No abstract

Objective: to explore the potential of 3D Power Doppler Angiography (3D PDA) to evaluate the cerebral circulation in normal and growth restricted fetuses (IUGR).Study design: in a pilot study, we enrolled 51 appropriate for gestational age (AGA) pregnancies and 17 singleton pregnancies presenting IUGR, all between 22 and 38 weeks of gestation. Using 3D power Doppler ultrasound, a volume acquisition of the fetal brain was performed. Two regions of interest (ROI) were defined within the fetal brain. Zone 1 is anterior to the cavum septi pellucidi (CSP). Zone 2 is defined by a rectangle obtained tracing a contour between the temporal bones as wide as the CSP, corresponding to the area of the middle cerebral artery. The Flow Index (FI), the Vascularization Index (VI), the Vascularization and Flow Index (VFI) were determined in both areas in both IUGR and AGA fetuses by a single operator. IUGR fetuses were divided into three groups: Group 1, with normal pulsatility index (PI) of umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV); Group 2, IUGR fetuses with abnormal UA PI, normal MCA PI, normal DV PI; in Group 3, IUGR fetuses with abnormal UA PI, MCA PI and DV PI.Results: FI and VFI values of zone 1 were increased in Group 1.Values of VFI in zone 2 were increased in Group 2.Conclusions: Our findings are in line with recent studies in growth-restricted fetuses suggesting that the anterior cerebral artery shows Doppler signs of vasodilatation before these are observed in the MCA, demonstrating the “frontal brain sparing effect”.

3D-PDA was not found better than 2D ultrasound at distinguishing benign from malignant disease in women with AUB and an endometrial thickness greater than 4.5mm.

We sought to evaluate the association of small abdominal circumference (AC < 10 th percentile) at third trimester ultrasound with gestational age (GA) at delivery. Methods: All women seen at our institution from 2009 through 2011 for measurements from 28 to 34 weeks' gestation with a singleton, non-anomalous pregnancy were included in this retrospective cohort. We compared GA at delivery, with preterm defined as < 37 weeks, among three groups: fetuses with normal AC and normal estimated fetal weight (EFW; both ≥ 10 th percentile; Group 1), small AC and normal EFW (AC < 10 th percentile, EFW ≥ 10 th percentile; Group 2), and small AC and small EFW (both < 10 th percentile; Group 3). Data are presented as medians (interquartile ranges (IQR)) and risk ratios (RR) with 95% confidence intervals (CI). Results: Of the 612 eligible pregnancies, 47.7% of the women were White, 17.2% Black, 15.4% Hispanic, 14.1% Asian and 5.7% other/unknown. The median GA at ultrasound was 32.0 weeks (IQR: 30.6-33.0) and median maternal age at delivery was 32.9 years (IQR: 28.8-36.7). A small AC was found in 10.6% of the fetuses. Compared to Group 1, fetuses with a small AC (Groups 2 and 3) had a lower GA at delivery and a higher incidence of preterm delivery. Fetuses in Group 2 were more than twice as likely to be delivered preterm than fetuses in Group 1, while the risk was more than six times higher in Group 3 compared to Group 1 (See Table). The RRs did not change appreciably after adjusting for maternal age and race/ethnicity. Conclusions: Small AC is associated with a higher incidence of preterm delivery. This effect was demonstrated even in fetuses with EFW ≥ 10 th percentile. Further studies should examine factors that influence this association.

STUDY QUESTION Has the practice of individualizing the recombinant-FSH starting dose been superseded after the largest randomized controlled trial (RCT) in assisted reproduction technology (ART), the OPTIMIST trial? SUMMARY ANSWER The OPTIMIST trial has influenced our ART daily practice to a limited degree, but adherence is still generally poor. WHAT IS KNOWN ALREADY Although the ‘one size fits all’ approach has been discouraged for decades by most authors, the OPTIMIST study group demonstrated in a large prospective RCT that, in general, dosage individualization does not improve the prospects for live birth, although it may decrease ovarian hyperstimulation syndrome (OHSS) risk in expected high responders. STUDY DESIGN, SIZE, DURATION Retrospective analysis of all first in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles from 1st January 2017 to 31st December 2018, before and after the OPTIMIST publication on November 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS Two thousand six hundred and seventy-seven patients, between 18 and 42 years old, undergoing their first IVF-ICSI cycle in seven Italian fertility centres, were included. Patients were allocated to three groups according to their ovarian reserve markers: predicted poor ovarian responders (POR), predicted normo-responders (NR) and expected hyper-responders (HRs). MAIN RESULTS AND THE ROLE OF CHANCE Between 2017 and 2018, there was an overall increase in prescription of the standard 150 IU dose proposed by the OPTIMIST trial and a reduction in the use of a starting dose &gt;300 IU. After subgroup analysis, the decrease in doses &gt;300 IU remained significant in the POR and NR sub-groups. LIMITATIONS, REASONS FOR CAUTION The retrospective nature of the study. Physicians need time to adapt to new scientific evidence and a comparison between 2017 and 2019 may have found a greater impact of the Optimist trial, although other changes over the longer time span might have increased confounding. We cannot be sure that the observed changes can be attributed to knowledge of the OPTIMIST trial. WIDER IMPLICATIONS OF THE FINDINGS Clinicians may be slow to adopt recommendations based on RCTs; more attention should be given to how these are disseminated and promoted. STUDY FUNDING/COMPETING INTEREST(S) No external funding was used for this study. E.P. reports grants and personal fees from MSD, grants from Ferring, from IBSA, grants and personal fees from Merck, grants from TEVA, grants from Gedeon Richter, outside the submitted work. E.S. reports grants from Ferring, grants and personal fees from Merck-Serono, grants and personal fees from Theramex, outside the submitted work. All other authors do not have conflicts of interest to declare. TRIAL REGISTRATION NUMBER Not applicable.