Incarcerated gravid uterus: a new treatment using the transvaginal ultrasound probe and narrative literature review.

BACKGROUND: 'Incarcerated gravid uterus' is a morbid complication that occurs in 1 in 3000 pregnancies. It is characterized by failure of a retropositioned uterus to become an abdominal organ between 12 to 14 weeks of gestation. If maternal symptoms develop or gestational age surpasses 14 to 16 weeks, replacement of a retropositioned uterus is recommended to reduce adverse outcomes. Previously described techniques for management include passive reduction, digital replacement, or more invasive methods such as laparoscopy, laparotomy, or sigmoidoscopy. These methods are either minimally effective, painful, or risky. OBJECTIVE: The objective of this report is to describe our clinical experience with a new minimally invasive technique that uses the transvaginal ultrasound probe for uterine replacement in cases of incarceration, to conduct a narrative literature review on 'incarcerated gravid uterus,' and to propose an algorithm for management of this condition. STUDY DESIGN: This is a case series of 8 patients with an incarcerated gravid uterus who were managed with the transvaginal ultrasound probe technique at one academic medical institution between March 2020 and July 2023, as well as a narrative review of the literature on 'incarcerated gravid uterus.' PubMed, Google Scholar, and Ovid MEDLINE databases were searched for the terms "incarcerated gravid uterus," "uterine incarceration," "uterine sacculation," and "retroverted uterus" up to April 2024. RESULTS: The transvaginal ultrasound probe technique resulted in successful uterine replacement, with resolution of symptoms, in all 8 patients. All pregnancies resulted in live births with good neonatal outcomes-7 out of 8 patients delivered at term, and 1 delivered in the late preterm period. CONCLUSION: Our proposed technique for treatment of an incarcerated gravid uterus with the transvaginal ultrasound probe is simple, minimally invasive and effective. Based on our experience and the narrative literature review, an algorithm for the management of an incarcerated gravid uterus is proposed.

Use of cervical elastography at 18 to 22 weeks' gestation in the prediction of spontaneous preterm birth.

BACKGROUND: Accurate identification of the women who will have spontaneous preterm birth continues to be a great challenge. The use of cervical elastography for prediction of preterm birth is promising, but several limitations exist. Newer cervical elastography technology has been developed that may prove useful in evaluation of risk of preterm birth. OBJECTIVE: This study aimed to develop standard cervical elastography nomograms for singleton pregnancies at 18 to 22 weeks' gestation using the E-Cervix ultrasound application, assess intraobserver reliability of the E-Cervix elastography parameters, and determine whether these cervical elastography measurements can be used in the prediction of spontaneous preterm birth. STUDY DESIGN: This was a prospective cohort study of pregnant women undergoing cervical length screening assessment via transvaginal ultrasound examination at 18 to 22 weeks' gestation. A semiautomatic, cervical elastography application (E-Cervix) was used during the transvaginal examination to calculate 5 quantitative parameters (internal os stiffness, external os stiffness, internal -to -external os stiffness ratio, hardness ratio, and elasticity contrast index) and create a standard nomogram for each one of them. The intraobserver reliability was calculated using Shrout-Fleiss reliability. Cervical elastography parameters were compared between those who delivered preterm (<37 weeks) spontaneously and those who delivered full term. A multivariable logistic regression model was performed to determine the ability of the cervical elastography parameters to predict spontaneous preterm birth. RESULTS: A total of 742 women were included, of which 49 (6.6%) had a spontaneous preterm delivery. A standard nomogram was created for each of the cervical elastography parameters from those who had a full-term birth in the index pregnancy (n=693). Intraobserver reliability was good or excellent (intraclass correlation, 0.757-0.887) for each of the cervical elastography parameters except external os stiffness which was poor (intraclass correlation, 0.441). In univariate analysis, none of the cervical elastography parameters were associated with a statistically significant increased risk of spontaneous preterm birth. In a multivariable model adjusting for history of preterm birth, gravidity, ethnicity, cervical cerclage, and vaginal progesterone use, increasing elasticity contrast index was significantly associated with an increased risk of spontaneous preterm birth (odds ratio, 1.15; 95% confidence interval, 1.02-1.30; P=.02). CONCLUSION: Cervical elastography parameters are reliably measured and are stable across 18 to 22 weeks' gestation. Based on our findings, the elasticity contrast index was associated with an increased risk of spontaneous preterm birth and may be a useful parameter for future research.

Coronavirus disease 2019 infection and placental histopathology in women delivering at term.

BACKGROUND: There is a paucity of data describing the effects of coronavirus disease 2019 on placental pathology, especially in asymptomatic patients. Although the pathophysiology of coronavirus disease 2019 is not completely understood, there is emerging evidence that it causes a severe systemic inflammatory response and results in a hypercoagulable state with widespread microthrombi. We hypothesized that it is plausible that a similar disease process may occur in the fetal-maternal unit. OBJECTIVE: This study aimed to determine whether coronavirus disease 2019 in term patients admitted to labor and delivery, including women without coronavirus disease 2019 symptomatology, is associated with increased placental injury compared with a cohort of coronavirus disease 2019-negative controls. STUDY DESIGN: This was a retrospective cohort study performed at NYU Winthrop Hospital between March 31, 2020, and June 17, 2020. During the study period, all women admitted to labor and delivery were routinely tested for severe acute respiratory syndrome coronavirus 2 regardless of symptomatology. The placental histopathologic findings of patients with coronavirus disease 2019 (n=77) who delivered a singleton gestation at term were compared with a control group of term patients without coronavirus disease 2019 (n=56). Controls were excluded if they had obstetrical or medical complications including fetal growth restriction, oligohydramnios, hypertension, diabetes, coagulopathy, or thrombophilia. Multivariable logistic regression models were performed for variables that were significant (P<.05) in univariable analyses. A subgroup analysis was also performed comparing asymptomatic coronavirus disease 2019 cases with negative controls. RESULTS: In univariable analyses, coronavirus disease 2019 cases were more likely to have evidence of fetal vascular malperfusion, that is, presence of avascular villi and mural fibrin deposition (32.5% [25/77] vs 3.6% [2/56], P<.0001) and villitis of unknown etiology (20.8% [16/77] vs 7.1% [4/56], P=.030). These findings persisted in a subgroup analysis of asymptomatic coronavirus disease 2019 cases compared with coronavirus disease 2019-negative controls. In a multivariable model adjusting for maternal age, race and ethnicity, mode of delivery, preeclampsia, fetal growth restriction, and oligohydramnios, the frequency of fetal vascular malperfusion abnormalities remained significantly higher in the coronavirus disease 2019 group (odds ratio, 12.63; 95% confidence interval, 2.40-66.40). Although the frequency of villitis of unknown etiology was more than double in coronavirus disease 2019 cases compared with controls, this did not reach statistical significance in a similar multivariable model (odds ratio, 2.11; 95% confidence interval, 0.50-8.97). All neonates of mothers with coronavirus disease 2019 tested negative for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction. CONCLUSION: Despite the fact that all neonates born to mothers with coronavirus disease 2019 were negative for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction, we found that coronavirus disease 2019 in term patients admitted to labor and delivery is associated with increased rates of placental histopathologic abnormalities, particularly fetal vascular malperfusion and villitis of unknown etiology. These findings seem to occur even among asymptomatic term patients.