Myomectomy scar pregnancy ‒ a serious, but scarcely reported entity: literature review and an instructive case

Objectives Uterine myomas are a frequent finding in reproductive age women with an estimated incidence 12–25%. 1. Treatment of uterine myomas to facilitate good pregnancy rates and outcome, such as hysteroscopic, laparoscopic, abdominal resection uterine artery embolization among others were evaluated in terms of pregnancy outcome. While the literature is replete of the pregnancy complication of uterine rupture after myomectomies, 2–4 there are very few publications evaluate a relatively rare pregnancy complication associated with placental implantation within the uterine cavity at the site of the previous myomectomy, namely the myomectomy scar pregnancy (MSP). Despite their relative rarity, this type of pathologically adherent placenta rightfully belongs to the well-known entity of placenta accreta spectrum (PAS). Case presentation We present a complicated case of MSP and review the available literature to raise attention to its clinical appearance, its prenatal diagnosis so appropriate intrapartum management can be planned. Conclusions Despite the rarity of MSP, continuous attention should be given at every single routinely scheduled or indication driven obstetrical US scan following myomectomies to evaluate the placental site implantation regardless of the route and technique of their initial surgical procedure.

Immunobiology of Gestational Diabetes Mellitus in Post-Medawar Era

Although the concepts related to fetal immune tolerance proposed by Sir Peter Medawar in the 1950s have not withstood the test of time, they revolutionized our current understanding of the immunity at the maternal-fetal interface. An important extension of the original Medawar paradigm is the investigation into the underlying mechanisms for adverse pregnancy outcomes, including recurrent spontaneous abortion, preterm birth, preeclampsia and gestational diabetes mellitus (GDM). Although a common pregnancy complication with systemic symptoms, GDM still lacks understanding of immunological perturbations associated with the pathological processes, particularly at the maternal-fetal interface. GDM has been characterized by low grade systemic inflammation that exacerbates maternal immune responses. In this regard, GDM may also entail mild autoimmune pathology by dysregulating circulating and uterine regulatory T cells (Tregs). The aim of this review article is to focus on maternal-fetal immunological tolerance phenomenon and discuss how local or systemic inflammation has been programmed in GDM. Specifically, this review addresses the following questions: Does the inflammatory or exhausted Treg population affecting the Th17:Treg ratio lead to the propensity of a pro-inflammatory environment? Do glycans and glycan-binding proteins (mainly galectins) contribute to the biology of immune responses in GDM? Our understanding of these important questions is still elementary as there are no well-defined animal models that mimic all the features of GDM or can be used to better understand the mechanistic underpinnings associated with this common pregnancy complication. In this review, we will leverage our preliminary studies and the literature to provide a conceptualized discussion on the immunobiology of GDM.

Preeclampsia and pathology of placentation

Etiology of pre-eclampsiaremainsunclear. However, it is recognized that genetic factors of both mothers and fathers sides can determine the development of this awesome complication of pregnancy. The interplay of genetic factors with external influences determines the risk level of pre-eclampsia. Today it is reasonable to assert that pre-eclampsia is a complication of pregnancy associated with the disturbances of the process of trophoblast invasion and changes in haemodynamics in spiral arteries. The process of trophoblast invasion proved to be coordinated by combined interaction of cytokines, factors of adhesion and different growth factors.Functional abnormalities of endothelium of placental and pre-placental vessels may be a result but not a cause of development ofpre-eclampsia, pathophysiology of which is studied still insufficiently. However, the disturbance оf NO, endothelein release and thrombocytes homeostasis as well are certain to be the main manifestations of this pregnancy complication. A fter revealing all the mechanisms of process of trophoblast invasion disturbances an actual possibility of early prevention and treatment of pre-eclampsia may be elaborated.

Achados clínicos maternos por infecção do sars-cov-2 na gestação: uma revisão integrativa

Objetivo: descrever evidências relacionadas às complicações maternas no período gestacional em virtude da infecção por SARS-COV-2. Método: A pesquisa foi realizada nas bases de dados da Medline via Pubmed, Cochrane e Embase via Elsevier, cuja busca foi desenvolvida no período entre março e abril de 2021. Os descritores utilizados estavam indexados no sistema Medical Subject Headings (MeSH) e no Emtree, quais sejam: Pregnancy Complications, Infectious, COVID-19, SARS-CoV-2, pregnancy complication e coronavirus disease 2019. Incluiu-se artigos publicados em português, inglês ou espanhol, publicados entre 2019-2021 e artigos na íntegra com acesso aberto via Portal de Periódicos Capes. Foram excluídos os artigos duplicados, artigos voltados para outras temáticas, relato de casos, carta ao editor e estudos de revisão. Inicialmente obtiveram 2.809 artigos, sendo realizada uma seleção conforme as seguintes etapas: identificação, triagem e elegibilidade. Foram incluídos 18 artigos para a síntese da amostra final. Resultados: As complicações principais foram abortos espontâneos, trombocitopneia, mortes perinatais, ruptura prematura das membranas, parto prematuro e morte fetal intrauterina. A maioria das mulheres foram admitidas na UTI e apresentaram hemorragia pós-parto. Observou-se um aumento nas cesarianas de emergências, e algumas sofreram de Perturbação de Estresse Pós-traumático, depressão pós-parto e depressão pós-aborto. Conclusão: Foram identificadas complicações maternas em virtude da contaminação pelo SARS-COV-2.

Pathophysiological Implication of Pattern Recognition Receptors in Fetal Membranes Rupture: RAGE and NLRP Inflammasome

Preterm prelabor ruptures of fetal membranes (pPROM) are a pregnancy complication responsible for 30% of all preterm births. This pathology currently appears more as a consequence of early and uncontrolled process runaway activation, which is usually implicated in the physiologic rupture at term: inflammation. This phenomenon can be septic but also sterile. In this latter case, the inflammation depends on some specific molecules called “alarmins” or “damage-associated molecular patterns” (DAMPs) that are recognized by pattern recognition receptors (PRRs), leading to a microbial-free inflammatory response. Recent data clarify how this activation works and which receptor translates this inflammatory signaling into fetal membranes (FM) to manage a successful rupture after 37 weeks of gestation. In this context, this review focused on two PRRs: the receptor for advanced glycation end-products (RAGE) and the NLRP7 inflammasome.

Management of hyponatraemia in pre-eclampsia with severe features

Pre-eclampsia is a common pregnancy complication with many associated maternal and fetal risks, yet its pathophysiology remains poorly understood. Hyponatraemia is a rarely described finding in pre-eclampsia that has been associated with both maternal and fetal complications and medically indicated delivery. We present a case of hyponatraemia in a patient admitted for induction of labour for gestational hypertension, which developed into pre-eclampsia with severe features requiring magnesium sulfate therapy for seizure prophylaxis. The patient’s hyponatraemia resolved with delivery, fluid restriction and serial sodium monitoring. Adjustment to the components of the patient’s magnesium sulfate infusion was made to reduce free water intake and avoid further exacerbation of her hyponatraemia. While there is currently no recommendation to routinely monitor sodium levels in hypertensive disorders of pregnancy, careful consideration of this potential finding in cases of pre-eclampsia should be given due to the overlap between symptoms of hyponatraemia and cerebral symptoms of pre-eclampsia.