Disseminated primary herpes simplex infection imitating preterm prelabor rupture of membranes - a case report.

Background: We describe a case of primary herpes simplex virus (HSV) infection imitating preterm prelabor rupture of membranes (PPROM) and review the intricacies of establishing the diagnosis. Case presentation: At 18 weeks of gestation, a patient was referred for suspected PPROM following leakage of fluid and a positive nitrazine test. The patient had a swollen inguinal lymph node, intermittent fevers, transaminitis, labial lesions, and cervical ulceration with vaginal discharge. Amniotic fluid volume was normal. An HSV PCR test was positive. Intravenous acyclovir followed by oral valacyclovir resulted in resolution of symptoms. Conclusion: Discharge from HSV cervicitis can present as nitrazine-positive pooling, imitating PPROM. A high index of suspicion is warranted, especially when the amniotic fluid volume is normal and arborization is not seen on microscopic exam.

Diagnosis of mid-second trimester fetal growth restriction and associated outcomes.

OBJECTIVE: To evaluate maternal and neonatal outcomes of low-risk singleton pregnancies, without underlying maternal medical conditions or genetic and fetal anomalies associated with fetal growth restriction, that were diagnosed with fetal growth restriction (FGR) (EFW < 10th %) in the mid-second trimester (between 17 and 22 weeks and 6 days' gestation). METHODS: A retrospective cohort study of all women who underwent a routine fetal anatomy ultrasound between 17 and 22 weeks and 6 days' gestation at a community-based academic hospital was performed to identify subjects with an EFW <10th%. Pregnancies with inadequate dating, multiple gestations, preexisting maternal vascular disease (chronic hypertension and pregestational diabetes), lethal fetal anomalies, and abnormal prenatal genetic screening were excluded. Descriptive statistics were computed to describe the study population. Subjects were stratified into two groups, estimated fetal weight (EFW) <5th% and EFW 5th-9th%. The primary outcome was a small for gestational age neonate (SGA) at delivery. Secondary outcomes included a composite adverse neonatal outcome, perinatal death, hypertensive disorders of pregnancy, medically indicated delivery, and mode of delivery. A comparison of the two groups, EFW <5th% and EFW 5th-9th %, was performed. Continuous variables were compared utilizing Wilcoxon Rank Sum tests and categorical variables were compared using Fisher's exact test or Chi-squared tests, and a dichotomous composite variable for adverse neonatal outcomes was also calculated. RESULTS: In total, 3,868 unique patient records were screened. Thirty-two patient records (0.8% of the total screened records) were eligible for inclusion. The primary outcome, SGA at delivery, occurred in 13/32 (41%) of the subjects. The secondary outcomes of the composite neonatal morbidity occurred in 9/32 (28%), hypertensive disorders of pregnancy in 10/32 (31%), and medically indicated delivery at <28 weeks gestation in 7/32 (22%) of the subjects. When comparing EFW <5th% and EFW 5th-9th%, EFW <5th% had a larger percentage of SGA newborns (66% vs. 25%, p = .02, OR = 8.0 95% CI 1.5-42.5). EFW <5th% was also significantly associated with a greater composite adverse neonatal outcome when compared to EFW 5th-9th% (54% vs. 10%, p = .015). The subgroup with an EFW <5th% also had higher rates of adverse outcomes including preeclampsia (42% vs. 10%, p = .073), abnormal umbilical artery Doppler studies (50% vs. 15%, p = .049), and medically indicated delivery <28 weeks (42% vs. 10%, p = .07). CONCLUSIONS: Early onset FGR is a associated with high rates of SGA at delivery, as well as several adverse maternal and neonatal outcomes which include hypertensive disorders of pregnancy, a greater composite neonatal morbidity, perinatal death, and medically indicated preterm delivery. EFW <5th% was associated with worse outcomes when compared to those with an EFW 5th%-9th%.

Outpatient Cervical Ripening with Balloon Catheters: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate whether outpatient cervical ripening with a balloon catheter results in a shorter amount of time in the labor and delivery unit when compared with use in the inpatient setting. DATA SOURCES: PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov were searched from their inception until December 2020. No restrictions for language or geographic location were applied. METHODS OF STUDY SELECTION: Using a predefined protocol and search strategy, 1,152 titles were identified and screened. Randomized controlled trials that compared outpatient and inpatient cervical ripening with balloon catheters were included. TABULATION, INTEGRATION, AND RESULTS: Data extraction and risk of bias assessments were performed by two reviewers. Meta-analysis was performed to produce mean difference for continuous data and risk ratio (RR) for dichotomous data, both with a 95% CI. The primary outcome was the amount of time from admission to the labor ward until delivery. Additional secondary maternal and neonatal outcomes were evaluated. Eight trials (740 patients) were included; six studies (571 patients) reported on our primary outcome. Compared with the inpatient group, outpatient balloon cervical ripening was associated with significantly less time in the labor and delivery unit (outpatient 16.3±9.7 hours vs inpatient 23.8±14.0 hours; mean difference -7.24 hours, 95% CI -11.03 to -3.34). There were no differences in total induction time or total hospital admission. The outpatient group was significantly less likely than the inpatient group to undergo cesarean delivery (21% vs 27%), RR 0.76 (95% CI 0.59-0.98). There were no differences in other maternal or neonatal outcomes. There were no deliveries outside of the hospital and no stillbirths. CONCLUSION: Outpatient balloon cervical ripening in low-risk patients is associated with a decreased amount of time from admission to labor and delivery until delivery. Outpatient balloon cervical ripening is a safe alternative for low-risk patients and has the potential for significant benefits to patients, and labor and delivery units. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42019140503.

Mode of Delivery in Monochorionic Compared With Dichorionic Twin Pregnancies.

OBJECTIVE: To compare mode of delivery between monochorionic and dichorionic twin pregnancies. METHODS: This was a retrospective cohort study of women undergoing delivery of diamniotic twins in a single maternal-fetal medicine practice in New York City between 2005 and 2021. We compared baseline characteristics and delivery outcomes between monochorionic and dichorionic gestations. The primary outcome was mode of delivery. For monochorionic-diamniotic twin pregnancies at or after 34 weeks of gestation, we also compared neonatal outcomes between women who did and did not attempt vaginal delivery. Data were analyzed using the χ2 test, Fisher exact test, and t test when appropriate. RESULTS: A total of 1,121 diamniotic twin pregnancies were identified, of which 202 (18%) were monochorionic and 919 (82%) were dichorionic. Mode of delivery did not differ between monochorionic and dichorionic pregnancies, both in the overall cohort (cesarean delivery rate 61% vs 63%, P=.54) and in the subgroup of women who attempted vaginal delivery (cesarean delivery rate 22% vs 21%, P=.80). For patients with a vaginal delivery of twin A, the mode of delivery for twin B did not differ between the groups. Among the patients with monochorionic pregnancies at or after 34 weeks of gestation, neonatal outcomes did not differ between women who did and did not attempt vaginal delivery. CONCLUSION: Monochorionic-diamniotic pregnancies are not at an increased risk of cesarean delivery when compared with their dichorionic-diamniotic counterparts.

Factors affecting fetal presentation in twin pregnancies across gestation.

OBJECTIVE: To describe pregnancy characteristics associated with the occurrence of spontaneous version in twin pregnancies from 20 weeks until delivery. STUDY DESIGN: Review of ultrasound and pregnancy data for all twin pregnancies delivered >24 weeks by one Maternal-Fetal Medicine practice from June 2005-May 2012. For each 4-week gestational age window, fetal presentations were recorded, as well as the likelihood of the final presentation being vertex for Twin A and vertex for both twins. Case-control analysis was performed to estimate associations between pregnancy characteristics and spontaneous version of Twin A. RESULTS: A total of 491 twin pregnancies were included. The distribution of fetal presentations changed significantly from 20 weeks to delivery, but the presentation at each gestational age interval was significantly associated with the final position of Twin A and the likelihood of vertex-vertex presentation at delivery. The likelihood of spontaneous version of Twin A decreased from 27.9% after 24-27 6/7 weeks, to 18.8% after 28-31 6/7 weeks, to 8.2% after 32-35 6/7 weeks. Pregnancy characteristics associated with spontaneous version of Twin A were a prior vaginal delivery and increased fetal size of either twin. CONCLUSIONS: The likelihood of spontaneous version of Twin A decreases as pregnancy advances. Parity and increased fetal size are associated with spontaneous version.