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ssisi3 - 5 D i C E M B R E 2 0 1 5

18° congresso nazionale simp 2015

presenTazioni orali


ssisi 3-5 dicembre 2015

002 . PreTerm birTH: GeNeTic ANd NON GeNeTic ASPecTS

lisTa aUTori E.Picchiassi1;F.Tarquini1;M.Centra1;G.Coata1;V.Bini2;G.C.DiRenzo1

aFFiliazioni 1.DepartmentofObstetricsandGynecology,UniversityHospitalofPerugia,Perugia,italy 2.DepartmentofinternalMedicine,UniversityHospitalofPerugia,Perugia,italy

inTroDUzioneGlobally, each year, an estimated 13 million infants are born before 37 completed weeks of gestation. Prematurity is the leading directcauseofearlyneonataldeath,responsiblefor27%orapproximately1millionannualneonataldeaths.Pretermbirth(PTB)alsoincreasestheriskofdyingfromothercauses.Theproportionofdeathsthataredirectlyrelatedtopretermbirthislowerinlowandmiddle-incomeCountries than inhigh-incomeCountries.However,other factors relatedtoneonataldeaths, suchasneonatal sepsisandbirthasphyxiaareoftenindirectlyrelatedtopretermbirth.Overall,prematurityanditsconsequencescontributetoanestimated50%ofneonataldeaths.Preterm birth also leads to significant neonatal morbidities. Compared with infants born at term, preterm infants have greater rates oftemperatureinstability,respiratorydistress,infections,apnea,hypoglycemia,seizures,jaundice,kernicterus,feedingdifficulties,necrotizingenterocolitis,periventricular leukomalacia,andrehospitalizations.Mortality rates increaseproportionallywithdecreasinggestationalage(andhencedecreasingbirthweight)andaregreatestamonginfantsbornatlessthan32weeks.infantsbornfrom32to36weeksrepresentapproximately75%ofallpretermbirthsandthegroupof infantswhomakeupthefastest-growingproportionofthepretermbirths inhigh-incomeCountries,witha25%increaseduring1990-2005.Althoughimprovementsinmedicalcarehaveledtoimprovedsurvivalandlong-termoutcomesamongmoderatelyandextremelypretermbabiesinhigh-incomeCountries,thesebabiesstillaccountforthemajorityofdeaths.TheoverallincidenceofPTBisbetween12-13%intheU.s.andbetween5%and10%inEurope;initalyisaround6.2%.Prematurebabiesareatriskofcomplicationsrelatedtoincompleteorgandevelopmentoradaptationproblemstoextra-uterinelife,andgenerally,theyhaveahigherriskofmortalityintheveryfirstyearoflifethanothertermbabies.Thedurationofpregnancyandthemomentofbirthismainlydeterminedbythepresenceofa“placentalclock”thatisactivatedfromtheearlystagesofpregnancyandwhichinvolvestheactivationofaseriesofhormonal,inflammatoryandapoptoticmechanisms,somealreadystudiedandothersstilltobeinvestigated.Thesemechanismscanberegulatedeitherbygeneticfactorssuchassinglenucleotidepolymorphisms(sNPs),oftenresponsibleforindividualsusceptibilitytodiseases,orbynon-geneticfactorssuchasethnicity,maternalage,BMi(BodyMassindex)previousabortionsorPTBorcaesareansectionsaswellaslifestyle(typeofjob,physicalactivityandeatinghabits).ThestudiesconductedtodateontheetiopathogenesisofPTBhavefocusedonthemolecularmechanisms,geneticallydetermined,involvedintheinflammationprocess,whilestilllittleattentionhasbeenpaidtotheinvolvementofapoptosisintheplacentalpretermbirth.sinceplacentalapoptosisisoneofthemechanismsresponsiblefortheonsetoflaborandthenthebirth,theaimofthisstudywastodeterminewhethercertainsNPsofgenesinvolvedinplacental-inducedoxidativestress(TNFa,JNK,Mst3,caspase3)andsomenon-geneticfactorscouldtriggerearlyandspontaneouslythatmechanismbringingtopretermdelivery

maTeriali e meToDiPregnant women admitted as inpatients to the Department of s.C. of Obstetrics and Gynaecology of the Hospital santa Maria dellaMisericordia,Perugiabetween22+0and36+6weeksofgestationforriskofPTBwereenrolledascaseswhilepregnantwomenbetween37+0and42+0weekswereincludedascontrols.TheriskofspontaneousPTBwasdefinedbasedontheresultsofthefollowingtests:fibronectintest,cervicometryandamnisuretest.Fibronectin test is based on identification of fetal fibronectin, a glycoprotein that acts as the glue between the maternal decidua andtheamnioticmembranes;itsdiscoveryinvaginalsecretions,takenwithasimplevaginalswab,from22+0weeksisasensitivemarkerofdetachmentoftheamnioticmembranesfromtheuterinewall,indicatingahighriskofPTB.Anegativetestallowstoexcludepatientsatrisk.Cervicometryisusedtomeasurethelengthofthecervixandismadebytransvaginalultrasound.ThemeasurementofthecervixisimportanttoidentifycasesthatmayprogresstoPTB.Furthermore,thetransvaginalultrasoundpermitstoidentifythechangeinexternalandtheinternaluterineorifice(funnelinganddilation),theprotrusionofthemembranesandtheirdetachment.Normally,thecervixmeasuresbetween35and45mmand,ifthemeasurementislessthan25mm(takenascutoff),thereisanincreasedriskofPTB.Amnisuretestisbasedontheidentificationofplacentalalpha1-microglobulin(PAMG-1)aproteinwhichisabundantintheamnioticfluidbutnearlyabsentinthecervicovaginalfluidintheabsenceofruptureofthemembranes.ThisproteinisidentifiedbytheuseofmonoclonalantibodiesandapositivetestisindicativeofruptureoffetalmembranesandthusofincreasedPTBrisk.Then,thegroupofcaseswillconsistofpregnantwomenwithpositivetestoffibronectinand/orcervicallenghtequalorlowerthan25mmand/orpositiveAmnisuretest.Enrollmentofbothcasesandthecontrolswasperformedaccordingtothefollowinginclusioncriteria:singlepregnancyandfetusapparentlynotmalformedorgeneticallyabnormal.Multiplepregnancies,fetalabnormalitiesandbirthbycesareansectionwithoutlaborwereinstead

Sessione 1: PArTO PreTermiNe



consideredexclusioncriteria.Aquestionnairewasgiventoeveryrecruitedpregnantwoman,theirmedicalhistorywascollectedandafterinformedofthepurposesofthestudy,aninformedconsentwasrequired.itwassubsequentlyperformedawithdrawalofperipheralbloodinEDTAtubes.Thebloodwascentrifugedtorecoverthebuffycoatstoredat-80°CuntiltheextractionofDNA.itwasalsoperformedplacentaltissuesamplingbyfreezingitinliquidnitrogenwithin10minutesafterdeliveryandthenstoringat-80°CuntiltheextractionofDNA.GenomicDNA,extractedbycommercialkitseitherfromnucleatedbloodcellspresentinthebuffycoatorfromplacentaltissuehomogenates,wasanalyzedbyRealTimePCR(7300sequenceDetectionsystem,AppliedBiosystems).sNPsareoneofthemostcommongeneticvariationandarecharacterizedbyapointmutationinapairofbasesinaspecificlocus,usuallyconsistingof2alleles(mutantandwildtype),ofwhichthefrequencyoftherare(mutant)isgreaterthan1%.Anindividualisconsideredtobehomozygouswhenthepolymorphismispresentonbothalleles (homozygousforthemutantallele)or innoneofthetwoalleles(homozygousforthewildtypeallele);ontheotherhand,anindividualisconsideredheterozygouswhenthepolymorphismispresentonlyononeallele.ThePCRusedtoidentifysNPsisbasedontheamplificationofexactsequencesofDNArecognizedbyspecificprimersandprobes.ThesesmallregionsofgenomicDNAcanbedirectlyanalyzedbytheuseoffluorescentmoleculesexcitedbyalaserduringtheamplificationreaction.Thesequencesofourinterest,situatedinthegenesTNFalpha,JNK,Mst3andCaspase3,andinparticulartheirrespectivesNPswereamplifiedwithtwoallele-specificfluorescentprobes,containingadifferentreporterdyeatthe5’end(FAMforthemutantandViCforthewildtype)andanon-fluorescentquencheratthe3’end.After the PCR reaction, the fluorescence signals were analyzed to determine the distribution of gene-specific polymorphisms (TNFa-rs180068318-rs1800629, JNK -rs7560, MsT3-rs9517320 and CAsP3-rs1049216) in the study population.The differences in the genotypefrequenciesbetweencasesandcontrolsanddeviationsofgenotypefrequenciesobservedfromHardy-Weinbergequilibrium,werecalculatedusingtheX2test.ThetestofMann-Whitneywasusedtoevaluatedifferencesbetweencasesandcontrolswithregardtothecontinuousvariables(eg.maternalage,gestationalage,BMi,weightofthenewborn,placentalweight).Theresultswereexpressedasthemedianofvalues.DataanalysiswasperformedusingiBMsPss(statisticalPackageforthesocialsciences)release20.0,August2011(sPssinc.,Chicago,iL,UsA)

risUlTaTiAmongthe357pregnantwomenenrolledinthestudy,300deliveredatterm(controls)and57pretermwithlabour(sPTB)(cases).Maternalagewas32and34yearsforcasesandcontrols,respectively.Thegestationalageatdeliveryforthecasegroupwas33weeksandforcontrolswas39weeks.BMianddeltaBMi(differencebetweenBMiatbirthandatthebeginningofpregnancy)weresignificantlylower(p<0.05)incontrolsthanincases(25.2kg/m2vs.26.7kg/m2,and3.5vs.4.8,respectively).inaddition,theweightoftheplacentaandthebabyweresignificantlylower(p<0.005)incasesthanincontrols(475vs575gand2,430gvs.3,340,respectively).Amongnon-geneticfactors,smokingandeatinghabitswerenotrelatedtosPTB.informationonmaternalsmokingandeatinghabitswerebasedonself-declarationofpregnantwomen.EatinghabitswerethenclassifiedaccordingtofivecriteriathatcharacterizetheMediterraneandiet:1st-consumption≥5servingsoffruitsandvegetablesaday;2nd-consumptionof≥2servingsoffishperweek;3rd-useofoliveoilforcookingandseasoning;4th-consumptionof≤2servingsofredmeatperweek;5th-consumption≤2cupsofcoffeeaday.Noneoftheenrolledpregnantwomenhadadietthatmetallfivecriteriasimultaneously.inaddition,71.4%ofpregnantwomenwhodeliveredpretermnotpracticedanysportorphysicalactivity,comparedto48.3%ofcontrols(p=0.01),confirmingthecorrelationbetweenthelackofsportorphysicalactivityandsPTB.itwasalsonotedthatinpregnantwomenwhodeliveredattermweremorefrequentpreviouscaesareansectionscomparedtothecases(16.4%vs.3.6%,p=0.037).Anysignificantdifferencewasfoundbetweenfemalefetusesandmalefetusesrespecttothepossibilitytodeliverpretermandanycorrelationwasfoundbetweenneonatalpathologiesatbirth,suchasneonatalbreathingproblemsandbradycardia,andsPTB.Asregardsthegeneticcomponents,allthesNPsanalyzedincasesandincontrolswereintheHardy–Weinbergequilibrium.ThedistributionofallelefrequenciesofeachsNPincasesandcontrolsareshowninTable1.Fromthesedata,itwasfoundthatbetweenthe5sNPsstudied,therewasnoassociationbetweengenotypefrequenciesandsPTBnorinplacentaltissueormaternalblood

conclUsioniOurresultsconfirmthatsPTBisinfluencedbymanyfactors,mainlyofnon-geneticnature.Amongnon-geneticfactors,obesityandhighincreaseofmaternalweightduringpregnancyrisetheriskofsPTB.ThisfindingisincontrastwiththoseofpreviousstudieswhereitwasdemonstratedthatobesepregnantwomenhadlowerriskofsPTBthannormalweightwomansincethefirstexhibitedlessuterineactivitythanthesecond.Unlikedemonstratedbyotherstudies,smokingandeatinghabitsarenotcorrelatedwithsPTB.Thisfindingcouldbeexplainedforthesmokebyabiasduetoself-declarationofpregnantwomenoftendonotmatchreality,resultinginunderestimationoftheactualnumberofwomenwhosmokeduringpregnancy.Reardingeatinghabits,sincenopregnantwomanhasfullysatisfiedthecriteriaoftheMediterraneandiet,probably,asignificantprotectionfortheriskofsPTBwasnotfound.ThefactthatnopregnantwomanfollowedatrueMediterraneandietreflectsthecurrentchangesindietorientedtoincreasedconsumptionoffoodsrichinfatandsugarandareductionofintakeoffruitsandvegetables.



inaddition,itwasconfirmedthebeneficialeffectonthepregnancyofthesportand/orphysicalactivity,whichreducetheriskofsPTB,PreviouscesareansectionsseemstoreducetheriskofsPTB:thereasonofthisfindingisunclear.Ontheotherhand,obesityandhighincreaseofmaternalweightduringpregnancyincreasetheriskofsPTB,probablyduetoagreatersystemicinflammationandthustooxidativestress,whichconsequentlycouldinduceapoptosis.Moreover,neitherfetalgendernorthestudiedneonatalpathologiesatbirthinfluencetheriskofsPTB.Asregardsthegeneticcomponent,noneofthe5sNPsstudiedwascorrelatedtosPTB.Finally,itwasnotpossibletodemonstratetherelationshipbetweengeneticandnon-geneticfactorsintheetiologyofsPTB.Theselatestfindingsmaydependonthenumberofpregnantwomenenrolledinthestudy,thatdespitesubstantial,maystillbescarceforastudyonthesNPs,characterizedbyfrequencydistributioninthegeneralpopulationverylow.Therefore,furtherstudiesshouldbeconductedbyincreasingthenumberofsamplestobeanalyzedinordertobetterevaluatetheinterferenceofgeneticandnon-geneticcomponentsintheetiopathogenesisofsPTB



021 . POSSibiLi APPLicAZiONi TrASLAZiONALi deLLA meTAbOLOmicA NeLLA diAGNOSi NON iNVASiVA di TrAVAGLiO A TermiNe e PreTermiNe lisTa aUTori R.Mereu;L.Barberini;s.F.Deiana;D.Porru;A.Noto;A.Meloni

aFFiliazioni 1.DipartimentoMaterno-Neonatale,UnitàdiOstetriciaeGinecologia,AziendaOspedaliera-UniversitariaCagliari,italia 2.DipartimentoMaterno-Neonatale,Unitàdicuraintensivaneonatale,istitutodiPuericulturaesezioneNeonatale,Azienda Ospedaliera-UniversitariaCagliari,italia

inTroDUzioneLametabolomicaappartieneallaclassedellescienzecosiddettescienze“omiche”insiemeallamRNA-trascrittomica,genomicaeproteomica.Attraversoessaèpossibilestudiarelacomplessitàmetabolicadellecellule,deitessuti,comeanchediinteriorganismi,valutandointalmodoilprodottofinaledelmetabolismoedottenendoilfenotipometabolicodelsingoloindividuo.Durantelagravidanzal’indagine“omica”puòcontribuireall’identificazionedimolecolechiaveincondizionifisiologiche,qualiiltravaglioatermine,maanchedialcunepatologiedellagravidanzacomelarotturaprematuradellemembrane,pretermineenon,edilpartopretermine.Diversistudihannomostratolecapacitàdellametabolomicaneldefinireiprofilimetabolicidicondizionisiadifisiologiachedipatologia,grazieallostudiodidiversifluidibiologici,ottenibilidallaquasitotalitàdell’organismoumano,mediantetecnichequalilaH-NMRelaGCMs,chespazianodalsangue,alplasma,alleurine,allefecieperfinoalliquoredalliquidoamniotico.soprattuttoquest’ultimohadato,nellostudiodelpartopretemine,interessantirisultati.Riteniamochequestasialascienzapiùadattaadelineareunquadrometabolicodellagravidanzafisiologicaearischioeadindividuare,infuturo,strumentidiagnosticiditipononinvasivoincondizioniclinichequaliiltravagliospontaneoamembraneintegreerotteediltravagliopretermine.Nelnostrostudioabbiamosceltodianalizzarel’urinagiacchéottenibileinmanieranoninvasivaeinvolumipiùampiepiùaccettatadallepazienti.ObiettivoL’applicazionedell’analisimetabolomicasulleurinedidonneingravidanzaabassorischio,perampliarelaconoscenzariguardoalleviemetabolichechesimodificanotrafasidiquiescenzaatermine(infasepre-travaglio)eintravagliodipartoatermine(Fase1).successivainclusionenellostudiodipazientiinregimediricoveroperPROM,(FAsE2)ePPROM,(FAsE3)

maTeriali e meToDisonostatereclutateper ilnostrostudiogestantiafferentiallaclinicaOstetrica-Ginecologicadell’AOUdiCagliari.Ciascunreclutamentoèstatoprecedutodaunafasedicolloquioinformativodelladonnaedallasottoscrizionedapartedellastessadiunconsensoscritto,previaapprovazionedalComitatoEticolocale.FAsE1:Abbiamoreclutatouncampionedi59donnefuoritravaglioingravidanzaabassorischio,(donnecongravidanzaatermineEG>37,assenzadipatologiamaternaofetalealreclutamento,fetosingoloinpresentazionecefalica),eleabbiamoseguitesinoaterminegravidanzainmododapoterraccoglieredeicampioniseriatidiurineincuianalizzareidiversimetaboliti.Perciascunadonnaèstatacompilataunaschedadiraccoltadatiditipoanagraficoedanamnestico,nonchédiunaseriediinformazioniclinicherilevatesiadurantelevisitefuoritravagliodellapaziente(visitaostetricaomonitoraggioatermine)cheduranteilperiododidegenzaperl’espletamentodelparto.Aquestomomentohafattoseguitolaraccoltadelcampionebiologico(campionediurina)inuroboxconservatoimmediatamentea-20°esuccessivamente,nell’arcoditempodelle24H,aliquotatoinprovetteda3mleripostoinfreezera–80°.Uncodicealfanumerico(AOU+numprogressivo)èstatoassegnatoaciascuncampione,identificandonecosìlecaratteristiche(datipaziente,dataeorario).35campionisonostatiraccoltidurantevisitediroutineaterminedigravidanzamentreirestanti24duranteiltravagliodipartoinfaseattiva(dilatazionedellaboccauterinadi3-4cmeattivitàcontrattileuterinaregolareedolorosa) lacuidiagnosièstataconfermata inmanieraretrospettiva.icampionisonostatiinizialmentescongelatiportandoliatemperaturaambiente,centrifugatia12000rpmper10minutia4°C.successivamentesonostatianalizzaticonduetecniche:la1H-NMRelaGC/Ms.FAsE2:Abbiamoreclutatouncampionedi11donne in regimedi ricoveroperPROM,abbiamoraccoltoe analizzaton°52campionidiurinedicuiilprimoraccoltoprimadellarotturadellemembraneediseguentialmomentoosuccessivamentealladiagnosidiPROM.Perciascunadonnaèstatacompilataappositaschedadiraccoltadati,icampioniraccoltiinuroboxsonostaticonservatiimmediatamentea-20°esuccessivamente,nell’arcoditempodelle24H,aliquotatiinprovetteda3mleconservatiinfreezera–80°.Uncodicealfanumerico(AOU+numprogressivo)èstatoassegnatoaciascuncampione,identificandonecosìlecaratteristiche(datipaziente,dataeorario).icampionisonostatiscongelati,portatiatemperaturaambiente,centrifugatiperrendereilcampioneomogeneoedanalizzaticontecnicaGC/Ms.FAsE3:AttualmentestiamoreclutandoeraccogliendocampioniseriatidipazientiinregimediricoveroperPPROM



risUlTaTiFAsE1:L’indagineNMRhamostrato,qualimetabolitimaggiormenterappresentativideltravaglioattivo,inordinedecrescenteperimportanza,laglicina,l’acidolattico,l’acido3idrossibuttirrico,l’acidoacetoacetico,l’acetoneedilglucosio.AllaGC/Msimetabolitidiscriminantiiltravaglioattivosonorisultati:laglicina,gliacidi2,3,4triidrossibutirrici,l’acidosuccinico,l’acidoaconitico,l’acidoD-gluconico,ilD-galattosio,laNacetilglucosaminaedilmioinositolo.Consideratinell’insiemequestimetabolitidefiniscono,suicampioniesaminati,l’improntametabolicadeltravagliodipartodifferenziandoloinmanierasignificativadallagravidanzaquiescenteatermine.FAsE2:Attraverso l’analisiGC/Msdeicampionièstatopossibiledefinireun’improntametabolicapreliminaredeicasidi PROM.LaPLs-DAhamostratoinfattidueclassidimetabolitichedifferiscononelledonneconMACintegrerispettoaquelleconrotturaprematuradellemembrane,intravaglioefuoritravaglio.UtilizzandolapiattaformawebMETABOANALYsTabbiamopotutoidentificare5viemetabolichesignificativedellaPROM:1)labiosintesidiAminoacil-tRNA,2)ilciclodelCitrato,3)ilmetabolismodelNitrogeno,4)ilmetabolismodell’Alanina,dell’AspartatoedelGlutammatoe5)ilmetabolismodiD-GlutamminaeD-Glutammato

conclUsioniAvvalendosidelletecniche1H-NMReGC/Msl’analisideicampionifuoritravagliovstravagliohamostratoduedifferenticlusterdimetabolitiariprovadeldiversometabolismonelleduefasiedellapossibilità,infuturo,diottenereuntestdiagnosticoditravagliodipartodaaffiancareallaclinicaacui,adoggi,èancoraaffidataintototalediagnosi.Questoporterebbeadunadiagnosiditravaglioditipoprospetticoenonpiùretrospettivaqualequellaodierna,riducendo,senoneliminandodeltutto,iricoveriperfalsotravaglio.QuestisonoancoraoggicausadicostiinterminieconomiciperilssNedisfiduciaperlapazienteversosestessaedilpersonalemedico/ostetricochesivedespessoperciò“costretto”adintervenirealfinediaccelerareunprocessoche,forse,fisiologicamentenonsarebbedovutoverificarsiinqueldatomomento.Confortatidaidatipositividanoiottenutisuicampionidelledonneingravidanzaabassorischioesupportatidadatidellaletteratura,[3],abbiamoritenuto importanteestendere ilnostrostudioaicasidi rotturaprematuradellemembraneecompararliaquelligiàraccolti inprecedenza.La scelta è stata dettata sia dalla frequenza con cui tale evento patologico si verifica (10% di tutte le gravidanze, nel 20-40% si verificapretermineovveroprimadelle37settimane)masoprattuttoperl’importanzarivestitadatalecondizionenelpartopretermine(40%deicasi),sindromecherappresentalapiùimportantecausadimortalitàemorbilitàperinatale.Ancoraoggil’eziopatogenesidelpartopreterminenonèbendefinita,dipendedifattidall’intersecarsididifferentimodificazionibiologiche,cellulari,ormonali,molecolaricheportanoallaprematuraattivazionedeiprocessichepreludonoaltravagliodiparto(maturazionecervicale,attivazionemiometrialeerotturaprematuradellemembrane.)eancheladiagnosiclinicanonècertoscevradadifficoltà.PoterdisporrediunospettrometabolicosuicampioniprovenientidagravidanzeconPPROM,qualeanalogamenteaquellodanoiottenutosuicampionidiurinedidonneconPROM,acuirifarsipotrebbeconsentire,infuturo,diottenere,incasodiPPROM,untestprognosticoperilpartopretermineelecomplicanzeadessoassociate



034 . FATTOri NUTriZiONALi ed ePiGeNeTici ASSOciATi Ad UNA ridOTTA creSciTA POST-NATALe deLLA circONFereNZA crANicA iN NeONATi VLbW lisTa aUTori F.Moscuzza1;A.Massei1;E.Fiorentini1;A.Michelucci2;F.Lorenzoni1;R.T.scaramuzzo1;A.Cuttano1;A.Boldrini1;P.GhirriP1

aFFiliazioni 1.UONeonatologiaeTerapiaintensivaNeonatale,AOUP(PisA),italia 2.GeneticaMolecolare,AOUP(PisA),italia

inTroDUzioneUnarestrizionedicrescitadellacirconferenzacranica(HC)alladimissionerappresentauneventofrequentenelneonatopretermineVLBWecorrelaconunpeggioroutcomeneurocognitivoadistanza(1).Adeguatiapportinutrizionalisembranonecessarioltrecheperunnormaleaccrescimentosomaticoancheperunnormalesvilupponeurocognitivo. inoltre, imeccanismichesottendonolarelazionetracondizionicriticheembrio-fetali,bassopesoallanascita,crescitapost-nataleepatologiecronico-degenerativedell’adultosembranolegatiafenomeniepigenetici

maTeriali e meToDiNell’ambitodiunostudioretrospettivosu75neonatiVLBWconEG≤32settimane,abbiamoanalizzatoalcunifattoridirischiopre-epost-nataliperlosviluppodiunarestrizionedicrescitadellaHCalladimissione.inparticolare,perquantoriguardagliaspettiepigeneticiabbiamoanalizzato(allanascitaedalladimissione),suunpiccolocampionedellanostrapopolazione(n=10)ilgradodimetilazionedelDNAnellaregione15delbracciocortodelcromosoma11(11p15),laqualecontieneunclusterdigenisoggettiadimprintingconunimportanteruolonellaregolazionedellacrescita.Questoclusterèregolatodauncentrodiimprintingchepresentaunastrutturabipartita,caratterizzatadadueindipendentiimprintingcontrolregion(iCR)(iC1eiC2)checoordinanol’espressionediduediversi“pacchetti”digeni:iC1regolal’espressionediH19eiGF2(inparticolarequest’ultimohaunafunzionedistimolosullacrescita),mentreiC2coordinaigeniKCNQ10T1,KCNQ1,CDKN1CePHLDA2(questiultimitregenisonoconsiderati“growthinhibitors”).LarestrizionedicrescitaèstatadefinitacomeilriscontrodivaloridiHC<10°percentilerispettoallacrescitaintra-uterinaattesa,valutataalmomentodelladimissione,adun’etàpost-mestruale(EPM)trale36ele42settimane,utilizzandocomeriferimentolecarteantropometrichediBertino(2)

risUlTaTiTraifattoriprenatalilanascitasGArappresentaunfattoredirischiopertalecomplicanza(OR4,86-p=0,014).Lavalutazionedelpesotramitelozscorea36settimaneEPMevidenziaunaforteassociazioneconlosviluppodirestrizionedicrescitapost-nataleperHC:inparticolaremaggioreèilvaloredizscoreminoreèilrischiodiessereEUGRhc(OR0,15-p=0,001).L’analisideisingoliapportinutrizionalimedinellaprimasettimanadivitaevidenziacomel’apportoproteicogiochiunruolochiavenellosviluppodirestrizionedellacrescita,inparticolareineonatiEUGRhc(n=19)avevanoricevutoapportiproteicisignificativamente inferiori rispettoaineonatichenonpresentavanotalerestrizionedicrescita(n=56)(p=0,009).Un’alimentazioneesclusivaconlatteumanoèassociataadunpeggioraccrescimentodellaHCrispettoaineonaticheabbianoassuntounaformulaspecificaperpretermineocomunqueunallattamentoditipomisto(OR3,61-p=0,023).inoltre,valoridiTsHpiùelevatialladimissionerappresentanounfattoredirischioperlosviluppodiEUGRhc,(OR1,33-p=0,031).Perquantoriguardagliaspettiepigenetici,inaccordoconlaletteratura,ilnostrostudiohariscontratounacorrelazioneinversatralametilazionedelleiCRelacrescitadellacirconferenzacranica,chequindisiconfermaesseremarkerpiùsensibile,rispettoalpeso,delfetalprogramming.ineonatichepresentavanoalladimissionel’ipermetilazioneiniC1risultavanoessereglistessichepresentavanounarestrizionedicrescitadellacirconferenzacranicaedunridottoapportoproteico

conclUsioniUncostantemonitoraggiodellagravidanzaperridurrel’incidenzadellanascitasGAedunacorrettagestionedelneonatopretermineduranteladegenzainTiNconl’attentavalutazionedipossibilifattoridirischiosononecessariperridurreilfenomenodellarestrizionedicrescitapostnatale.imeccanismichesottendonolosviluppoelacrescitaneonatalesonoancorainlargapartesconosciuti,malerecentiacquisizioninel campo dell’epigenetica sembrano conferire loro un fondamento molecolare, correlando modificazioni ambientali occorse in periodicritici,embrio-fetaleeneonatale,acambiamentinelfenotipodell’individuo



062 . iS A WOOLeN cAP eFFecTiVe iN mAiNTAiNiNG NOrmOTHermiA iN PreTerm iNFANTS dUriNG KANGArOO cAre iN LOW-iNcOme cOUNTrieS? lisTa aUTori M.E.Cavicchiolo1;D.Trevisanuto1;G.Putoto2;G.segafredo2;D.Pizzol3;P.Lanzoni3;G.Azzimonti4;W.Massavon5;A.Tsegaye6; O.Wingi7;E.Onapa8

aFFiliazioni 1. DepartmentofWomenandChildrenHealth,UniversityofPadua,AziendaOspedalieradiPadova,Padova,italy 2.DoctorswithAfricaCUAMM,Padova,italy 3.DoctorswithAfricaCUAMM,Mozambique 4.DoctorswithAfricaCUAMM,Tanzania 5.DoctorswithAfricaCUAMM,Uganda 6.DoctorswithAfricaCUAMM,Ethiopia 7. Director,DepartmentofPediatricsandNeonatology,CentralHospitalofBeira,Mozambique 8. Director,HospitalofAber,Uganda

inTroDUzioneThedaysandweeksfollowingchildbirth–thepostnatalperiod–isacriticalphaseinthelivesofmothersandnewbornbabies.Mostmaternalandinfantdeathsoccurduringthistime.1in this period, neonatal hypothermia is an important challenge associated with morbidity and mortality.2 Hypothermia increases thenewborn’smetabolicrequirementsandisassociatedwithhypoglycemia,hypoxia,andultimatelysevereinfectionsandnewbornmortality.3Preventingneonatalhypothermiaisimportantinhighresourcecountries,butisoffundamentalimportanceinlowresourcesettingswheresupportivecareislimited.Forthepostnatalcareofthenewborn,theWorldHealthOrganization(WHO)guidelinesstate:“Appropriateclothingofthebabyforambienttemperatureisrecommended.Thismeansonetotwolayersofclothesmorethanadults,anduseofhats/caps.”Wheneverpossible,KCisalsostronglyrecommendedfortemperaturemaintenance.4Previousstudiesshowthatneonatalheatlossfollowingdeliverymaybereducedorpreventedbytheapplicationofsimplewoolenhats.5-7Ontheotherhand,alsohyperthermiashouldbeavoided.8AlthoughWHOguidelinesrecommendtheuseofcap/hatduringKC,theeffectofthecaponneonataltemperatureduringthedaysandweeksfollowingchildbirthhasnotbeenpreviouslystudied.it’sunknownwhethercoveringtheheadoftheneonatewithawoolcapduringKCmayhelptemperaturemaintenance.TheresultsofthepresentstudywillallowtounderstandwhethertheuseofacapduringKCwillbeeffectiveandsafe.Theaimofthepresentstudywillbetoassesstheeffectivenessandthesafetyofawoolencapinmaintainingnormothermiainlowbirthweightinfants(LBWi)duringKC

maTeriali e meToDiThisisamulti-center,prospective,unblinded,randomizedclinicaltrialofKCtreatmentwithandwithoutawoolencapinLBWithatwillberunthroughacollaborationoftheDepartmentofWomenandChildrenHealth,UniversityofPaduaandDoctorswithAfricaCUAMM,anon-governmental-organizationthatworkstostrengthenhealthcareservicesinAfrica.ThestudywillbeconductedinthreehospitalsthathavedifferentlevelsofhealthcareinthreeAfricancountriesandthreedifferentattitudetoKangarooCare(wellestablished,mediallyestablishedandnotestablishedyet)whereDoctorswithAfricaCUAMMhasongoingprojectsonmaternal-neonatalhealth.Theyare:-theCentralHospitalofBeirainMozambique,whichisagovernmentalhospital(iiilevel);-thest.LukeWolissoHospitalinEthiopia,whichisanot-for-profitzonalhospital(iilevel);-theAberHospitalinUganda,whichisanot-for-profitruralhospital(ilevel).inclusioncriteriaforthestudyare:1.birthweight<2500g(and)2.candidatetoKCtreatment(and)3.parentalconsent;awritteninformedconsentwillbeobtainedbyamemberoftheneonatalteaminvolvedinthestudyfromaparentorguardianbeforeKCtreatment.Whiletwins,patientswithmajorcongenitalmalformations,orbabieswithparentalrefusaltoparticipatetothestudy,willbeexcluded.Thestudywillenrollatotalnumberof400patientswhowillberandomlyassignedtoKC+caporKCgroupwithoutcapina1:1ratioaccordingto a computer-generated, randomized sequence.The primary outcome measure will be the time spent by the neonate in the normaltemperaturerange(36.5-37.5°C)incourseofKCduringthefirstweekoflife.inallparticipants,axillarytemperaturewillbemeasuredwitha



digitalthermometer4timesperday.ForeachpatientswillalsobeestimatedthenumberofhoursspentinKC.secondaryvariableswillbe:numberofepisodesofapnea,sepsis,mortalitybeforehospitaldischarge,in-hospitalgrowthandageatdischarge

risUlTaTiinthistrial,weexpecttoassesstheefficacyandthesafetyofusingawoolencapduringKCtreatment.WealsoexpecttodetectdifferentialeffectofusingwoolencapsstratifiedforthenumberofhoursspentinKCbypatients

conclUsioniThereareuniquefeaturesofthistrialcomparedtopriorstudiesonKC.WorldHealthOrganizationguidelinesrecommendtheuseofacapduringKCtreatment,butevidenceforthispracticeisstilllacking



Sessione 2: ASFiSSiA PeriNATALe

003 . cONTiNGeNT VerSUS rOUTiNe THird-TrimeSTer ScreeNiNG FOr LATe FeTAL GrOWTH reSTricTiON

lisTa aUTori s.Triunfo;E.Gratacos;F.Figueras

aFFiliazioni Fetali+DFetalMedicineResearchCenter,BCNatal-BarcelonaCenterforMaternal-FetalandNeonatalMedicine(HospitalClínicand HospitalsantJoandeDeu),iDiBAPs,UniversityofBarcelona,spain. CentreforBiomedicalResearchonRareDiseases(CiBER-ER),spain

inTroDUzioneAnnually~400,000pregnanciesintheEuropealonecanbecomplicatedbyfetalgrowthrestriction(FGR).However,antenataldetectionfallsshortinclinicalpractice,failingtorecognizeupto75%ofbabiesatriskofFGRbeforedelivery1.suchpoorperformancetakesatollintermsofperinatalhealth,giventhatsmallbabieswhoareoverlookedhavehigherrisksofadverseperinataloutcomesandstillbirth.2,3ThereareseveralbaselineriskfactorsthatshouldraisesuspicionofFGR.4Nevertheless,theperformanceofthesefactorsispoor,withdetectionrates(DRs)of50%and20%forearly-andlate-onsetFGR,respectively.5UterineDoppler(toassesstrophoblasticinvasion)hasbeenproposedasascreeningtool,yieldingDRsofabout25%and75%atfirstandsecondtrimesters,respectively.6,7BycombininguterineDopplerfindingsandbaselinematernalcharacteristics,DRsforearly-onsetFGRreachclinicallyacceptable levels.5,8Unfortunately,FGRdevelopinglate inpregnancyisstilllargelyundetected9-12,althoughrepresentingthelargestfractionofadverseperinataloutcomesandstillbirths.10Currentgrowthscreeningstrategiesinvolvemeasuringthesymphysisfundalheight,butlessthan25%ofsmall-for-gestational-ageinfantswillbedetectedusingthismethodologyinalow-riskpopulation.13Routinethirdtrimesterscanforfetalgrowthassessment, inplaceinmanycountries,hasDRsrangingfrom50%to80%,2,11butthebeneficialimpactonperinataloutcomeisalsounclear.Eighttrialshavebeenincludedinarecentlyupdatedmeta-analysis12concludingthatroutinelatepregnancyultrasound(Us)inlow-riskorunselectedpopulationsdoesnotconferbenefitonmotherorbaby,costissuesaside.Furthermore,serialthirdtrimesterUshavenotbeendemonstratedtoimprovethisperformance.14,15BecausethereisnoevidencetosupportaroutinethirdtrimesterUs,itseemsreasonabletoselectsubgroupsofwomenwhoareatthehighestrisk,forwhomthird-trimestergrowthassessmentmaybebotheffectiveandefficient.Theaimofthisstudywastoevaluatetheperformanceofthird-trimesterUsdoneonacontingencybasis(accordingtoriskaccruedatsecondtrimester)inanunselectedpopulation,asameansofpredictinglateFGR

maTeriali e meToDistudypopulationBetweenJanuary,2010andDecember,2012,aprospectivecohortofconsecutivesingletonpregnancieswasrecruited,eachreferredtotheDepartmentofMaternal-FetalMedicineintheHospitalClinicofBarcelonaforroutinefirst-trimesterscreeningofaneuploidies(8+0to13+6weeksofgestation).Calculatedgestationalagewasbasedoncrown-rumplengthatfirst-trimesterscan.16Anypregnancieswithaneuploidiesormajorfetalabnormalities,andthoseinvolvingtermination,miscarriageorfetaldeath,suspectedFGR(estimatedfetalweight1715%wereconsideredrelevant.Fortypeierrorrateof5%andtargetpowerof90%,requiredinstancesofFGRwas65(for0.2correlationrankcoefficient).Assuminga5%prevalenceofFGR,amaximumtotalsamplesizeof1300wasestimated.19Becauseavalidationcohortwasdesignedofthesamesizethantheconstructioncohort,thefinalsamplesizewassetat2600.OutcomemeasuresandclinicalmanagementFGR was defined as birth weight <3rd percentile by local standards18; or birth weight between 3rd and 10th percentiles with prenatalabnormalitiesofcerebroplacentalratio(95thpercentile).21inpregnanciescomplicatedbyFGRaspecificclinicprotocolwasapplied.22Todefinepreeclampsia,guidelinesoftheinternationalsocietyforthestudyofHypertensioninPregnancy23wereapplied.Allwomenunderwentcontinuousfetalmonitoringduringlabour,usingathree-tieredclassificationforhearttracings.24Non-reassuringfetalstatusduringlabourwasdefinedasapathologicalfetalheartrate23orasuspicioustracingwithafetalbloodscalpsamplingbelow7.15orbelow7.20intwosample30-minuteapart.NeonatalmetabolicacidosisatbirthwasdefinedasumbilicalarterialpH90thpercentile(12mEq/L).25Predictivevariables1. MaternalcharacteristicsData on maternal characteristics, including age, ethnicity, low socioeconomic status (routine occupation, long-term unemployment, orneverworked),bodymassindex(BMi),nulliparity(nopriordeliveriesafter22weeksofgestation),smokingstatus,methodofconception(spontaneousorassistedreproductivetechnique[ART]includingovulationinduction, invitrofertilizationandoocytedonation),medical



history(knownchronicdisease,suchashypertension,diabetesmellitus,renaldisease,autoimmunedisorder,andcongenitaloracquiredthrombophilicconditions),andobstetrichistory(includingpriorpregnancycomplicatedbystillbirth,FGRandpreeclampsia)wererecordedinthehospitaldatabaseatstudyinclusion.inaddition,alldatapertainingtofollow-up,developingcomplications,Usevaluations,andperinatalconditionswereprospectivelycollected.2. BiophysicalparametersAtfirst-trimesterscreening,bloodpressurewasrecordedbyanurse inouroutpatientclinic, inaccordancewithstandardprocedure.Anautomatedcalibrateddevice(M6Comfort;OmronCorp,Kyoto,Japan)wasused,selectingonearm(rightorleft)atrandom,withsubjectsseatedaftera5-minrest.Meanarterialpressure(MAP)wascalculatedas:diastolicBP(systolic–diastolic)/3.3. UltrasoundevaluationFirst trimester screening for chromosomal abnormalities by a combination of fetal nuchal translucency and biochemical measurements(previouslyobtainedat8+0to9+6weeks)wasofferedat11+0to13+6weeksofgestation.second-andthird-trimesterUsexaminations(regularlyperformedat19+0to21+6andat32+0to33+6weeks,respectively)includedthefollowingbiometricparameters:biparietaldiameter(BPD),headcircumference(HC),abdominalcircumference(AC),andfemurlength(FL).Allmeasurementswereobtainedbyoneofseventrainedsonograhers,adheringtorecommendedtechnique.26Atthirdtrimester,estimatedfetalweight(EFW)wascalculatedusingtheHadlockformula.174. DopplermeasurementsPrenatalDopplerstudieswereconductedusingeitherasiemenssonolineAntares(siemensMedicalsystems,Malvern,PA,UsA)oraGeneralElectricVolusonE8(GEMedicalsystems,Zipf,Austria),eachequippedwitha6-2MHzlinearcurved-arraytransducer.UterinearteryDopplerevaluationswereperformedtransabdominallyinsecondtrimester,accordingtorecommendedmethodology.21Meanpulsatilityindex(Pi)representedanaverageofrightandleftarterialvalues.statisticalanalysisThecohortwasrandomlysubdivided(1:1ratio)intoconstructionandvalidationsub-cohorts.student-ttest,Pearsonchi-squaredorFisher’sexacttestwereperformedtomakeunivariatecomparisonsofquantitativeandqualitativevariables,respectively,betweentwogroups.Abinomialdistributionmodelwasusedtodeterminethe95%confidenceinterval(Ci)ofproportions.Thefollowingsteps(detailedinsupplementarydata)weretakentodevelop(intheconstructioncohort)thefullmodelforpredictinglateFGR:1. LogarithmictransformationstonormalizemeanMAP,UtA-Piandallfetalbiometricparameters.2. Multiplelinearregression(forwardstepwiseselection,withp-valuecutpointsof0.05forinclusionandexclusion)formulaswerecalculatedtoderivefirst-trimesterexpectedlogMAP;second-trimesterexpectedlogUtA-Pi,BPD,HC,AC,andFL;andthird-trimesterexpectedlogBPD,HC,AC,FL,andEFW.3. individualexpectedlogvalueswerethenpredictedforbothaffectedandunaffectedpregnancies.4. Fromexpectedlogvaluescalculatedinthesteps2&3,multiplesofthemedian(MoM)werecalculatedforeachsubjectasfollows:observedlogvalues–expectedlogvalues.5. Receiver-Operator-Characteristic(ROC)curvestopredictFGRwereconstructedforeachpredictor(logMoMvalues).Multiplelogisticregressionanalysis(forwardstepwiseselectionwithpvaluescut-offsforinclusionandexclusionof0.05)wasperformedforindividualestimatesofthefollowingFGRrisks:6. Aprioririsk(covariables:maternalage,BMi,ethnicity,lowsocioeconomicstatus,nulliparity,smoking,ART,previousobstetriccomplications,medicaldiseases).7. Aposteriorifirst-trimesterrisk(covariables:nuchaltranslucency,MAP,meanUtA-Pi,andaprioririsk).8. Aposteriorisecond-trimesterrisk(covariables:biometricmeasures,meanUtA-Pi,aposteriorifirst-trimesterrisk).9. Aposteriorithird-trimesterrisk,fullmodel(covariables:biometricmeasures,EFW,aposteriorisecond-trimesterrisk).in the validation cohort, predictive performances of the various strategies stipulated for contingent third-trimester scanning (based onsecond-trimesteraposterioririskandconductedin10%,25%,or50%ofthestudypopulation)weredelineatedinROCcurves,andeachROCcurvewastested27againstthefullmodel(i.e.,routinethird-trimesterscan).Withhighlycorrelatedmeasurements(R>0.75),suchasUsbiometricmeasures,onlyavariablewiththelargestindividualareaundertheROCcurvewasenteredinamodelforregression.Assumptionsforregressionwerecheckedineachmodel,andgoodness-of-fitwasassessedbycalculatingR2orNagelkerkeR2forlinearandlogisticmodels,respectivelyThestatisticalsoftwareRversion2.15.1(TheRFoundationforstatisticalComputing)withthepackagepROCversion1.7.2wasusedforallstatisticalanalysisandgraphconstruction

risUlTaTiOfthe2,775womenrecruitedinfirsttrimesterofpregnancy,79(2.8%)wereexcludedforthefollowingreasons:1)losttofollow-up(n=20),2)miscarriage(n=13),3)congenitalmalformation/chromosomopathy(n=20),4)terminationofpregnancywithoutmedicalindication(n=5),



5)stillbirth(<32weeks)(n=6)and6)early-onset(<32weeks)FGR/preeclampsia(n=15).Atotalof155(5.7%)ofthe2,696womenanalyzedexhibitedFGR,thatwererandomlydividedintoconstruction(73FGRand1320controls)andvalidation(82FGRand1221controls)sub-cohorts.Table1inthesupplementarymaterialdetailstheepidemiologicandperinatalcharacteristicsofbothsub-cohorts.Ofnote,significantdifferencesbetweentheconstructionandvalidationsub-cohortswereonlyfoundinwhiteethnicity(63.1%vs.59.3%),chronichypertension(0.9%vs.2.1%)andgestationaldiabetes(6.8%vs.4.9%).Epidemiologic,clinicalcharacteristicsandperinataloutcomesofthevalidationcohortaresummarizedinTable1.Maternaldemographics(ethnicity, smoking status, and medical and obstetric maternal histories) differed significantly in pregnancies with and without FGR. Asexpected,perinataloutcomesintermsofpreeclampsia,emergencycaesareansectionfornon-reassuringfetalstatus,andneonatalmetabolicacidosiswerepoorerinFGRpregnancies.Biophysicalandultrasoundvariablesofthevalidationcohortinfirst,secondandthirdtrimestersarereportedinTable2,whereAUCsaredetailedindividuallyforeachparameter.ThefollowingmodelsbestfitspecificrisksforlateFGR:AprioririskLogit=-1.613-0.064*BMi+0.133 ifLatin-Americanethnicity -0.746 ifnulliparity+1.506 ifsmoker+1.036 ifpreviousadverseobstetricoutcomes;R210%Aposteriori1sttrimesterriskCalculationofLogMAP(mmHg):ExpectedLogMAP(mmHg)=1.84+0.00153*BMi+0.000602*maternalage;Logit=0.421+2.491*Logaprioririsk+11.884*LogMoMMAP;R212.4%Aposteriori2ndtrimesterriskCalculationofACMoM:ExpectedLogAC=2.006-0.0058*GA(weeks)+0.00074*GA2+0.0061ifmaleCalculationofUtA-PiMoM:ExpectedLogUtA-Pi=1.946-0.176*GA+0.0039*GA2+0.0125ifmaleLogit=0.199+2.796*Log1sttrimesteraposterioririsk–31.614*LogMoMAC+3.456*LogMoMUtA-Pi:R2=22.4%Aposteriori3rdtrimesterriskCalculationofEFWMoM:Exp_Log_EFW=-1.891+0.28*GA–0.00368*GA2+0.00604ifmaleLogit=-1.591+1.841*Log(aposteriori2ndtrimesterrisk)–29.1*LogMoMEFW;R247.5%Table3andfigure1providethepredictiveperformanceofeachmodelderived.Atfirsttrimester,acombinationofaprioririskandMAP(i.e.,aposteriorifirst-trimesterrisk)yieldedanAUCof0.71(95%Ci0.65-0.77)(DRof36.6%at10%FPR).Atsecondtrimester,aposteriorifirst-trimesterriskcombinedwithsecond-trimesterACandUtADoppler(i.e.,aposteriorisecond-trimesterrisk)yieldedanAUCof0.81(95%Ci0.74-0.87)(DRof43.1%at10%FPR).Finally,thecombinationofaposteriorisecond-trimesterriskplusthird-trimesterEFW(fullmodel)yieldedanAUCof0.92(95%Ci0.88-0.96)(DRof74%at10%FPR).Allformulasforcalculatingtheserisksareappendedassupplementarymaterial.Cut-offsforsecond-trimesterrisk,asthebasisforcontingentthird-trimesterscanningof10%,25%,and50%ofsubjects,were12.3%,5%,and1.7%,respectively.inotherwords,third-trimesterscanningwaswarrantedataposteriorisecond-trimesterriskabovethesecutpoints.RespectiveAUCvalues(95%Ci) formodelsat10%,25%,and50%ofsubjectswere0.81(0.75-0.88),0.84(0.78-0.91)and0.89(0.84-0.94),respectively.Onlythe50%contingencymodelprovedstatisticallyequivalenttothefullmodel(p=0.11).Table4andFigure2showROCcurvesofeachcontingentmodelandthefullmodel

conclUsioniinpredictinglateFGR,ourstudyshowsthatastrategyofscanningatthirdtrimesterin50%ofthepopulationbasedonthecombinedfirstandsecondtrimesterrisksisequivalenttoroutinelyscanningthewholepopulationofpregnantwomen.Althoughevidencefromrandomizedtrialsfailstodemonstrateanyrealbenefitfromroutinethird-trimesterscanning7,12,itmaybearguedthattheresultsofthismeta-analysishavelimitedcontemporaryvalidityasitincludedstudiesusingoutdatedsurrogatesoffetalgrowth,suchasBPD28,orprotocolswherediagnosisofFGRelicitednochangeinmanagement.subsequently,atrialtoinvestigatetheimpactofthird-trimesterUsshouldfindwillingparticipants29,butalargesamplesizewouldbemandatorytoassesstheeffectsonhardoutcomes,suchasperinatalmortalityrelatedtobirthweightpercentileoutsidethenormalranges.Theeffectivenessofroutinethird-trimesterUsbiometryindiagnosingFGRisalsounclear.DRofACforabirthweight<10thpercentilerangesfrom48-87%,withaspecificityof69-85%.30ForEFW,DRsof25-100%andspecificitiesof69-97%havebeenreported.14,30ArecentandlargestudyshowsthatimprovementsinthedetectionsGAcanbeobtainedcombingmaternalcharacteristicsandfetalbiometryat30-34week,achievingdetectionratesof80%ofneonatesdeliveringwithin5weeksafterassessment.31Recently,Lesmesetal32demonstratedthepotentialvalueofuterinearterypulsatilityindexat19-24weeks’gestation,incombinationwithmaternalcharacteristics,medicalhistoryandfetalbiometryforpredictionofdeliveryofsGAbabies,achievingDRof66%and43%forthosedeliveringat32-36and≥37weeks’gestation,respectively.ByrefiningourdefinitionofFGRtoincludeonlythosepregnancieswithevidenceofplacentalinsufficiencybeforedeliveryorseveresmallnesswetriedtominimizethecontaminationofourcohortwithconstitutionalsmallbabies,whichrepresenttheendofthespectrumofthenormalpopulationanddonotrepresentapredictivetargetinitself.



soukaetal11havealreadyevaluatedacontingencystrategyforsGA,rescanning50%ofanunselectedcohort(N=2310)accordingtofirst-trimesterrisk.DRsherewere50-60%,witha5-10%false-positiverate.Ourhigherrateofdetectionisattributabletotheincorporationofsecond-trimesterUtADoppler,whichisknowntobethesinglebestpredictorofFGR.12inviewofthegoalofimprovinghealthcaresystem,economicevaluationsofinterventionsagainstthenotwelljustifiedscansareincreasinglyrecommended.Veryfewstudieshaveaddressedcost-effectivenessofultrasoundscans.EstimatedcostsfromapayerperspectiveforanUsexamintheUnitedstateshaveincluded200$in199833and43$to74$(yearunreported)forMedicaidreimbursement.34inEuropearoutinethirdtrimesterpolicyisinplaceinmostcountries35,36,resultinginanexceedinglylargenumberofscans.Atanestimatedcostof29-39€37perultrasound,thispolicycangenerateannualcostsofover95-125million€.35,36Additionally,whenscansareperformedbysonographers,ratherthansonographistsortechnicians,thecostsarelikelytobemuchhigher,upto20%more.38Acontingentstrategymayresultinrelevantsavings,and,accordingtoourfindings.Theresearchofnewstrategiesforimprovingtheeconomicbalanceinhealthcoastscouldbenefitfromareductionof50%ofthenumberofthirdtrimester,withoutanyreductionintheoverallpredictivecapacityforFGR.Consequently,inthislessexpensivescenario,UstargetcanbeidentifiedandmanagedaccordingprotocolsthatintegratecurrentevidencestoclassifystagesofdeteriorationinFGR,andestablishesbothfollow-upintervalsandoptimaldeliverytimings.22Wedoconcedesomelimitationstoourstudy.First,wehavenoavailableinformationonDoppleratthirdtrimester.ExistingevidencedoesnotprovideconclusiveevidencethattheuseofroutineumbilicalarteryDopplerultrasound,orcombinationofumbilicalanduterinearteryDoppler39,orcombinationofmeanarterialpressureanduterinearteryDopplerbenefitseithermotherorbabyinlow-riskorunselectedpopulations.40 Recent evidence from observational studies suggests that uterine Doppler at third trimester, as a proxy of trophoblasticinvasion,addstobiometricalmeasurementinthedetectionofFGR.41,42itcouldbearguedthatuterineDopplerearlierinpregnancycouldalready identify those cases of defective trophoblastic invasion. However, it is interesting to note that in recently reported longitudinalseries43,approximatelyone-thirdofabnormalthird-trimesteruterineDopplerstudiesoccurredinwomenwithnormalscansduringthesecondtrimester,alsosuggestingthatasegmentofplacentaldiseaseemergeslateinpregnancy.Finally,asopposedtoroutinescanbefore34weeks(asdoneinthisstudy),itcouldbearguedthatbecauselagginggrowthisaccentuatedastermapproaches,routinethird-trimesterUsstudiesneartermmayimprovedetectionratesofseveregrowthrestriction.indeed,arecentstudy44showedthatUsat35-37weekspredicted89%ofsGAneonates(birthweight<5thpercentile)deliveringwithin2weeksfollowingassessment.Furthermore, the addition of cerebral Doppler in term pregnancies has recently been suggested to improve the detection of placentalinsufficiency.45Ourfindingsofasimilarperformanceofbased-riskscreeningandroutinethirdtrimesterultrasoundcouldnotbetranslatedintootherstrategiesofscanninglateinthethirdtrimester.inconclusion,apolicyofscanningatthirdtrimesterin50%ofthepopulationbasedonthecombinedfirstandsecondtrimesterrisksachievesadiagnosticperformanceforFGRthatisequivalenttothatresultingfromperformingaroutinethirdtrimesterscantothewholepopulationofpregnantwomenpredictinglateFGR



038 . PLAceNTAL GrOWTH FAcTOr (PLGF) AS A PredicTiVe mArKer OF PreecLAmPSiA (Pe)/ iNTrAUTeriNe GrOWTH reSTricTiON (iUGr) iN WOmeN WiTH A PrecONcePTiON riSK OF deVeLOPiNG Pe ANd/Or iUGr lisTa aUTori V.Giardini2;i.Cetin1;M.Mazzocco1;s.Calabrese1;P.Algeri2,1;L.Todyrenchuk2;L.Giunti2;C.Callegari2;P.Vergani2

aFFiliazioni 1. UnitofObsandGyn,L.saccoHospital,CenterforFetalResearchGiorgioPardi,UniversityofMilan,italy 2. UnitofObsandGyn,s.GerardoHospital,UniversityBicocca,Monza,italy

inTroDUzioneToevaluatetheclinicalutilityofplacentalgrowthfactor(PlGF)asapredictivemarkerofpreeclampsia(PE)/intrauterinegrowthrestriction(iUGR)inwomenwithapreconceptionriskofdevelopingPEand/oriUGR

maTeriali e meToDiProspectivestudywasperformedintwoUniversityHospitalsofNorthernitalyandincluded72pregnantwomeninthefollowinggroups:(1)patientswithuncomplicatedpregnancies(n=11);(2)patientswithapreconceptionriskofdevelopingPEand/oriUGR(n=61).Bloodsampleswerecollectedatprenatalvisitorduringhospitalization.PlasmaconcentrationsofPlGFweremeasuredusingcommerciallyavailableELisAkits.serumplacentagrowthfactorlevelswereanalyzedaccordingtopregnancyoutcome.ChangesinthematernalplasmaconcentrationsofPLGFwerecomparedamongnormalpatientsandthosedestinedtodevelopPEoriUGR

risUlTaTiserumPlGFlevelsweresignificantlylowerafter32weeksamongwomenwhodevelopedPE/iUGR(n=10)comparedwithwomencontrolsandwomenwithpreconceptionrisksbutnormaloutcomeinthenextpregnancy[table1andfigure1]

conclUsioniOurstudyshowsthatmaternalserumPlGFconcentrationlevelsdecreasefrom32weeksofgestationinpregnancieswithapreconceptionriskofdevelopingPEand/oriUGRanddestinedtodevelopPE/iUGRalsointhenextpregnancy.ThereforethePlGFdosageafterthisgestationalagecanbeusefultoselectwomenathighriskofadverseoutcomeandsotomanagethesepregnancies



076 . meTAbOLic diSOrderS iN PreGNANT WOmeN WiTH GeSTATiONAL diAbeTeS meLLiTUS ANd FeTAL cArdiOVAScULAr riSK lisTa aUTori s.Visentin;V.DiGiovanni;M.Camerin;A.Borghero;E.Cosmi

aFFiliazioni DipartimentodisalutedellaDonnaedelBambino,UniversitàdiPadova,italia

inTroDUzioneGestationaldiabetesmellitus(GDM),definedasanydegreeofglucoseintolerancewithonsetorfirstrecognitionduringpregnancy,thatisnotclearlyovertdiabetes,affectsfrom5–6%to15–20%ofpregnanciesworldwide,dependingonpopulationdemographics,screeningmethodology,diagnosticcriteriainuseandmaternallifestyle.GDMseemstobeassociatedtoanincreasedriskofsubsequentdevelopmentofdiabetesmellitustype2inadultlifeorobesityinchildhood.AnearlyidentificationoffetalandmaternalriskfactorspredictiveofpooroutcomesinGDMpatientsiscriticaltoprovidingprimarypreventionstrategiesduringpregnancyandearlyinlife.The aim of the study was to compare GDM patients with a control group by evaluating fetal ultrasonographic markers and maternalbiochemicalprofiletoevaluateifthematernalmetabolicenvironmentmightinfluencethefetalvascularsystem

maTeriali e meToDiThiswasacase-controlstudy.singletonpregnanciesaffectedbyGDMandcontrolswereincluded.Thepatientsunderwenttoasonographicevaluationat30weeksandat35weeksofgestationtoassessfetalbiometryandfetal-maternalDoppler.Foreverypatient,wecollectedrace,age,parity,maternalglucidicprofile(OGTT,theareaunderthecurve(AUC)executedat24-25weeks,HbA1c)andlipidicprofile(cholesterol,triglyceride,HighDensityLipoprotein,LowDensityLipoprotein).Duringtheultrasoundexaminations, fetalaorta intimamediathickness(aiMT),amarkerofendothelialdysfunction,wasalsoevaluated.Deliverydatawerecollected(birthweight,modeandgestationalageatdelivery,indicationofcaesareansection,Apgarscoreat5’)

risUlTaTiOnehundredandthirtycasesand130controlswereincluded.Therewerenotdifferencesbetweenthegroupsaboutmaternalage,ethnicityandrateofnulliparous.BMiat30weekswashigherinGDMgroupthancontrol(29.8vs27.6,p<0.001).Estimatedfetalweightandabdominalcircumferencewerestatisticallydifferentinthetwogroups(p0.001),whilematernalandfetalDopplerweresimilar.FetalaiMTwassignificantlyhigherinGDMgroupthancontrols,at30weeksand35weeks(0.86vs0.70,p<0.0001;0.74vs0.64,p0.0006).AUCwashigherinGDMgroup(966vs709,p<0.0001)andpresentedapositivecorrelationwithbirthweight(p<0.0001).Finally,aiMTshowedaapositivecorrelationwithAUC(at30wksr20.11andp0.03;at35wksr20.10andp0.01),maternalcholesterollevels(at30wksr20.31andp0.0002;at35wksr20.71andp<0.0001)andanegativeassociationwithmaternalHDL(at30wksr2p<0.0001;at35wksr20.30andp<0.0001)

conclUsioniMaternalhyperglycemiaanddislipidemiainpresenceofGDMcouldinfluencefetalvascularfunction.PrenatalGDMdiagnosisshouldbeaimedprimaryatthepreventionoflabouranddeliverycomplications,butnotlessimportantly,shouldhelptorecognizedriskfactorsforthedevelopmentofcardiovasculareventsandmetabolicsyndromelaterinlife



093 . iNdOLeAmiNe-2,3-deOXYGeNASe (idO1) OXYGeN-mediATed reGULATiON iN NOrmAL, PreecLAmPTic ANd cHrONic KidNeY diSeASe (cKd) PLAceNTAe lisTa aUTori E.Terzolo;G.B.Piccoli;A.Nuzzo;D.Giuffrida;T.Todros;A.Rolfo

aFFiliazioni DipartimentodiscienzeChirurgicheUniversitàdeglistudidiTorino,PresidioO.i.R.M.sant’Anna FondazioneGiorgioPardi

inTroDUzioneiDO1iskeyaheme-enzymeexpressedbythehumanplacenta.Throughdepletionofoxygenandtryptophanandkynuerenineproduction,itreducesproliferationandactivityofTcellsavoidingmaternal-placental“rejection”.Moreover,iDO1playsaroleinreactiveoxygenspeciesmanagementanditisinverselycorrelatedtooxidativestress(Oxs).Preeclampsia (PE) is a placenta-related syndrome characterized by abnormal maternal immune-response leading to aberrant placentadevelopmentandoxidativestress.Accordingtothematernal/placentalimmune-maladaptationmodel,aroleforiDO1inPEpathogenesishasbeenhypothesizedbutneveraccuratelydemonstrated.Herein,wecharacterizediDO1placentaloxygen-mediatedregulationanditsexpressioninPEandCKDplacentae,clinicallyindistinguishablefromPEdespiteadifferentetiologyandnoplacentalcompromise

maTeriali e meToDiHumantermplacentalvillousexplants (n=21)wereculturedfor12hat20%pO2.Next,explantsweretreatedoxygen-fillednanobubbles(OLNs-500ul)andincubatedinhypoxicconditions(3%pO2)orstandardconditions(20%pO2)for8h.Untreatedexplantsat3%/20%pO2wereusedascontrols.Physiological(n=15),PE(n=15)andCKD(n=21)placentaewerecollected.PlacentalbiopsiesandexplantswereprocessedformRNAisolation.iDO1mRNAlevelsweredeterminedbyRealTimePCR

risUlTaTiiDO1mRNAlevelsweresignificantlyincreasedin20%pO2+OLNs(p<0.05,8.3Foldincrease;Oxscondition)and3%pO2(p<0.05,4.6Foldincrease)explantsvs20%pO2controls. interestingly,3%pO2+OLNsexplantsshoweda reductionof iDO1mRNA levels (p<0.05,2.0Folddecrease)vs3%pO2controls.iDO1expressionwassignificantlyreducedinPEcomparedtobothCKDandcontrolplacentae(p<0.05)

conclUsioniinthepresentstudy,wedemonstrated,forthefirsttimetoourknowledge,iDO1oxygen-mediatedexpressioninthehumanplacenta.iDO1down-regulation further contributes to the pathological Oxs environment typical of PE placentae. CKD placentae showed normal iDO1expression,underlyingaphysiologicalplacentalenvironment



Sessione 3: iNFeTTiVOLOGiA PeriNATALe

009 . mATerNAL ONe cArbON meTAbOLiSm ANd FirST TrimeSTer embrYONic GrOWTH USiNG VirTUAL reALiTY: THe rOTTerdAm PericONcePTiONAL cOHOrT (PredicT STUdY)

lisTa aUTori F.Parisi1,2;M.Rousian1;A.H.J.Koning1;s.P.Willemsen1;i.Cetin2;E.A.P.steegers1;R.P.M.steegers-Theunissen1

aFFiliazioni 1.ErasmusMC,UniversityMedicalCentre,Rotterdam,TheNetherlands 2.OspedaleLuigisacco,UniversitàdeglistudidiMilano,Milan,italy

inTroDUzioneDerangements in maternal one carbon (i-C) metabolism are related to impaired fetal growth and increased risk of adverse pregnancyoutcome.Theaimofthisstudyistoassesstheassociationbetweenmaternalbiomarkersofi-Cmetabolism(vitaminB12,serumfolate,totalhomocysteine(tHcy))andfirsttrimesterembryonicgrowthtrajectories

maTeriali e meToDiinaprospectivepericonceptionalcohortstudy,236singletonpregnantwomenenrolledbefore8weeksofgestationunderwentweeklytransvaginal three-dimensionalultrasound(3D-Us)scans from6+0upto12+6weeksofgestation.Embryoniccrown-rumplength(CRL)andvolume(EV)weredeterminedusingvirtualreality(V-scopesoftwareprogram,BARCOi-space).FirsttrimestermaternalvenousbloodsampleswerecollectedforvitaminB12,tHcyandfolateassessment.AssociationsbetweenbiomarkerconcentrationsandlongitudinalCRLandEVmeasurementswereinvestigatedusinglinearmixedmodelsadjustedforpotentialconfounders(parity,alcoholuse,smokinghabit,folicaciduse,maternalage,BMiandcomorbidity,fetalgender)inthetotalpopulation(n=236),spontaneoussubgroup(n=139)andassistedreproductivetechnology(ART)subgroup(n=97)

risUlTaTiAmedianoffivescansperpatientwasperformed.1029outof1207datasetswereofsufficientqualitytoperformCRLmeasurements(85.3%)and941forEVmeasurements(78%).VitaminB12waspositivelyassociatedwithCRLandEVmeasurementsinthetotalpopulationandinthespontaneousgroup(table1).tHcyconcentrationswereinverselyandstronglyrelatedtoCRLandEVmeasurementsinallthestudygroups.inthetotalpopulation,highertHcylevels(+2sD,correspondingto10.3µmol/l)decreasedCRLby1.7mm(-13.4%)andEVby0.10cm3(-33.3%)at7weeksandby3.6mm(-7.1%)and1.65cm3(-16.1%)at11weekscomparedtolowertHcyconcentrations(-2sD,correspondingto3.0µmol/l)

conclUsioniThisstudyshowsthatmaternaltHcyandvitaminB12significantlyimpactembryonicgrowthtrajectories.Thesedataprovidesupporttotheroleofmicronutrientstatusinthepericonceptionalperiod,notonlyforpreventionofmalformations,butalsoforearlyembryonicgrowth,potentiallyimpactingperinatalconceptusgrowthandhealth



035 . FAT mASS ANd cYTOKiNeS PLASmA LeVeLS iN PreGNANT OVerWeiGHT/ObeSe WOmeN iNcLUded iN A LiFeSTYLe PrOGrAm lisTa aUTori V.Tamborrino;EPetrella;R.Bruno;G.Pedrielliì;i.Neri;F.Facchinetti

aFFiliazioni DepartmentofObstetricsandGynecology,Mother-infantDepartment,PoliclinicoHospitalofModena,italy

inTroDUzioneTodetermineapossiblecorrelationbetweenmaternalfatmass(FM)andtheplasmalevelsofproandanti-inflammatorycytokines(iL-1a,iL-1b,iL-2,iL-4,iL-6,iL-8,iL-10,iL-12,iFN-gammaandTNF-alfa)amongoverweight/obesepregnantwomen

maTeriali e meToDi57 women (40 obese, 17 overweight) with BMi ≥ 25 Kg/m2 included in a lifestyle program (a low glycemic hypocaloric diet andmoderatephysicalactivity)wereenrolled.Weight,FM(evaluatedthroughabioimpedenceanalysis,BiA),andplasmacytokinesweremeasuredat9th-12thweekandat35th-36thweek.BiAevaluatedthedistributionofFMforthewholebodyandforthedifferentbodysegments,namelyarms,trunkandlegs

risUlTaTiMeanBMiatenrollmentwas34.7±6.4(range25.8-54.6)Kg/m2andFMpercentagewashigherinobese(44.9±4.5)thaninoverweightwomen(40±2.7).Amongtheinvestigatedcytokines,onlyiL-6atfirsttrimestercorrelatedwithBMi(p<0.001;r=0.614)andFM(p=0.002;r=0.405).Changesthroughoutpregnancyarereportedintable.significantdecreaseofiL-1aeiL-2andincreaseofiL-6werefound.TheincreasedlevelsofiL-6correlatedwithbothGWG(p=0.002;r=0.454),increasedFM(p=0.022;r=0.340)andincreasedtrunkFM(p=0.001;r=0.482),whilenotwitharmsandlegsFM.Atthirdtrimester,aregressionanalysisprovedthatiL-6isanindependentpredictorforFM(p<0.001;R2=0.864)andfortrunkFM(p=0.046;R2=0.381),aftercorrectingforpre-pregnancyBMiandage

conclUsioniiL-6 strongly correlates with BMi and body composition in overweight/obese pregnant women. it increases during pregnancy inrelationtoGWGanditisamarkerofvisceralFMincrease



077 . GeSTATiONAL WeiGHT GAiN (GWG) iS AN iNdePeNdeNT riSK FAcTOr FOr AdVerSe PreGNANcY OUTcOme iN WOmeN WiTH GeSTATiONAL diAbeTeS (Gdm) lisTa aUTori s.DeCarolis1;E.diPasquo1;F.Macri’1;D.Pitocco2;C.Martino1;s.Garofalo1;A.Botta1;A.Lanzone1

aFFiliazioni 1.DepartmentofObstetricsandGynecologyPoliclinicoAgostinoGemelli,Roma,italia 2.DepartmentofinternalMedicinePoliclinicoAgostinoGemelli,Roma,italia

inTroDUzionePre-pregnancybodymassindex(BMi),obesityandgestationalweightgain(GWG)areindependentriskfactorsforanadversepregnancyoutcome.TheincreasingofmaternalBMiisasignificantriskfactorforGestationalDiabetesMellitus(GDM).AlltheseconditionsareassociatedwitharisingoccurrenceofLargeforgestationalage(LGA)babiesandfoetalmacrosomia,arisingoccurrenceofCaesareansectionsandshoulderdystocia.Furthermore,theincreasingprevalenceoftheseconditionsisrelatedtoahigherriskofdevelopingmetaboliccomplicationsintheoffspring.TheincidenceofobesityandGDMisrisingworldwideandapproximately40%ofpregnantwomengainmoreweightthanthatrecommended.somestudiesdemonstratedthatlimitingGWGinoverweightandobesewomencouldbebeneficialforabetterpregnancyoutcome.Whenobesity,overweightandGDMcomplicatepregnancy,theonlymodifiablefactorscouldbetheglycaemiccontrolandGWG.TheaimofthepresentstudyistoinvestigateifinwomenaffectedbyGDMwithanoptimalglycaemiccontroltheexcessiveGWG(eGWG)isariskfactorforadverseobstetricaloutcomeindependentlyfrompre-pregnancyBMi

maTeriali e meToDiThreethousandfifth-hundredeightwomenwithasingletonpregnancywerefollowedinourtertiaryreferralcentrefromJanuary2009toJanuary2014.AnOralGlucoseToleranceTest(OGTT)wasperformedbetween24and28pregnancyweek.AccordingtoHAPOstudythresholds,393womenresultedaffectedbyGDM.Afterthediagnosis,allpatientswereprovidedwithareflectometer forcapillarybloodglucoseself-monitoring(sMBG)withtheindicationtointensifyglycaemiccontrolwithatargetvalue<6.1mmol/lbeforemeals,<7.8mmol/L1hourpostprandialand<6.7mmol/l2hourspost-prandial.Boththegynaecologistandthediabetologistassistedallwomen,andglycaemicvalueswereseriallycontrolledfromthediagnosisofGDMtillthedelivery.Afterthediagnosis,allwomenstartedadiettherapeuticregimenandthecapillarybloodglucoseself-monitoring.inpatientsthatdidnotachieveaglycaemiccontrol,thediettherapeuticregimenwasconvertedtoaninsulintherapy.Optimalglycaemiccontrolwasdefinedwhenawomanrequirednomorethantwochangesintherapyorincreasingininsulindose.Twohundredeighty-threewomenhadanoptimalglycaemiccontrol.According to the WHO indications, pre-pregnancy BMi (kilograms/meters2) was categorized as underweight (BMi<18.5), normalweight(BMi≥18.5and<25.0),overweight(BMi≥25.0and<30.0),obese(BMi≥30.0)women.Totalgestationalweightgain(GWG)wascalculatedasthedifferencebetweenmaximum-recordedweightgainduringpregnancyandbodyweightrecordedatthefirstvisit18.0Kgforunderweightwomen,>15.8Kgfornormalweightwoman,>11.3Kgforoverweightwomenand>9.0Kgforobesewomen.Gestationalagewasdefinedonthebasisof the lastmaternalmenstrualdateconfirmedbyearlyultrasoundexamination.Pretermbirthwasdefinedasadeliveryoccurred≤37thegestationalweek.Macrosomiawasdefinedasanewborninfantwithabirthweight≥4000g;LargeforGestationalAge(LGA)wasdefinedasabirthweight>90°PcandsmallforGestationalAge(sGA)wastraditionallydefinedasanestimatedfoetalweight<10°percentile,accordingtothenationalstandardcurveforsingletonbirth.statisticalanalysiswasperformedbyusingthestatisticalPackageforsocialscience(sPss),release15.0.AlldatawerefirstanalysedfornormalityofdistributionusingtheKolmogorov-smirnovtestofnormality.Continuousvariables(Maternalage,GWG,BirthWeight,GWatdeliveryandWeightPercentile)wereexpressedasmean±sD,categoricalvariables(LGA,Macrosomia,PretermDeliveryandCaesareansections)displayedasfrequencies.Appropriateparametric(one-wayANOVA,student-Newmann-Reuls’sposthoc-test)ornon-parametrictest(χ2test)wereusedtoassesssignificanceofthedifferencesamongsubgroups.Multiplelinearorlogisticregressionwithbackward-stepwisemethod(Reducedmodel)wasalsoperformedtostudythedependenceofneonatalweightandneonatalweightpercentilebymaternalandfoetalcovariates:BMiclasses,GWG,hypertension,macrosomia,gestationalweekatGDMdiagnosis,fastingglucoselevels,pretermdelivery,birthweight.Covariatesintroducedinthemodelwerevariablessignificantlycorrelatedattheunivariateanalysis.Allofthetestsforstatisticalsignificanceweretwo-sidedandaPvalue<0.05indicatedasignificantdifference



risUlTaTiData from283womenwereanalysed.Ninety-threewomen (32.9%)demonstratedaneGWG.Therewerenosignificantdifferencesbetweenthetwogroupsintermofmaternalage,ethnicity,parity,gravidity,pre-pregnantBMiandmeanglucosevalueat60minand120minofOGTTtesting.MeanbasalglucoselevelsweresignificantlyhigherinwomenwithaneGWG(92,70±19,31vs.88,66±11,66,P=0.03).Table 1 shows the pregnancy and neonatal outcome between the two groups.Women with an eGWG had a significantly higherincidence of LGA infants, macrosomia and hypertensive disorders of pregnancy. Furthermore, mean birth weight and mean birthweightpercentile,wereincreasedinthisgrouprespecttowomenwithanormalGWGaccordingtoiOMrecommendations.A multivariate logistic regression was carried out to evaluate the independent association between exposure variables and thefollowingoutcomes:macrosomia,LGA,hypertensivedisordersandmeanbirthpercentile.Bothpre-pregnantBMiandeGWGresultedtobeindependentriskfactorsformacrosomiaandLGAafteradjustingforotherriskfactors(parity,maternalage,insulintreatment,basalglycaemia).Pre-pregnantBMiwasassociatedwiththeriskofdevelopinghypertensivedisordersofpregnancy(P<0.001),whileeGWGwasnotanindependentriskfactorforthisoutcome.Furthermore,eGWG,pre-pregnantBMiandparitywereindependentriskfactorsforahigherbirthweightpercentile.Figure1showsthepercentageofLGAnewbornsamongthedifferentpre-pregnantBMicategoriesinwomenwitheGWGandnormalGWG(nGWG).TheproportionofLGAinfantswassignificantlyhigherinwomenwithaneGWGthaninthosewithanGWG,bothinobese(P= .005)andoverweightwomen(P= .002).Excessivegestationalweightgainwasassociatedwithan increasedrisk forLGAnewbornthatisa7.8-foldhigherinobesewomen(OR=7.83Ci1.6to38.9;p=0.01)anda9.3-foldincreasedriskinoverweightwomen(OR=9.33Ci1.82to47.71;p=0.007).Asimilartrendwasobservedinnormalandunderweightwomenevenifthisdifferencewasnotsignificantlydifferentprobablyduetothesmallsamplesize(OR=1.07Ci0.11to10.76;P=0.95)

conclUsioniForthefirsttime,anexclusivelycohortofdiabeticwomenwithanoptimalglycemiccontrolwasconsideredandtheevaluationofGWGwasundertakenaccordingtotheiOMguidelines.Regardingbaselinecharacteristics,meanbasalglucoselevelswerehigherinwomenwith eGWG.This may highlight that the eGWG could start during the first gestational weeks and could be related to the imparedglucosetoleranceatthebasaltest.OurprincipalfindingsabouteGWGrelatedtoneonataloutcomeand,inparticular,toindicesofapathologicalfetalgrowth(rateofLGA,macrosomia).ThesedataarenovelintestingtheimportanceofGWGinapopulationofwomenathighriskforthepresenceofGDMintensivelymanagedduringpregnancyalso innormalweightingwomen.Bythemultivariateanalysisadjustedforotherpotentialconfounders,wedemonstratedthateGWGisassociatedwithfetalgrowth(expressedbybirthpercentile)(P=0.002)andwiththeriskofmacrosomia(OR=4.97)andLGAinfants(OR=4.43)independentlybypre-pregnantBMi.WealsoobservedincreasingproportionofLGAamongBMicategoriesbutinobeseandoverweightwomeneGWGisanindependentriskfactorforLGAinfants.Althoughthisresultcannotbeexplainedbythecurrentanalysisduetothesmallsample,theincidenceofhypertensivedisordersofpregnancyishigherinwomenwitheGWG.However,multivariateanalysisshowsthatonlypre-pregnantBMiisanindependentriskfactorforthisoutcome.WhenaGDMoccur,GWGcouldbetheonlymodifiablerisk factor.Ourdatasuggestthatan improvedobstetricaloutcomecanbeachievedusingan intensivecontrolofGWGforallwomenwithdiabetes, irrespectiveofantenatalBMi.Careprovidersshouldgivethesameattentionindietary,lifestyleinterventionandweightgaincontrolbothinobeseandinnormalweightwomenanduse,asatarget,iOMrecommendationsaccordingtothedifferentBMiclasses.inconclusion,understandingtheinterplaybetweenGDM,obesity,GWG,hypertensivedisordersandmetabolicsyndromeisimperativeforbothcareprovidersandwomenandpregnancyisauniqueoccasiontoinformwomenontheirfuturehealth



100 . eFFecTS OF mOdULATOrS OF NiTric OXide SiGNAL ON VALPrOic Acid-iNdUced TerATOGeNiciTY lisTa aUTori A.Ponzano;G.M.Tiboni

aFFiliazioni UniversitàG.D’annunzioChieti-Pescara-DipartimentodiMedicinaescienzedell’invecciamento

inTroDUzioneValproicacid (VPA) isanantiepilepticdrug largelyused for thetreatmentofepilepsy,migraineandbipolardisorder.Although it iswell known that the in utero exposition toVPA leads to an increase risk of major congenital malformations, the exact mechanismunderlyingitsteratogenicityremainspoorlyunderstood.increaseinoxidativestress,alterationinfolatemetabolismandmorerecentlyinhibition of histone deacetylase (HDAC) have been postulated to account for the teratogenicity of this drugs. intriguingly, resultsfromrecentstudiescarriedoutusinginvitrosystemssuggestedthatVPAmayhavetheabilitytoinhibitnitricoxidesynthase(NOs).Consideringthecrucialroleofnitricoxide(NO)inorganogenesis,webecameinterestedonthepossiblelinkbetweenNOandVPA-inducedteratogenicity.ThepresentstudywasundertakentoevaluatetheeffectsofagentswiththecapacityofmodulatingtheNOsignalontheteratogenicitymediatedbyVPAinthemouse

maTeriali e meToDiinthefirstexperiment,micewere injectedongestationday8withanon-teratogenicdose(20mg/kg)ofthenitricoxidesynthase(NOs)inhibitorN(G)-nitro-L-argininemethylesther(L-NAME).Thirtyminuteslater,animalsreceivedateratogenicdoseofVPA(400or500mg/kg).Developmentalend-pointswereevaluatedneartheendofgestation.Halfofthefetuseswerepreparedfortheskeletalexamination.TheremainingfetuseswerefixedinBouin’ssolutionandsubsequentlyexaminedforvisceralanomalies.inthesecondstudy,iCR(CD-1)miceweretreatedongestationday8bygastricintubationwithsildenafilcitrate(sC)at0(vehicle),1.0,2.5,5.0or10mg/kg.Onehourlater,animalsreceivedateratogenicdoseofVPA(600mg/kg)orvehicle.Developmentalendpointswereevaluatedneartheendofgestation.inthisexperiment,allthefetuseswerepreparedforskeletalexamination

risUlTaTiAfter treatment with VPA at 400 mg/kg, 35.2% of fetuses exhibited skeletal teratogenesis. The rate of skeletally affected fetusessignificantly increased to 53.7% after L-NAME co-administration. in the group treated withVPA at 500 mg/kg group, L-NAME pre-treatmentincreasedtheincidenceofexencephalyfrom5.4%to22.2%.Twenty-eighthpercentoffetusesexposedtoVPAhadneuraltubedefects(exencephaly).PretreatmentwithsCat2.5,5.0or10mg/kgsignificantly reducedthe rateofVPA-inducedexencephaly to15.9%,13.7%,and10.0%, respectively.Axial skeletaldefectswereobservedin75.8%ofVPA-exposedfetuses.Pre-treatmentwithsCat10mg/kg,butnotatlowerdoses,significantlydecreasedtherateofskeletallyaffectedfetusesto61.6%

conclUsioniTheseresultssupporttheconceptthatNOplaysaprotectiverolefromVPA-inducedteratogenesis.specifically,theuseofaNOsinhibitor(L-NAME), a substance with the propriety to reduce the NO levels, resulted in an enhancement of theVPA-induced teratogenicityleadingtoanincreaseofboth,exencephalyrateandskeletalmalformations.Coherently,thepre-treatmentwithsC,asubstancethatactprolongingtheNOsignalresultedeffectiveinthepreventionofVPA-inducedexencephalyinadose-dependentmanner.ithasbeenreportedthatVPA(likeothersHDCAsinhibitors)mayinterferewithNOsleadingtoareductionofNOlevelsincellscultureandthattheseeffectscanbereversedbytheuseofaNOdonor.itiswellknownthatNOisamoleculewhichplaysfundamentalrolesinreproductionanddevelopmentandthatitsimbalancemayalterorganogenesis.Focusingontheprocessofneurogenesis,studiescarriedoutinchickembryosshowedthatproperlevelsofNOarerequiredforthecorrectdevelopmentofneuraltubesystem.OurresultsseemstobeinlinewiththisrecentlineofresearchindicatingthepossiblerelationshipbetweenVPA-teratogenicityandalterationinNOstatus.Overall,thefindingsofthepresentstudy,mayberelevantnotonlyintermsofthecomprehensionofmechanismsbehindVPAteratogenesis,butalsointhedevelopmentofpotentialinterventionstoreducetheoccurrenceofneuraltubedefectsinbabiesdeliveredbymothersrequiringVPAtreatmentduringpregnancy



Sessione 4: i NATi dA PArTO VAGiNALe O dA TAGLiO ceSAreO: cOme cAmbiA LA NOSTrA SPecie?

007 . HOW LATe iS TOO LATe FOr VAGiNAL deLiVerY: eFFecT OF AdVANced mATerNAL AGe ON ObSTeTric OUTcOmeS

lisTa aUTori C.Plevani1;A.Pintucci1;M.incerti2;D.Delsorbo3;L.Merlino4;A.Locatelli1

aFFiliazioni 1.DepartmentofObstetricsandGynecology,DesioandVimercateHospital,CarateBrianza,UniversityofMilano-Bicocca,italy 2.DepartmentofObstetricsandGynecology,sanGerardoHospital,MBBMFoundation,UniversityofMilano-Bicocca,italy 3.Departmentofinformatics,DesioandVimercateHospital,Vimercate,italy 4.LombardiaRegion,GeneralManagementforHealth;Milano,italy

inTroDUzioneCesareanDelivery(CD)raterisesatmaternalageincrease.Advancedmaternalagehasbeenassociatedwithanincreasedriskofobstetricalcomplications,buttheassociationbetweenCDandmaternalagealoneiscontroversial.Theobjectiveofourstudyistocompareobstetricoutcomesbetweenmothersunderandover40yearsusingtheRobsonclassificationsysteminLombardia

maTeriali e meToDiWeincludedalldeliveriesoccurredinthe82hospitalsofLombardiabetweenJanuaryandDecember2013.Patientsweredividedintotwogroupsaccordingtomaternalage:A)lessthan40years(ys);B)40ysorolder.Thecertificateofdeliverycare(CeDAP)hasbeenusedasdatasource.TheRobsonclassificationofCDwasappliedtocomparetherateofCDinthedifferentclassesbetweenthetwogroups.Pregnancyoutcomeswereanalyzedasantepartumandintrapartum.T-studenttestwasusedtocomparerecurrenceratesinthecomparisonbetweenthetwostudiedgroups

risUlTaTiDuringthestudyperiod8,416/87,681(9.6%)womenaged40yearsorolder.OverallCDratewas28.3%(24,776/87,681).Thisratewassignificantlyhigherinwomenaged≥40yscomparetoaged<40ys(42.2%vs27.5%,p<0.001).Thedifferenceswerehighlysignificantlydifferent in Robson classes i (nulliparous, single cephalic, ≥ 37 weeks, with spontaneous labor) and Viii (all multiple pregnancies,includingpreviousCD),approachingsignificanceinallotherclasses,excludingpreviousCD(RobsonclassV)andclassesforwhichfetalmalpresentationwasthemainindicationforsurgery(classesViiandiX)(table1)

conclUsioniRiskforCDishigherinwomenolderthan40yearscomparetoyoungerwomeninLombardia.indeed,anulliparouswomenaged40yearsorolderwithspontaneoustermcephalicdeliveryhasa27%probabilityofCD,thatistwiceasawomenunder40years.Moreover,maternalagedoesnotinfluencetherateofCDinthecategoryofpreviousCD.Thepreferencesoftheindividualcareproviderandthemotheronmodeofdeliverymayplayakeyroleandrequirefurtherinvestigation



024 . ANHedONiA, ANXieTY, ANd dePreSSiON cOmPONeNTS OF ediNbUrGH POSTNATAL dePreSSiON ScALe iN ceSAreAN deLiVered mOTHerS lisTa aUTori L.Giliberti;F.Volpe;G.soldera;G.Tesolat;R.Maione1;G.straface;V.Zanardo

aFFiliazioni 1.PoliclinicoAbanoTerme.AbanoTerme(PD),italia

inTroDUzioneBACKGROUND.Previous studies have indicated that cesarean delivery might pose risk factors for post-partum depression (PPD). However, results areconflictingandhavefailedtoclearlydistinguishbetweenelectiveandemergencycesareansectionOBJECTiVE.TherateofelectivecesareandeliveryisrapidlyincreasingallovertheworldanditisimportanttoidentifywhetherthemodeofdeliveryhasaninfluenceofPPD.TheEdinburghPostnatalDepressionscale(EPDs)isawidelyusedinstrumentforPPDscreening,alsocapabletodetectinsubscalesanhedonia,anxiety,anddepressionfactors

maTeriali e meToDiAcohortof959italianmothersdeliveringahealthybabyatPoliclinicoAbanoTerme,italy,completedtheEPDs2daysafterdelivery

risUlTaTiEPDsscoreswerelowerinmotherswithavaginaldeliverycomparedtomotherswithacaesareandelivery(6.1±4.2vs.7.0±4.8,p<0.01)andlessfrequently(25.2vs.6%,p9.Butonlythewomenwhoelectedtohaveacaesareansectionhadsignificantlyhigherscores(7.1±3.9vs.6.8±4.1,p<0.001)andmorefrequently(25.2vs.39.4%,p9.Additionally,thefactoranalysisofEPDsindicatedthatanhedonia,anxiety,anddepressionweresignificantlyhigherinmotherswithacaesareandeliverycomparedtomotherswithavaginaldelivery(anhedonia:0.32±0.59vs.0.19±0.48,p<0.003;anxiety:0.07±0.88vs.1.16±0.93,p<0.02;depression:0.53±0.72vs.0.37±0.65,p<0.007),butonly thewomenwhoelected tohaveacaesareansectionhadsignificantlyhigherscores:anhedonia (0.19±0.48vs.0.31±0.64,p<0.001),anxiety(1.17±0.93vs.1.07±0.88,p<0.006),anddepression(0.37±0.65vs.0.45±0.68,p<0.004).Ofnote,anhedoniawasquantitativelymoreimportantalsoinEmCDwomencomparedtoVDwomen(0.19±0.48vs.0.30±0.68,p<0.002)

conclUsioniTheresultsofourstudyindicatethatwomenwhohadanElCDhaveanincreasedriskofdevelopingearlysymptomsofpost-partumdepression,anxiety,andanhedonia.inparticular,thisstudyshowsthattheuseofEPDssubscalesintheimmediatepost-partumisagoodtooltobetterunderstandingthespectrumofmaternalpost-partumpsychologicalproblemsrelatedtodeliverymode



032 . PLAceNTAL WeiGHT-birTH WeiGHT rATiO: AN iNdeX FOr THe PeriNATAL OUTcOmeS lisTa aUTori A.Vitagliano1;M.Noventa1;M.V.DiGiovanni1;F.Esposito1;s.Borgato1;A.DeVirgilio1;M.Quaranta2;s.Gizzo1

aFFiliazioni 1. DipartimentodisalutedellaDonnaedelBambino,UniversitàdeglistudidiPadova,italia 2. DepartmentofObstetricsandGynecology,NorthamptonGeneralHospitalNHsTrust,Northampton,UnitedKingdom

inTroDUzionein clinical practice placental weight is usually recorded in all delivery room. its value is still under discussion as to have a correctinterpretation.Fetushealthandnewbornisassociatedtoenvironmentduringpregnancy.Placentalweightreflectsplacentalefficiencyand growth as well as it is able to provide an explanation for the underlying mechanism by which birth weight is associated withmorbidityandmortalityininfants,childrenandadults.Thecorrelationbetweenfetalweightandplacentalweightisthefetoplacentalweightratio(FPR).TheprimaryendpointofthestudywastocorrelatetheFPRatbirthwithneonataloutcome(Apgarscoreat5°and10°minute,pHatbirthandBE)inordertodetectpossibleassociationwithneonatalwell-being.ThesecondaryendpointwastofindcorrelationbetweenFPRweightwithpathologiesofthe3rdstageoflaborsuchaspostpartumhemorrhage(intrapartumbleeding>1000ml),manualremovalofplacenta(MROP),instrumentalrevisionoftheuterinecavitybecauseofplacentalretention.Thetertiaryendpointwastoevaluateifplacentalweightisinfluencedbymaternalhistory,pregnancyanddelivery

maTeriali e meToDiAnobservationalprospectivecohortstudyonpregnantsinglewomenadmittedtothedeliveryroomofUniversityofPadua,WomanandChildHealthDepartment,wasconducted.Wecollected data on maternal characteristics: maternal age, parity, race, weeks of gestation, BMi in early pregnancy and at term ofpregnancy.Obstetriccharacteristicswereanalyzed:spontaneousoriVFpregnancy,modeoflabor(spontaneousorinduced),modeofdelivery(vaginaloroperativedelivery,electivecaesareansection,emergencycaesareansection)andpossibledifficultiesduringthe3rdstageoflabor.Weobtaineddataonfetal-neonatalcharacteristics:fetalpresentationatbirth,sex,weight,Apgarscoreat5°and10°minute,pHatbirth,baseexcess(BE)andtheneedofintensivecare.Placentalcharacteristicswerecollected:placentalinsertionsitedetectedwithultrasound,weightplacentalatbirthanditsmorphology

risUlTaTiA cohort of 702 patients was eligible for our study. The comparison between placental weight and obstetric history showed astatisticallysignificantdifferencewithpre-gestationalmaternalweight[p<0.001],maternalbaselineBMi[p<0.05],maternalweightatterm[p<0.05],maternalBMiatthedelivery[p<0.05]andgestationalage[p<0.001].WefoundsignificantdifferencesbetweenthePFRandperinataloutcomesintermsofApgarscoreat5°/10°minute,neonatalpHandBE.Withratiogreaterthan0.29(meanvalueratioofoursample0.195)weobserveda5°minuteApgarscore<of7withanestimatedexponentialgrowthtrendcomparedtotheincreaseratio.Wefoundthesameresultsanalyzingtheratiocutoffand10°minuteApgarscore.Themeanratiocutoffobtained(0.125) isstatisticallyconnectedtopHvaluesatbirthconsiderednormal.ThecorrelationbetweenPFRandpathologiesofthe3rdstageoflaborshowedstatisticallysignificantdifferencesonlyinbloodloss>1000mlforcutoffratiobetween0.195-0.29[pthan0.29[p<0.001]

conclUsioniHighvaluesofFPRareassociatedwithadverseperinataloutcomes(linkedtoApgarscore<7at5°minuteand<8at10°minute,alteredpHvaluesatbirthandnon-physiologicalBE).Postpartumhemorrhage(bloodloss>1000ml)isassociatedtoheavierplacentalweightinrelationtonormalneonatalweight.Placentalweight iscorrelatedtomaternalBMipre-pregnancyandatterm.Even ifplacentalweightincreaseswithadvancingofgestationalage,highplacentalweightwerefoundalsobetween35and38weeksofgestation



065 . cTG PArAmeTerS iN A LArGe POPULATiON OF HeALTHY Term SiNGLeTON PreGNANcieS iS NOT iNFLUeNced bY FeTAL GeNder lisTa aUTori E.R.MagroMalosso;s.D’Ottavio;C.Ferrata;G.Masini;M.DiTommaso

aFFiliazioni AziendaOspedalieraUniversitariaCareggi,Firenze,italia

inTroDUzioneFetal gender has been identified as an important factor influencing both fetal and maternal outcomes. in pregnant patients withmale fetusesan increasedriskofdeliveringpreterm,undergoingcesareansection, failing labor induction,sufferingastillbirthanddeveloping gestational diabetes has been demonstrated. Pregnant women with female fetuses instead have an increased risk ofdevelopinggestationalhypertension,preeclampsia,iUGRalthoughfemaleshavebetterperinataloutcomes.Thesedifferencesonthebasisoffetalgenderhavebeentheorizedtobetheresultofadifferenthormonalsecretionofvarioussubstancesduringpregnancyinfluencedbyfetalsexand/oralterationsinthefunctioninganddevelopmentoftheplacentainmalesandfemales.Giventhisdifferenceinobstetricandperinataloutcomesbetweenmaleandfemalefetuses,variousauthorshaveexaminedfetalhearthratechangesduringlabor,deliveryandantepartumperiodbutonlyinparticularconditions,relatedtoindividualfetalbehavioralstatesthuswithminimalapplicabilityintheclinicalsetting.TheobjectiveofthisstudywastoassessshortTermVariabilityandotheradditionalCTGparametersinrelationtofetalgenderduringdailyclinicalactivities,referringtoalargepopulationofuncomplicatedsingletontermpregnanciesbetween37to40weeksofgestation

maTeriali e meToDiWeconductedaretrospectiveanalysisofcomputerizedFHRmonitoringinpregnantwomenwithuncomplicatedsingletongestationbetween37to40weekswhowerereferredtotheoutpatientclinicoftheUniversityofFlorence-CareggiHospitalforanuncomplicatedtermgestation.Consentwasobtainedfromallparticipants,inaccordancewiththeHelsinkiDeclaration.FHRmonitoringwasperformedwiththesonicaidFM800.subjectclinicalinformationwasobtainedfromthesonicaindFM8000dataregistryandmatchedwiththeelectronicpatientrecord(Argos3.34DedalusspAitaly)WhenevaluatingCTGdataobtainedfromthesonicaidFM800thefollowinginformationwasevaluated:thelengthoftheregistrationinminutes,baselineFHR,presenceorabsenceofuteruscontractileactivity,numberofaccelerationsand/ordecelerations,episodesofhighvariability,shorttermvariability(sTV),percentageofsignalloss,timetoterminationandfetalmovements.Categoricalvariableswerecomparedusingthechi-squaretest,continuousvariableswerecomparedusingtheMann-Whitneytest,given a non-normal distribution of the data. For multivariate analysis we used a linear regression model with a binary outcome(dependent variable) and several predictors (independent variables). specifically, the multivariate analysis pooled together thematernaldemographicscharacteristicsandtheCTGresultsinordertoexcludepossibleconfoundersduringdatainterpretation.ThesoftwareusedforthestatisticalanalysiswassPss23.0(iBM,UsA)

risUlTaTiConsideringtheweaknessesofthepreviousstudies,weexaminedalargestudygroupof689fetuseswhere335weremaleand354were female . No statistically significant difference regarding the characteristics of the mothers distributed by fetal sex was foundexceptfortheethnicoriginofthepatientsduringunivariateanalysiswhichwasnotconfirmedbymultivariatelinearregression.TherewasnodifferenceinApgarscore,pH,sBE,gestationalageatdeliveryandmodeofdeliverybetweengenders.Theonlydifferencefoundwasinthebirthweight,whichwashigherinmalefetusesthaninfemaleones(p<0.05).AnalyzingtheCTGresultsofthenewborngender,therewasnosignificantdifferenceintermsofsignalloss,contractions,movements,accelerations, decelerations, HVT and sTV in both uni- and multivariate analysis. in the univariate analysis there was a statisticallysignificantdifferenceinFHR(meanvaluewas135bpmformalesand136bpmforfemalewithp<0.05),whichwasnotconfirmedbyamultivariateanalysis(Tab.3)

conclUsioniCTG parameters in a population of healthy term singleton pregnancies is not influenced by fetal gender. Considering the closeconnectionbetweenpregnancydiseasestatusandCTGchanges,itwouldbeworthevaluatingalargerpopulation,includingpretermandpathologicalpregnancies

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