Perceived Impact of a Core Rotation on Hawai'i Island on Future Career Intentions among Obstetrics and Gynecology Residents.

Hawai'i Island faces a growing shortage of obstetric and gynecology providers. Increased exposure of obstetrics and gynecology residents to rural rotations during their core training may increase their interest in rural practice after graduation. In an effort to address the health care needs of women on Hawai'i Island, the University of Hawai'i Obstetrics and Gynecology Residency Program established a 4-week required gynecology rotation in the town of Hilo. Between July 2019 and June 2020, third- and fourth-year obstetrics and gynecology residents provided outpatient gynecologic care and participated in gynecologic surgeries at Hilo-based medical facilities. A total of 9 residents participated in this Hilo-based rotation. This retrospective study extracted data from post-rotation evaluations. Eight out of 9 participating residents (89%) felt that the rotation slightly or far exceeded their expectations. After the rotation, 7 residents (78%) reported an interest in practicing in a rural community, while only 3 residents (33%) reported having this interest prior to the rotation. Underserved rural areas seeking to recruit and retain obstetrics and gynecology physicians may benefit from partnering with residency training programs.

Maternal telehealth: innovations and Hawai'i perspectives.

Access to maternal-fetal medicine (MFM) subspecialty services is a critical part of a healthcare system that optimizes pregnancy outcomes for women with complex medical and obstetrical disorders. Healthcare services in the State of Hawai'i consist of a complicated patchwork of independently run community health clinics and hospital systems which are difficult for many pregnant patients to navigate. Maternal telehealth services have been identified as a solution to increase access to subspecialty prenatal services for women in rural communities or neighboring islands, especially during the COVID-19 pandemic. Telehealth innovations have been rapidly developing in the areas of remote ultrasound, hypertension management, diabetes management, and fetal monitoring. This report describes how telehealth innovations are being introduced by MFM specialists to optimize care for a unique population of high-risk patients in a remote area of the world such as Hawai'i, as well as review currently available telemedicine technologies and future innovations.

Monochorionic Triplet Pregnancies With Twin Reversed Arterial Perfusion and Acardiac Triplet: Report of Two Cases and Literature Review.

TRAP pregnancies involving monochorionic triplets are extremely rare, calculated to be 1 in 4.5 million. We report two cases of monochorionic triplet pregnancies with an acardiac triplet. In one case, the mother was a 33-year-old G2P1 who underwent dilation and evacuation at 20 weeks due to poor prognosis. The other case involved a 21-year-old G1P0 mother presenting in advanced preterm labor at 21 weeks who elected expectant management. Seventeen cases of monochorionic triplets with TRAP were identified in the literature. Invasive intervention was performed in 10 cases; 9 cases resulted in the survival of the nonacardiac twins and 1 case resulted in the survival of 1 fetus. Our two cases had common sonographic features which included polyhydramnios of all fetuses. Placental features shared between both cases included being large for gestational age and velamentous insertion of the acardiac twin. The acardiac twins in both of our cases were hydropic and demonstrated developed pelvis and lower extremities. One had an omphalocele. Most case reports in the literature review demonstrate similar findings. Two cases of monochorionic triplets with TRAP and acardiac twin are herein described. Successful treatment by invasive interventions have been described in this condition, highlighting the importance of early diagnosis.

Obstetric hospital preparedness for a pandemic: an obstetric critical care perspective in response to COVID-19.

The Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) pandemic has had a rapid and deadly onset, spreading quickly throughout the world. Pregnant patients have had high mortality rates, perinatal losses, and Intensive Care Unit (ICU) admissions from acute respiratory syndrome Coronavirus (SARS-CoV) and Middle East respiratory syndrome Coronavirus (MERS-CoV) in the past. Potentially, a surge of patients may require hospitalization and ICU care beyond the capacity of the health care system. This article is to provide institutional guidance on how to prepare an obstetric hospital service for a pandemic, mass casualty, or natural disaster by identifying a care model and resources for a large surge of critically ill pregnant patients over a short time. We recommend a series of protocols, education, and simulation training, with a structured and tiered approach to match the needs for the patients, for hospitals specialized in obstetrics.

Academic clinical learning environment in obstetrics and gynecology during the COVID-19 pandemic: responses and lessons learned.

COVID-19 pandemic is changing profoundly the obstetrics and gynecology (OB/GYN) academic clinical learning environment in many different ways. Rapid developments affecting our learners, patients, faculty and staff require unprecedented collaboration and quick, deeply consequential readjustments, almost on a daily basis. We summarized here our experiences, opportunities, challenges and lessons learned and outline how to move forward. The COVID-19 pandemic taught us there is a clear need for collaboration in implementing the most current evidence-based medicine, rapidly assess and improve the everchanging healthcare environment by problem solving and "how to" instead of "should we" approach. In addition, as a community with very limited resources we have to rely heavily on internal expertise, ingenuity and innovation. The key points to succeed are efficient and timely communication, transparency in decision making and reengagement. As time continues to pass, it is certain that more lessons will emerge.

Three dimensional power Doppler of the placenta and its clinical applications.

The aim of this review is to discuss three dimensional (3D) power Doppler of the placenta and its clinical applications. There is a strong clinical need to develop noninvasive, simple and widely available methods of evaluating in vivo placental function to assess fetal wellbeing. While conventional ultrasound is a proven tool in the evaluation of fetal structural anomalies and health, its ability to assess placental function, especially prior to the onset of fetal compromise, is the subject of ongoing investigation. Three dimensional power Doppler has the ability to detect vascularity and blood flow with greater detail than conventional ultrasound, which has led to its investigation in preeclampsia, fetal growth restriction, and other placental vascular abnormalities. While more data are needed on the optimal imaging protocol and its predictive ability for clinical outcomes, 3D power Doppler is emerging as a promising new technology that will improve the evaluation of placental function.

Placenta accreta: diagnosis, management and the molecular biology of the morbidly adherent placenta.

Placenta accreta is now the chief cause of postpartum hemorrhage resulting in maternal and neonatal morbidity. Prenatal diagnosis decreases blood loss at delivery and intra and post-partum complications. Ultrasound is critical for diagnosis and MRI is a complementary tool when the diagnosis is uncertain. Peripartum hysterectomy has been the standard of therapy but conservative management is increasingly being used. The etiology of accreta is due to a deficiency of maternal decidua resulting in placental invasion into the uterine myometrium. The molecular basis for the development of invasive placentation is yet to be elucidated but may involve abnormal paracrine/autocrine signaling between the deficient maternal decidua and the trophoblastic tissue. The interaction of hormones such as Relaxin which is abundant in maternal decidua and insulin-like 4, an insulin-like peptide found in placental trophoblastic tissue may play role in the formation of placenta accreta.

Managing Diabetes in Pregnancy Using Cell Phone/Internet Technology.

In Brief For pregnant women with diabetes, using cell phone/Internet technology to track and report self-monitoring of blood glucose results improves compliance and satisfaction compared to using the more traditional methods of log books, telephone calls, and voicemail messages.

Obesity and the challenges of ultrasound fetal abnormality diagnosis.

Prenatal ultrasound has become an essential clinical tool for aneuploidy screening, detection of fetal congenital anomalies, and assessment of fetal growth and well-being. Maternal obesity, an increasing global problem, has been shown to decrease the accuracy of ultrasound examination in high-risk pregnancy. The purpose of this review is to provide an evidenced-based perspective on the challenges of performing fetal ultrasound in obese women and to provide a practical guide on how to care for these patients in the ultrasound suite.

Management of the adnexal mass in pregnancy.

PURPOSE OF REVIEW: With the increased use of ultrasonography in the first trimester, up to 1% of all pregnancies are diagnosed with an adnexal mass. Yet, the management of asymptomatic adnexal masses in pregnancy continues to be controversial as management guidelines are mainly based on case-control or observational studies. The purpose of this article was to review the recent literature and provide clinical guidance on patient management. RECENT FINDINGS: This review will highlight the increasing sensitivity of ultrasound imaging in diagnosing the rare malignant lesion, allowing for antenatal expectant management of benign asymptomatic adnexal masses until delivery or postpartum. The recent literature also highlights the well tolerated use of laparoscopy for the antenatal removal of suspicious or symptomatic masses and that expectant management of asymptomatic masses does not increase the risk of adverse pregnancy outcomes. SUMMARY: Most adnexal masses are benign and ultrasound characteristics can help guide the assessment of asymptomatic ovarian masses. When surgical management is chosen, laparoscopy can be safely performed in pregnancy. Ovarian torsion is a complication for persistent masses in pregnancy.

Ethnic variation of gastroschisis and omphalocele in the United States of America.

OBJECTIVE: Gastroschisis and omphalocele are the most common fetal abdominal wall defects (AWDs). Ethnic factors have been implicated in the incidence data from some states in the United States. Our aim was to examine ethnic variation in the prevalence of gastroschisis and omphalocele in the US live birth population between 2006 and 2010. METHODS: AWDs were identified through gastroschisis and omphalocele checkboxes from publicly available US Natality data (2006 to 2010). Ethnicity was evaluated by individual category using National Center for Health Statistics (NCHS) definitions. Adjusted multinomial logistic regression (SPSS v.19) was used to generate odds ratios (OR) in order to quantify the disparities. RESULTS: In the US, 7867 live births were identified with AWD. All ethnic groups showed a significantly higher OR when compared with women of East/South Asian descent, which experienced the lowest prevalence. Women of indigenous ethnicity had the highest individual OR while their adjusted OR remained greater than 4.0. CONCLUSIONS: Women of indigenous origin from North America and the Pacific had the highest rates of AWD. Within this group, women of Hawaiian descent had the highest point estimate of AWD when compared with other ethnic groups, though not significant.

Persistent ovarian masses and pregnancy outcomes.

OBJECTIVE: To determine if persistent ovarian masses in pregnancy are associated with increased adverse outcomes. METHODS: This is a retrospective cohort of 126 pregnant women with a persistent ovarian mass measuring 5 cm or greater who delivered at two university hospitals between 2001 and 2009. Maternal outcomes included gestational age (GA) at diagnosis, delivery and surgery as well as miscarriage, preterm birth (PTB), ovarian torsion and hospital admission for pain. Neonatal outcomes included birth weight, respiratory distress syndrome (RDS), intra-ventricular hemorrhage (IVH), death and sepsis. RESULTS: A total of 1225 ovarian masses were identified (4.9%) in 24,868 patients. A persistent ovarian mass was found in 0.7%. Average GA at diagnosis was 17.8 weeks. Miscarriage rate was 3.3%. Average GA at delivery was 37.9 weeks. Of the patients, 8.5% had ovarian torsion, 10.3% had admission for pain and 9.3% had PTBs. The mean cesarean delivery rate was 46.3%. The average neonatal weight was 3273 g. There was one neonatal death in this cohort. The rate of RDS was 2.8%, IVH 0.9% and neonatal sepsis 1.9%. The most common surgical pathologic diagnosis was dermoids (37.6%). No overt malignancies were seen. CONCLUSION: A persistent ovarian mass in pregnancy does not confer an increased risk of adverse pregnancy outcomes.

Comparison between antenatal neurodevelopmental test and fetal Doppler in the assessment of fetal well being.

AIMS: The primary aim of this study was to compare circulatory changes in the fetal brain under certain pathological conditions with alterations in fetal behavior. PATIENTS AND METHODS: A prospective longitudinal cohort study on fetal behavior of fetuses from singleton pregnancies between the 28th and 38th gestational week in the period from March 2009 to October 2011 was undertaken. There were 596 fetuses in the high-risk group and 273 fetuses in the low-risk group. Elevated umbilical artery Doppler pulsatility index and reduced middle cerebral artery pulsatility index obtained in the absence of fetal movements were considered abnormal. The Kurjak Antenatal Neurodevelopmental Test (KANET) was used to assess fetal behavior. RESULTS: Statistically significant differences in the distribution of normal, abnormal, and borderline KANET scores between low-risk and high-risk groups were found. Furthermore, 596 fetuses from the high-risk group were subdivided into subgroups according to the risk factor. The largest proportion of abnormal KANET scores (23.9%) was in the subgroup of fetuses whose mothers had an offspring diagnosed with cerebral palsy (23.9%), followed by the proportion of borderline KANET scores in the subgroup of fetuses from febrile mothers (12.7%). Fetal behavior was significantly different between the normal group and the following subgroups of fetuses: fetal growth restriction (FGR), gestational diabetes mellitus, threatened preterm birth, antepartal hemorrhage, maternal fever, sibling with cerebral palsy, and polyhydramnios. CONCLUSIONS: A new clinical application of the KANET test in early identification of fetuses at risk for adverse neurological outcome was demonstrated.

Fetal biometry: a comparison between experienced sonographers and automated measurements.

OBJECTIVE: We compared the performance between sonographers and automated fetal biometry measurements (Auto OB) with respect to the following measurements: biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL). METHODS: The first set of experiments involved assessing the performance of Auto OB relative to the five sonographers, using 240 images for each user. Each sonographer made measurements in 80 images per anatomy. The second set of experiments compared the performance of Auto OB with respect to the data generated by the five sonographers for inter-observer variability (i.e., sonographers and clinicians) using a set of 10 images per anatomy. RESULTS: Auto OB correlated well with manual measurements for BPD, HC, AC and FL (r > 0.98, p < 0.001 for all measurements). The errors produced by Auto OB for BPD is 1.46% (sigma = 1.74%), where sigma denotes standard deviation), for HC is 1.25% (sigma = 1.34%), for AC is 3% (sigma = 6.16%) and for FL is 3.52% (sigma = 3.72%). In general, these errors represent deviations of less than 3 days for fetuses younger than 30 weeks, and less than 7 days for fetuses between 30 and 40 weeks of age. CONCLUSION: The measurements produced by Auto OB are comparable to the measurements done by sonographers.

Three-dimensional sonography of the placental and uterine spiral vasculature: influence of maternal age and parity.

PURPOSE: : To test the influence of maternal age and parity on placental volume and uterine spiral vasculature volume, their mean gray value, and 3-dimensional power Doppler (3DPD) indices in normal pregnancy. METHODS: : Women with a gestational age of 14-25 weeks were included in the study. Exclusion criteria included posterior placenta, structural or chromosomal anomaly, pregnancy complications, and unknown pregnancy outcome. 3D sonograms of the placenta and uterine spiral vasculature were obtained. Virtual Organ Computer-aided AnaLysis imaging software was used to calculate the volumes, mean gray value, and 3DPD indices. RESULTS: : The study included 199 women, the majority of whom were Filipino, Japanese, or part Hawaiian. The placental volume, uterine spiral vasculature volume, mean gray value, and 3DPD indices were similar in all women regardless of maternal age. However, uterine spiral vasculature volume was significantly larger in women younger than 25 years, compared with women 35 years of age and older. Parity influenced all placental 3DPD indices, whereas placental volume, uterine spiral vasculature volume, mean gray value, and 3DPD indices remained unaffected. CONCLUSION: : Maternal age influenced uterine spiral vasculature volume, whereas parity influenced all placental 3DPD indices.

Risks of third-trimester amniocentesis.

OBJECTIVE: To establish the risk of immediate complications from third-trimester amniocentesis. STUDY DESIGN: The entry criterion was amniocentesis done in the third trimester (28 or more weeks of gestation). The primary study outcome was any complication within 24 hours after the procedure. The secondary outcome was mode of delivery and pregnancy outcome. RESULTS: One hundred eleven patients were enrolled in this study with a known postprocedure course and pregnancy outcome. The average patient age was 29.8 years, average gravidity 2.9, average gestational age 36 weeks, average amount of amniotic fluid withdrawn 12.9 mL and average number of attempts to perform amniocentesis 1.03. The most common indication for the procedure was fetal lung maturity study and workup for chorioamnionitis. The list of complications observed within 24 hours included: regular contractions (2 patients, or 1.8%), ruptured membranes (1 patient, or 0.9%) and minimal vaginal bleeding (1 patient, or 0.9%). The overall complication rate was 3.6%. There was no perinatal or maternal morbidity directly linked to the procedure. No patients with complications needed urgent delivery. CONCLUSION: Third-trimester amniocentesis carried a complication rate of 3.6%. All complications were self-limited.

Placental and spiral artery volume and gray-scale value assessment via 3-dimensional sonography in the second trimester.

PURPOSE: Extreme placental size has been associated with abnormal pregnancy outcomes. The purpose of this study was to establish normal values for placental and spiral artery volume and gray-scale value as assessed via 3-dimensional (3D) sonography in the second trimester. METHODS: The entry criterion was a documented singleton pregnancy at 14-25 weeks' gestation. Patients with normal pregnancy outcome were stratified into 6 subgroups representing 2-week intervals. Automatic 3D sonographic acquisition of the placental and spiral artery volume and gray-scale value, expressed as a percentage, was obtained. RESULTS: Out of 199 patients with normal pregnancy outcome, the placental volume was between 77.7 and 213.9 cm(3) and the gray-scale value was between 28.6 and 29.2 cm(3) (depending on gestational age). The spiral artery volume adjacent to placenta was between 47.9 and 108.7 cm(3), and the gray-scale value was between 27.5 and 29.5 cm(3). Statistical analysis in each subgroup of patients revealed a significant difference between placental and spiral artery volumes but no difference when the gray-scale value was compared. CONCLUSIONS: We defined normal placental and spiral artery volume and gray-scale value in the second trimester of normal pregnancy using 3D sonography.