Do all patients with history of pelvic ring injuries need a cesarean section? - A survey of orthopaedic and obstetric providers.

OBJECTIVE(S): The recommended mode of delivery following pelvic ring fractures with surgical fixation is unclear. The objective of this study was to assess expert opinions from orthopaedic surgeons and obstetrician gynecologists on their recommended delivery recommendations for pregnant individuals with a history of pelvic ring injury, and to see if there was any difference in recommendations between the two specialties, and what factors influenced recommendations. STUDY DESIGN: An electronic, web-based survey was administered to a convenience sample of orthopaedic surgeons and obstetrician gynecologists, via advertisement to members of the Orthopaedic Trauma Association (OTA), the Society for Maternal Fetal Medicine, and querying obstetrician gynecologists practicing within the Military Health System. The survey was administered from November 2021 to December 2022. A two-proportion z-test, Chi-square or Fisher's Exact Test, and descriptive statistics were used to analyze data. RESULTS: Survey respondents included 44 orthopaedic surgeons and 37 obstetricians. A total of 74 % obstetricians would recommend a trial of labor with hardware in place, while orthopaedic surgeon's recommendations varied based on the type of fixation. Forty four, 100 % of orthopaedic surgeons, recommended trial of labor if non-operative pelvic injury or unilateral posterior fixation only, 88 % recommended trial of labor if bilateral posterior fixation only, and 47.7 % for anterior trans-symphyseal plating only, 50 % for unilateral posterior and trans-symphyseal plating, and 43.2 % for bilateral posterior fixation with trans-symphyseal plating. CONCLUSIONS: The results of these surveys demonstrate the lack of consensus as to the most appropriate birth plan for patients with a history of pelvic ring injuries. Vaginal delivery following pelvic ring fracture and fixation is possible, yet these patients are significantly more likely to undergo cesarean section than the general population. As such, we recommend that women who become pregnant after operative treatment of a pelvic ring injury develop an in-depth birthing plan with their obstetrician to determine the best course.

Chronic hypertension and risk of preterm delivery: National Longitudinal Study of Adolescents to Adult Health.

BACKGROUND: Chronic hypertension during pregnancy is associated with increased risk of adverse birth outcomes. In 2017, the American College of Cardiology and American Heart Association (ACC/AHA) lowered thresholds to classify hypertension in non-pregnant adults to SBP ≥ 130 mmHg and DBP ≥ 80 mmHg (ie stage I hypertension), resulting in an additional 4.5-million reproductive-aged women meeting criteria for hypertension. Little is known about effects of pre-pregnancy blood pressure (BP) in this range. OBJECTIVES: To examine the effect of pre-pregnancy maternal BP on preterm delivery. METHODS: We analysed the data from two waves of the National Longitudinal Study of Adolescent to Adult Health, including participants that had measured BP at Wave IV (2008-09) and a pregnancy that resulted in a singleton live birth between Waves IV and V (2016-18; n = 2038). We categorised BP using ACC/AHA cut-offs: normal (SBP < 120 mmHg and DBP < 80 mmHg), elevated (SBP 120-129 mmHg and DBP < 80 mmHg), hypertension stage I (SBP 130-139 mmHg or DBP 80-89 mmHg) and hypertension stage II (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg). We estimated risk ratios (RR) with log-binomial regression adjusting for maternal demographics, anthropometrics and medication use. RESULTS: The prevalence of preterm delivery was 12.6%. A standard deviation (SD) increment in SBP (SD = 12.2 mmHg) and DBP (SD = 9.3 mmHg) was associated with a 14% (95% confidence interval [CI] 2, 27) and 20% (95% CI 4, 37) higher risk of preterm delivery. Compared to normotensive controls, stage I (RR 1.33, 95% CI 1.01, 1.74) and stage II (RR 1.34, 95% CI 0.89, 2.00) hypertension were associated with increased risk. CONCLUSIONS: We observed greater risk of preterm delivery among women with higher pre-pregnancy BP. Women with stage I hypertension during pregnancy may benefit from increased BP monitoring. Additional studies on the utility of foetal surveillance in this group are warranted.

Two-dimensional sonographic cine imaging improves confidence in the initial evaluation of the fetal heart.

OBJECTIVES: Initial screening sonography of the fetal heart with static images is often inadequate, resulting in repeated imaging or failure to detect abnormalities. We hypothesized that the addition of short cine clips would reduce the need for repeated imaging. METHODS: Two-dimensional (2D) static sonograms and short 2D cine clips of the 4-chamber view and left and right ventricular outflow tracts were obtained from 342 patients with gestational ages of greater than 16 weeks. A diagnostic radiologist and a perinatologist retrospectively reviewed the static and cine images independently and graded them as normal, abnormal, or suboptimal. RESULTS: A statistically significant increase in the number of structures called normal was seen when 2D cine clips were added to static imaging for both observers (P < .05); the radiologist called 86.5% normal with combined static and cine images versus 61.9% with static images alone, whereas the perinatologist recorded 68.1% as normal versus 58.8%, respectively. The radiologist called 77.8% of structures normal with cine images only versus 61.9% with static images only (P < .001), whereas the perinatologist called fewer structures normal with cine images alone (38.9%) versus static images alone (58.8%). The use of cine loops alone resulted in no significant increase in the ability to clear the heart as normal. The maternal body mass index was inversely associated with the ability to clear structures when 2D cine images were added to static images (P < .05). CONCLUSIONS: The addition of 2D cine clips to standard 2D static imaging of the fetal heart significantly improves the number of structures cleared as normal. Two-dimensional cine clips are easily obtained, add little time to a study, and require minimal archival space.

Radiosensitization of cervical cancer cells via double-strand DNA break repair inhibition.

PURPOSE: LY294002, a phosphatidylinositol 3-kinase (PI3K) inhibitor, has been found to radiosensitize various human cancer cells. However, its potential to act as an effective therapeutic agent is diminished by its toxicity levels. The purposes of this study were to determine the mechanism by which LY294002 radiosensitizes. MATERIALS AND METHODS: Cell growth curves and clonogenic assays were performed with increasing LY294002 exposure times proximate to the radiation dose. Protein levels of downstream PI3K effectors were analyzed. Detection of phosphorylated histone H2AX (gammaH2AX) was used to identify DNA double-strand breaks at various time points post-radiation. RESULTS: LY294002 significantly radiosensitized HeLa cervical cancer cells when administered for just 12 h following radiation. Cell growth curves also decreased with brief LY294002 application. DNA double-strand breaks are typically repaired within 2-6 h following radiation. Interestingly, at 48, 72, and 96 h post-irradiation, gammaH2AX was still significantly elevated in cells radiated in combination with LY294002. Protein expressions of ATM and ATR downstream effectors showed no differences among the treated groups, however, DNA-PK activity was significantly inhibited by LY294002. CONCLUSIONS: These results lead us to conclude that the central mechanism by which LY294002 radiosensitizes is via DNA-PK inhibition which induces DNA double-strand break repair inhibition. We are currently investigating radiosensitization induced by DNA-PK-specific inhibition in efforts to find a less toxic, yet equally effective, chemotherapeutic agent than LY294002.