time of increased risk for both mother and fetus. However, pregnancies in affected women are rare; only case reports and small studies have been reported so far. We present the case of a 20-year-old woman with PNH who, while undergoing medical tests in preparation for a bone marrow transplant, was discovered to be pregnant. We also review the obstetric literature on pregnancy complicated by PNH, which indicates that both maternal and fetal mortality is exceptionally high (11.6% and 7.2%) with the major cause of maternal mortality being thromboembolism. Major maternal complications are more frequent postpartum (30.2%) than antepartum or intrapartum (16.3%). Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that paroxysmal nocturnal hemoglobinuria (PNH) during pregnancy increases adverse events for both the mother and the fetus, state that maternal and fetal mortality are both high, and explain that the major complications occur in the postpartum period. The authors have disclosed that they have no financial relationships with or interests in any commercial companies pertaining to this educational activity. The authors have disclosed that eculizumab has not been approved by the U.S. Food and Drug Administration. Lippincott Continuing Medical Education Institute, Inc. has identified and resolved all faculty conflicts of interest regarding this educational activity.

Research paper thumbnail of Prenatal Diagnosis of Isolated Limb Defects: An Updated Review

Fetal Diagnosis and Therapy, 2005

Abnormalities of bone segments, either isolated or in combination with others, may affect any sin... more Abnormalities of bone segments, either isolated or in combination with others, may affect any single bone. Given the relatively low incidence of such defects and the relevance of the clinical issues involved, it could be useful to evaluate all the diagnostic and procedural aspects that should be considered at prenatal diagnosis, when obstetricians are confronted with an event that is certainly unfamiliar to most of them: a fetus with an isolated limb defect. In fact, with comparatively infrequent abnormalities investigators often tend to neglect some diagnostic aspects that could be useful both in terms of prenatal counseling and of optimum management of the affected fetus. Therefore, a multidisciplinary approach is required that supplements ultrasound diagnostics with additional tests and examinations, even of the invasive type, depending on the complexity of the condition. This updated review may represent a useful tool to reach the stated objectives.

Research paper thumbnail of Changes in interleukin-6 and IGF system and their relationships in placenta and cord blood in newborns with fetal growth restriction compared with controls

European Journal of Endocrinology, 2006

Objectives: The IGF system is central to fetal growth. Recently, the relationships between cytoki... more Objectives: The IGF system is central to fetal growth. Recently, the relationships between cytokines and the IGF system have been shown in specific tissues. It is unknown whether these occur in the placenta. The aim of this study was to assess whether interleukin-6 (IL-6) modulated the IGF system. Methods: Whole villous tissue and cord serum were collected from fetal growth restriction (FGR) neonates diagnosed before birth with altered Doppler velocimetry and controls. Sixteen FGR and 20 controls, born after week 32 of gestation from elective Caesarean sections, were compared. Total RNA was extracted from the placenta samples, reverse transcribed, and real-time quantitative reverse transcriptase (RT)-PCR was performed to quantify cDNA for IGF-I, IGF-II, IGF binding protein (IGFBP)-1, IGFBP-2, and IL-6. The same proteins were assayed in placenta lysates and cord serum using specific commercial kits and western immunoblotting. Results: FGR subjects had significantly more IGFBPs-1 and ...

Research paper thumbnail of Diagnostic accuracy of IOTA ultrasound morphology in the hands of less experienced sonographers

The Australian and New Zealand Journal of Obstetrics and Gynaecology, 2008

The purpose of our study was to evaluate the ability of the International Ovarian Tumor Analysis ... more The purpose of our study was to evaluate the ability of the International Ovarian Tumor Analysis (IOTA) classification and its impact on the identification of benign and malignant adnexal masses by less experienced sonographers. Methods: One hundred and five patients undergoing elective surgical treatment for single adnexal masses at the University of Parma were enrolled. After the final diagnosis, we had the ultrasound recordings reviewed retrospectively by a group of three residents, and the features of each adnexal mass were evaluated according to the morphological score reported by the IOTA Group. Results: Based solely on the qualitative classification of the IOTA Group unilocular cysts were associated with a high, significant probability of a benign lesion (odds ratio (OR) = 12.6 (95% CI, 1.61-99.10), P < 0.001). This probability remained high also with multilocular cysts (OR = 7.9 (95% CI, 1.00-62.38), P < 0.05). By contrast, multilocular-solid cysts were significantly associated with the probability of malignancy (OR = 6.4 (95% CI, 1.81-22.70), P < 0.001), as were solid masses (OR = 5.5 (95% CI, 1.48-20.92), P < 0.05). None of the five ultrasound categories of lesions could be significantly correlated with borderline masses. Conclusions: A simple qualitative classification based solely on the recognition of five different ultrasound categories may be enough to guide the physician to an accurate identification of the nature of the mass. Our findings confirm the diagnostic reliability of the IOTA Group classification by less experienced sonographers. This system is especially helpful because it is capable of discriminating between ovarian masses without further tests and clinical examinations.

Research paper thumbnail of Diagnostic accuracy of fetal renal pelvis anteroposterior diameter as a predictor of significant postnatal nephrouropathy: Second versus third trimester of pregnancy

American Journal of Obstetrics and Gynecology, 2006

Fetal hydronephrosis Ultrasound Prenatal diagnosis Neonatal outcome Receiver operating characteri... more Fetal hydronephrosis Ultrasound Prenatal diagnosis Neonatal outcome Receiver operating characteristic curve Objective: The objective of the study was to determine the most effective fetal renal pelvis anteroposterior diameter thresholds and the best gestational age in predicting significant neonatal nephrouropathy and neonatal nephrouropathy requiring surgery. Study design: Eighty-three newborns with prenatal ultrasound evidence of unilateral or bilateral fetal renal pelvis dilatation (anteroposterior diameter 4 mm or more) before the 26th week of gestation were systematically and prospectively investigated prenatally and postnatally. Results: Receiver operating characteristic curve analysis showed that third-trimester anteroposterior diameter cutoffs were more reliable than second-trimester cutoffs in predicting significant neonatal nephrouropathy, the best threshold being 8 mm. No significant differences were found between the 2 trimesters in the screening of fetuses at risk of neonatal nephrouropathy requiring surgery. Conclusion: Significant neonatal nephrouropathy is better predicted at the third trimester, the best threshold being 8 mm, but the screening of patients at greater risk of surgery is also possible during the second trimester. An anteroposterior diameter of 11 mm or more, with an odds ratio of 128.33 (95% confidence interval 11.68 to 1408.98), is a very effective cutoff and a reliable prognostic indicator of neonatal nephrouropathy requiring surgery, even before the 26th week.

Research paper thumbnail of 722: Is FHR baseline > 150 bpm associated with a higher risk of an adverse outcome?

American Journal of Obstetrics and Gynecology, 2020

with access to a cell phone with text ability. Enrollees were given an OmronÒ 3 series bp710n BP ... more with access to a cell phone with text ability. Enrollees were given an OmronÒ 3 series bp710n BP cuff, instructed on use, and sent two reminder text messages to check BP 2x/ day for 10 days after hospital discharge. All BPs were recorded on a web-based platform available for provider review. BPs that exceeded SBP >160 or DBP >100 mm Hg prompted a provider text with BP result. After day 10 participants completed a survey on the program. We measured the proportions of eligible and enrolled women, those who measured BP, and survey responses. RESULTS: 199 (65%) of 305 potentially eligible women enrolled. 190 (96%) of 199 women recorded at least one BP. 131 (66%) recorded a BP within the first 3-4 days, 167 (84%) within 7-10 days, and 124 (62%) recorded a BP during both times. 70 (35%) had at least one BP > 160/100; 31 (16%) were started on oral antihypertensive treatment; and within 2 weeks of discharge, 10 (5%) women had a hospital readmission for hypertension. 98 (49%) of women completed the survey. Almost all thought it was easy to read and receive texts. 92 (94%) agreed that 'Texts helped to pay attention to BP' , and 91 (93%) agreed 'I would recommend this program to a friend or family member'. Results by each site are shown in the table. CONCLUSION: Postpartum women are willing and able to use the Heart Safe Motherhood Program. This text-based home BP monitoring may improve compliance with close BP surveillance, identify those who would benefit from a clinic visit, and avoid the burden of a clinic visit among the majority of women who remain normotensive. The impact of the Heart Safe Motherhood Program on severe postpartum morbidity should be evaluated.

Research paper thumbnail of Achieving an appropriate cesarean birth (CB) rate and analyzing the changes using the Robson Ten‐Group Classification System (TGCS): Lessons from a Tertiary Care Hospital in Italy

Birth, 2022

BACKGROUND To describe the interventions that were implemented at a Tertiary University Hospital ... more BACKGROUND To describe the interventions that were implemented at a Tertiary University Hospital and how they affected the rate of cesarean birth (CB) and main obstetrics and neonatal outcomes. STUDY DESIGN An analysis of the contemporaneously collected data from all deliveries that occurred from 2014 to 2018. Major obstetric and neonatal outcomes were analyzed and grouped according to the Ten-Group Classification System (TGCS). RESULTS A significant decrease in CB rates, from 28.4% to 23.0% (P < 0.001), was found over the study period. Although the relative sizes of both nulliparous (groups 1 + 2) and multiparous (groups 3 + 4) women remained stable over the study period, a significantly higher incidence of CB was reported in 2014 for both groups, compared with 2018 (2.6% vs. 13.0%, P < 0.001 for nulliparous women and 7.5% vs. 3.3%, P < 0.001 for multiparous women). In contrast, the relative size of Group 5 was significantly lower in 2014 than in 2018 (9.9% vs. 11.5%, P = 0.003), but a 13.3% reduction in CB was also reported for this group. No significant differences were noted in the occurrence of major obstetrics and neonatal outcomes that were reported. CONCLUSIONS A reduction in CB rate may be safely achieved through implementing a multifaceted strategy.

Research paper thumbnail of Hyperechoic amniotic membranes in patients with preterm premature rupture of membranes (p-PROM) and pregnancy outcome

Journal of Perinatal Medicine, 2020

Objectives The early identification of women with preterm premature rupture of membranes (p-PROM)... more Objectives The early identification of women with preterm premature rupture of membranes (p-PROM) who are at higher risk of imminent delivery remains challenging. The aim of our study was to evaluate if an increased echogenicity of the amniotic membranes may represent a sonographic marker of impending delivery in women with p-PROM. Methods This was a prospective study including women with singleton pregnancies and diagnosis of p-PROM between 22 and 37 gestational weeks. A sonographic examination was performed within 24 h from the hospital admission and the appearance of the amniotic membranes close to the internal os was specifically evaluated. The membranes were defined as hyperechoic when their echogenicity was similar to that of the fetal bones or normoechoic in the other cases. The primary aim of the study was to compare the admission to spontaneous onset of labor interval and the pregnancy outcome between the cases of p-PROM with and without hyperechoic membranes. Results Overa...