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Placenta accreta is a rare and potentially life-threatening complication of pregnancy characterized by abnormal adherence of the placenta to the uterine wall. A previously scarred uterus or an abnormal site of placentation in the lower segment is a major risk factor. The aim of this study was to investigate the change in the incidence of placenta accreta and associated risk factors along four decades, from the 1970s to 2000s, in a tertiary south Italian center. We analyzed all cases of placenta accreta in a sample triennium for each decade. The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta.

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clinicaltrials.gov Identifier: NCT02716909.

Femoral hypoplasia-unusual CASE REPORTS Case 1A 30-year-old primigravida was referred to our unit at 21 weeks' gestation because of a suspicion of severe bilateral femoral hypoplasia in her male fetus. The family history was negative for congenital anomalies. The patient did not have insulin-dependent diabetes mellitus. Ultrasound examination showed fetal biometry consistent with a gestational age of 21 weeks, with the exception of the femora, which appeared severely hypoplastic. The left femur was completely absent whereas the right one measured only a few millimeters (Figure 1a and b). Ultrasound imaging of the fetal face revealed the presence of unilateral right cleft lip and palate (Figure 1d). Unilateral right renal agenesis was also observed. In the counseling session, the couple was informed of the putative diagnosis and outcome of femoral hypoplasia-unusual facies syndrome (FHUFS), and the possible management options.After counseling, the couple opted for termination of the pregnancy. The diagnosis of FHUFS was confirmed at autopsy. In particular, severe bilateral and asymmetric femoral hypoplasia (Figure 1c), unilateral cleft lip/palate ( Figure 1e) and unilateral renal agenesis were found. In addition, the face showed the typical features of FHUFS: a long philtrum, thin upper lip, moderate micrognathia and low-set ears (Figure 1e). Other features consistent with the diagnosis of FHUFS found at autopsy included a short neck and a pelvis with vertically orientated iliac blades. Case 2A 28-year-old obese woman (gravida 2, para 1) with insulin-dependent diabetes mellitus was referred to our unit at 21 weeks' gestation because of an abnormal second-trimester anomaly scan. The family history was unremarkable, with no consanguinity reported. On ultrasound examination, severe hypoplasia of the left femur was observed (Figure 2a), whereas the contralateral femoral shaft appeared unremarkable, with length in the normal range 1 . Examination of the fetal face revealed severe micrognathia (Figure 2c) and the ears appeared low set. No other abnormalities were observed. A diagnosis of FHUFS was made. After counseling, the couple opted for termination of the pregnancy. At autopsy, severe unilateral hypoplasia of the left femur, severe micrognathia and low-set ears were confirmed (Figure 2b and d). Also noted were a short nose with a broad tip, a thin upper lip and a cleft palate (Figure 2d, inset), confirming the diagnosis of FHUFS. Case 3A 24-year-old primigravida was referred to our unit at 13 weeks' gestation after the detection of abnormal lower limbs at the nuchal translucency scan. There was no

Objectives-To evaluate the effectiveness of cervical pessary for preventing spontaneous preterm birth (SPTB) in singleton gestations with a second trimester short cervix.Methods-Electronic databases were searched from their inception until February 2016. We included randomized clinical trials (RCTs) comparing the use of the cervical pessary with expectant management in singletons pregnancies with transvaginal ultrasound cervical length (TVU CL) 25 mm. The primary outcome was incidence of SPTB <34 weeks. The summary measures were reported as relative risk (RR) with 95% confidence interval (CI).Results-Three RCTs (n 5 1,420) were included. The mean gestational age (GA) at randomization was approximately 22 weeks. The Arabin pessary was used as intervention in all three trials, and was removed by vaginal examination at approximately 37 weeks. Cervical pessary was not associated with prevention of SPTB <37 (20.2% vs 50.2%; RR 0.50, 95% CI 0.23 to 1.09), <34, <32, and <28 weeks, compared to no pessary. No differences were found in the mean of GA at, interval from randomization to delivery, incidence of preterm premature rupture of membranes and of cesarean delivery, and in neonatal outcomes. The Arabin pessary was associated with a significantly higher risk of vaginal discharge.Conclusions-In singleton pregnancies with a TVU CL 25mm at 20 0 -24 6 weeks, the Arabin pessary does not reduce the rate of spontaneous preterm delivery or improve perinatal outcome. Individual patient data meta-analysis may clarify whether cervical pessary may be beneficial in subgroups, such as only singleton gestations without prior SPTB or by different CL cutoffs.

Human immunodeficiency virus-infected women had an increased risk of preeclampsia. Some of this risk seems to be linked to HAART.