Society for Maternal-Fetal Medicine Consult Series #72: Twin-twin transfusion syndrome and twin anemia-polycythemia sequence.

30% of spontaneously occurring twins are monozygotic, of which two-thirds are monochorionic, possessing a single placenta. A common placental mass with shared inter-twin placental circulation is key to the development and management of complications unique to monochorionic gestations. In this Consult, we review general considerations and a contemporary approach to twin-twin transfusion syndrome and twin anemia polycythemia sequence, providing management recommendations based on the available evidence. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend routine first trimester sonographic determination of chorionicity and amnionicity (GRADE 1B); (2) we recommend that ultrasound surveillance for twin-twin transfusion syndrome begin at 16 weeks of gestation for all monochorionic-diamniotic twin pregnancies and continue at least every 2 weeks until delivery, with more frequent monitoring indicated with clinical concern (GRADE 1C); (3) we recommend that routine sonographic surveillance for twin-twin transfusion syndrome minimally include assessment of amniotic fluid volumes on both sides of the inter-twin membrane and evaluation for the presence or absence of urine-filled fetal bladders, and ideally incorporate Doppler study of the umbilical arteries (GRADE 1C); (4) we recommend fetoscopic laser surgery as the standard treatment for stage II through stage IV twin-twin transfusion syndrome presenting between 16 and 26 weeks of gestation (GRADE 1A); (5) we recommend expectant management with at least weekly fetal surveillance for asymptomatic patients continuing pregnancies complicated by stage I twin-twin transfusion syndrome, and consideration for fetoscopic laser surgery for stage I twin-twin transfusion syndrome presentations between 16 and 26 weeks of gestation complicated by additional factors such as maternal polyhydramnios-associated symptomatology (GRADE 1B); (6) we recommend an individualized approach to laser surgery for early- and late-presenting twin-twin transfusion syndrome (GRADE 1C); (7) we recommend that all patients with twin-twin transfusion syndrome qualifying for laser therapy be referred to a fetal intervention center for further evaluation, consultation, and care (Best Practice); (8) after laser therapy, we suggest weekly surveillance for 6 weeks followed by resumption of every-other-week surveillance thereafter, unless concern exists for post-laser twin-twin transfusion syndrome, post-laser twin anemia polycythemia sequence, or fetal growth restriction (GRADE 2C); (9) following the resolution of twin-twin transfusion syndrome after fetoscopic laser surgery, and without other indications for earlier delivery, we recommend delivery of dual-surviving monochorionic-diamniotic twins at 34 to 36 weeks of gestation (GRADE 1C); (10) in twin-twin transfusion syndrome pregnancies complicated by post-treatment single fetal demise, we recommend full-term delivery (39 weeks) of the surviving co-twin to avoid complications of prematurity unless indications for earlier delivery exist (GRADE 1C); (11) we recommend that fetoscopic laser surgery should not influence the mode of delivery (Best Practice); (12) we recommend that prenatal diagnosis of twin anemia polycythemia sequence minimally requires either middle cerebral artery Doppler peak systolic velocity values >1.5 multiples of the median and <1.0 multiples of the median in donor and recipient twins, respectively, or an inter-twin Δ middle cerebral artery peak systolic velocity >0.5 multiples of the median (GRADE 1C); (13) we recommend that providers consider incorporating middle cerebral artery Doppler peak systolic velocity determinations into all monochorionic twin ultrasound surveillance beginning at 16 weeks of gestation (GRADE 1C); (14) consultation with a specialized fetal care center is recommended when twin anemia polycythemia sequence progresses to a more advanced disease stage (≥ stage II) prior to 32 weeks of gestation or when concern arises for co-existing complications such as twin-twin transfusion syndrome (Best Practice).

Third trimester uterine artery Doppler for prediction of adverse perinatal outcomes.

PURPOSE OF REVIEW: Abnormal uterine artery Doppler (UtAD) studies early in gestation have been associated with adverse pregnancy outcomes. However, their association with complications in the third trimester is weak. We aim to review the prediction ability for perinatal complications of these indices in the third trimester. RECENT FINDINGS: Abnormal UtAD waveforms in the third trimester are associated with preeclampsia, small-for-gestational age infants (SGA), preterm birth, perinatal death, and other perinatal complications, such as cesarean section for fetal distress, 5 min low Apgar score, low umbilical artery pH, and neonatal admission to the ICU, particularly in SGA infants. UtAD prediction performance is improved by the addition of maternal characteristics as well as biochemical markers to prediction models and is more precise if the evaluation is made closer to delivery or diagnosis. SUMMARY: This review shows that the prediction accuracy of UtAD for adverse pregnancy outcomes during the third trimester is moderate at best. UtAD have limited additive value to prediction models that include PlGF and sFlt-1. Serial assessments rather than a single third trimester evaluation may enhance the prediction performance of the UtAD combined models.

N95 Filtering Facepiece Respirator Use during Pregnancy: A Systematic Review.

OBJECTIVE: This study was aimed to systematically review the use of filtering facepiece respirators, such asN95 masks, during pregnancy. STUDY DESIGN: A comprehensive search for primary literature using Medline, Embase, Scopus, Web of Science, and ClinicalTrials.gov was conducted from inception until April 2020 to find articles reporting outcomes of pregnant women using filtering facepiece respirator (FFR). Studies were selected if they included the use of FFR in pregnant women and reported an outcome of interest including physiologic changes (heart rate, respiratory rate, pulse oximetry, and fetal heart rate tracing) or subjective measures (thermal or exertional discomfort or fit). The Newcastle-Ottawa Quality Assessment scale was used to assess the risk of bias. The main outcome was to describe the physiologic changes in pregnant women compared with nonpregnant women. Due to the small number of studies and heterogeneity of reported outcomes a meta-analysis was not conducted. Results of the studies were synthesized into a summary of evidence table. RESULTS: We identified four studies, three cohort studies and one crossover study, comprising 42 women using FFR during pregnancy. Risk of bias was judged to be low. Studies were consistent in showing no significant increase in maternal heart rate, respiratory rate, oxygen saturation, and fetal heart rate between pregnant and nonpregnant women using N95 FFRs for short durations. Repeat fit testing was not supported for women gaining the recommended amount of weight during pregnancy. No evidence was found to reach conclusions about prolonged N95 FFR use in pregnancy. CONCLUSION: Limited duration N95 FFR use during pregnancy is unlikely to impart risk to the pregnant women or her fetus. KEY POINTS: · Limited N95 use unlikely to impart risk to pregnant woman/fetus.. · Prolonged N95 use in pregnancy is unstudied.. · Repeat fit testing in pregnancy likely unnecessary..

Prenatal diagnosis of aortopulmonary window associated with aberrant subclavian artery.

Aortopulmonary window is a rare cardiac developmental anomaly characterised by a communication between the ascending aorta and the pulmonary artery. Aortopulmonary window may be isolated or associated with cardiac defects such as ventricular septal defect, atrial septal defect, interrupted aortic arch, and tetralogy of Fallot. We report a case of aortopulmonary window associated with aberrant subclavian artery based on fetal two-dimensional echocardiogram. The mother was referred for fetal echocardiography because of multiple fetal anomalies. Prenatal echocardiography at 30 weeks of gestation revealed a defect between the main and right pulmonary arteries and the ascending aorta (type III). The patient was born at 38 weeks of gestation via caesarean delivery, and was admitted to the neonatal intensive care unit because of respiratory failure and multiple congenital anomalies. Postnatal echocardiogram and cardiac MRI confirmed the prenatal findings. In addition, this patient had severe Dandy-Walker malformation and renal anomalies with poor prognosis. The family decided to withdraw respiratory care support on day of life 4, and the neonate passed away shortly after.

Prolonged latency of preterm premature rupture of membranes and risk of neonatal sepsis.

BACKGROUND: Preterm premature rupture of membranes (PPROM) is associated with inflammation and infection, and it may involve the loss of a barrier to ascending infection from the vagina, and it is possible that prolonged PPROM could be an independent risk factor for neonatal sepsis. OBJECTIVE: The objective of the study was to determine whether prolonged latency after PPROM is associated with an increased risk of neonatal sepsis. STUDY DESIGN: This secondary analysis of the randomized controlled trial of magnesium sulfate for the prevention of cerebral palsy evaluated whether the time interval between diagnosis of PPROM and delivery was associated with an increased risk of neonatal sepsis. Latency time was categorized by weeks of latency (0 weeks to ≥ 4 weeks). The primary outcome was confirmed neonatal sepsis. Logistic regression was used to control for confounders. RESULTS: A total of 1596 patients with PPROM were analyzed, of whom 1390 had a < 4-week interval and 206 had an interval of ≥ 4 weeks. Confirmed neonatal sepsis occurred in 15.5% of patients in the cohort. In the univariate analysis, patients in the prolonged PPROM group were less likely to have neonatal sepsis (6.8% vs 17.2%, relative risk, 0.40 95% confidence interval, 0.24-0.66). This relationship was retained in the multivariable model; patients with prolonged PPROM ≥ 4 weeks had an adjusted odds ratio of 0.21 (95% confidence interval, 0.10-0.41) for neonatal sepsis. Neonatal sepsis was also significantly associated with earlier gestational age at rupture of membranes. CONCLUSION: Prolonged exposure to an intrauterine environment of PPROM does not increase the risk of neonatal sepsis; prolonged PPROM ≥ 4 weeks was associated with decreased risk of neonatal sepsis.

Age-stratified risk of unexpected uterine sarcoma following surgery for presumed benign leiomyoma.

BACKGROUND: Estimates of unexpected uterine sarcoma following surgery for presumed benign leiomyoma that use age-stratification are lacking. PATIENTS AND METHODS: A retrospective cohort of 2,075 patients that had undergone myomectomy was evaluated to determine the case incidence of unexpected uterine sarcoma. An aggregate risk estimate was generated using a meta-analysis of similar studies plus our data. Database-derived age distributions of the incidence rates of uterine sarcoma and uterine leiomyoma surgery were used to stratify risk by age. RESULTS: Of 2,075 patients in our retrospective cohort, 6 were diagnosed with uterine sarcoma. Our meta-analysis revealed 8 studies from 1980 to 2014. Combined with our study, 18 cases of leiomyosarcoma are reported in 10,120 patients, for an aggregate risk of 1.78 per 1,000 (95% confidence interval [CI]: 1.1-2.8) or 1 in 562. Eight cases of other uterine sarcomas were reported in 6,889 patients, for an aggregate risk of 1.16 per 1,000 (95% CI: 0.5-4.9) or 1 in 861. The summation of these risks gives an overall risk of uterine sarcoma of 2.94 per 1,000 (95% CI: 1.8-4.1) or 1 in 340. After stratification by age, we predict the risk of uterine sarcoma to range from a peak of 10.1 cases per 1,000, or 1 in 98, for patients aged 75-79 years to <1 case per 500 for patients aged <30 years. CONCLUSION: The risk of unexpected uterine sarcoma varies significantly across age groups. Our age-stratified predictive model should be incorporated to more accurately counsel patients and to assist in providing guidelines for the surgical technique for leiomyoma.

Does magnesium exposure affect neonatal resuscitation?

OBJECTIVE: Research on immediate neonatal resuscitation suggests that maternal magnesium exposure may be associated with increased risk of low Apgar scores, hypotonia, and neonatal intensive care unit admission. However, not all studies support these associations. Our objective was to determine whether exposure to magnesium at the time of delivery affects initial neonatal resuscitation. STUDY DESIGN: This is a secondary analysis of the Randomized Controlled Trial of Magnesium Sulfate for the Prevention of Cerebral Palsy that evaluated whether the study drug (magnesium or placebo) that was administered at the time of delivery was associated with increased risk for a composite adverse neonatal resuscitation outcome (5-minute Apgar score <7, oxygen administration in the delivery room, intubation, chest compressions, hypotension, and hypotonicity). A subgroup analysis was performed among patients who delivered at ≥30 weeks of gestation. Log-linear regression was used to control for possible confounders. RESULTS: Data for 1047 patients were analyzed, of whom 461 neonates (44%) were exposed to magnesium. There was no increased risk for the primary composite outcome associated with magnesium exposure. Individual adverse neonatal outcomes and other secondary short-term neonatal outcomes that were evaluated also did not demonstrate an association with magnesium exposure. CONCLUSION: Exposure to magnesium sulfate did not affect neonatal resuscitation or other short-term outcomes. These findings may be useful in planning neonatal care and patient counseling.

Does the clinical presentation of a prior preterm birth predict risk in a subsequent pregnancy?

OBJECTIVE: The objective of the study was to determine whether risk of recurrent preterm birth differs based on the clinical presentation of a prior spontaneous preterm birth (SPTB): advanced cervical dilatation (ACD), preterm premature rupture of membranes (PPROM), or preterm labor (PTL). STUDY DESIGN: This retrospective cohort study included singleton pregnancies from 2009 to 2014 complicated by a history of prior SPTB. Women were categorized based on the clinical presentation of their prior preterm delivery as having ACD, PPROM, or PTL. Risks for sonographic short cervical length and recurrent SPTB were compared between women based on the clinical presentation of their prior preterm birth. Log-linear regression was used to control for confounders. RESULTS: Of 522 patients included in this study, 96 (18.4%) had prior ACD, 246 (47.1%) had prior PPROM, and 180 (34.5%) had prior PTL. Recurrent PTB occurred in 55.2% of patients with a history of ACD compared with 27.2% of those with PPROM and 32.2% with PTL (P = .001). The mean gestational age at delivery was significantly lower for those with a history of ACD (34.0 weeks) compared with women with prior PPROM (37.2 weeks) or PTL (37.0 weeks) (P = .001). The lowest mean cervical length prior to 24 weeks was significantly shorter in patients with a history of advanced cervical dilation when compared with the other clinical presentations. CONCLUSION: Patients with a history of ACD are at an increased risk of having recurrent preterm birth and cervical shortening in a subsequent pregnancy compared with women with prior preterm birth associated PPROM or PTL.

Mode of delivery at periviability and early childhood neurodevelopment.

OBJECTIVE: Little is known regarding the impact of mode of delivery in the periviable period. Even less is understood regarding the effect of mode of delivery on neurodevelopment. Our objective is to determine if the mode of delivery at time of periviability impacts Bayley II scores at 2 years of age. STUDY DESIGN: This is a secondary analysis of a randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy, a multicenter trial where women at imminent risk for delivery were assigned to receive magnesium sulfate or placebo. For this secondary analysis we included nonanomalous singleton gestations delivered between 23 4/7 and 25 6/7 weeks. We excluded women with missing exposure or outcome data. The primary exposure of interest was mode of delivery. The primary outcome was Bayley II scores <70 (mental and motor) at 2 years of age. Log binomial regression was used to control for possible confounders including gestational age at delivery, presentation at time of delivery, chorioamnionitis, years of maternal education, maternal body mass index, and original study treatment group. RESULTS: A total of 158 women met inclusion criteria. In all, 91 had a vaginal delivery and 67 had a cesarean delivery. Exposure to magnesium sulfate, maternal education, chorioamnionitis, years of maternal education, and maternal body mass index were similar in both groups. There was no difference in either mental or motor Bayley II scores <70 or <85 by mode of delivery in either univariable or multivariable analysis. CONCLUSION: There is no detectable difference in Bayley II scores between mode of delivery at time of periviability. This adds to the literature supporting obstetric indications dictating mode of delivery at this gestational age.

Impact of perinatal exposure counseling on patient reported emotional outcomes and decisional empowerment.

BACKGROUND: Exposures during pregnancy are common and most pregnant patients utilize at least one medication during pregnancy. The lack of reliable information on medication safety during pregnancy available to providers and patients is a stressor and obstacle to decision-making about medication use in pregnancy. Previous studies showed that exposures in pregnancy are associated with guilt, worry, and decisional conflict. Although prior research has evaluated changes in patient knowledge after teratogen counseling, studies have not examined emotional outcomes or patients' decisional empowerment. This quasi-experimental study measured changes in patients' feelings of guilt, anxiety, and decisional empowerment after receiving exposure counseling from trained teratogen information specialists. METHODS: We administered pre- and post-counseling surveys to patients referred to a perinatal exposure clinic in Tampa, Florida. Validated scales were used to measure anxiety and guilt, and the 'SURE' measure was used to assess decisional empowerment. Paired samples t-tests evaluated changes in anxiety and guilt and a McNemar test assessed for changes in empowered decision making. RESULTS: Among the 34 participants who completed both surveys, anxiety, and guilt scores decreased significantly (p < .001). While only 21% felt informed and empowered to make a decision related to their exposure(s) before counseling, this increased to 85% (p < .001) on the post-survey. CONCLUSION: Comprehensive counseling with a trained teratogen information specialist improves patient emotional outcomes as well as feelings of empowerment to make an informed decision regarding medication use in pregnancy. This study highlights that patient-centered teratogen counseling goes beyond simple changes in patient knowledge.

Vitamin D and maternal and child health: overview and implications for dietary requirements.

The essentiality of vitamin D for normal growth and development has been recognized for over 80 years, and vitamin D fortification programs have been in place in the United States for more than 70 years. Despite the above, vitamin D deficiency continues to be a common finding in certain population groups. Vitamin D deficiency has been suggested as a potential risk factor for the development of preeclampsia, and vitamin D deficiency during infancy and early childhood is associated with an increased risk for numerous skeletal disorders, as well as immunological and vascular abnormalities. Vitamin D deficiency can occur through multiple mechanisms including the consumption of diets low in this vitamin and inadequate exposure to environmental ultraviolet B rays. The potential value of vitamin D supplementation in high-risk pregnancies and during infancy and early childhood is discussed. Currently, there is vigorous debate concerning what constitutes appropriate vitamin D intakes during early development as exemplified by differing recommendations from the Institute of Medicine Dietary Reference Intake report and recent recommendations by the Endocrine Society. As is discussed, a major issue that needs to be resolved is what key biological endpoint should be used when making vitamin D recommendations for the pregnant woman and her offspring.

Detection of alcohol use in the second trimester among low-income pregnant women in the prenatal care settings in Jefferson County, Alabama.

BACKGROUND: Prenatal alcohol use, a leading preventable cause of birth defects and developmental disabilities, remains a prevalent public health concern in the United States. This study aims to detect the proportion and correlates of prenatal alcohol use in the prenatal care settings in Alabama. Prenatal care settings were chosen because of their potential as stable locations to screen for and to reduce prenatal alcohol use within a community. METHODS: We conducted a cross-sectional study of 3,046 women in the 22 and 23 weeks of gestation who sought prenatal care in 8 community-based public clinics and participated in the Perinatal Emphasis Research Center project in Jefferson County, Alabama, from 1997 to 2001. Frequency and quantity of alcohol use in the past 3 months were assessed by research nurses during face-to-face interviews. We conducted logistic regression analyses to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of correlates of prenatal alcohol use. RESULTS: Participants were predominantly young, African American, and unmarried, 86.5% on Medicaid. The proportion of alcohol use in the second trimester of pregnancy was 5.1%; 0.3% of women reported 4 or more drinks on a drinking day to research nurses. Older maternal age (OR = 1.11; 95% CI = 1.08 to 1.15), use of welfare (OR = 1.43; 95% CI = 1.02 to 2.02), and male partner-perpetrated violence (OR = 2.96; 95% CI = 1.92 to 4.56) were positively associated with elevated risk of prenatal alcohol use. Protective factors included higher levels of self-esteem (OR = 0.94; 95% CI = 0.89 to 0.98) and more years of education (OR = 0.88; 95% CI = 0.78 to 0.98). CONCLUSIONS: Prenatal alcohol use remains a public health issue among low-income pregnant women in Jefferson County, Alabama. Research nurses detected it in the second trimester. Future studies need to encourage screening for prenatal alcohol use in the prenatal care settings by obstetrician-gynecologists, family physicians, nurses, and midwives. Combined interventions to educate and empower women and strengthen families are needed.

Teratogen update: methotrexate.

Methotrexate and aminopterin are folic acid antagonists that inhibit dihydrofolate reductase, resulting in a block in the synthesis of thymidine and inhibition of DNA synthesis. Methotrexate has been used for the treatment of malignancy, rheumatic disorders, and psoriasis and termination of intrauterine pregnancy. Recently, methotrexate has become a standard treatment for ectopic pregnancy. The misdiagnosis of an intrauterine pregnancy as an ectopic pregnancy can result in exposure of a continuing pregnancy to dose levels of methotrexate of 50 mg/m(2) (maternal body surface area). Experimental animal studies have associated methotrexate therapy with embryo death in mice, rats, rabbits, and monkeys. Structural malformations have been most consistently produced in rabbits at a maternal dose level of 19.2 mg/kg. Abnormalities in rabbits include hydrocephalus, microphthalmia, cleft lip and palate, micrognathia, dysplastic sacral and caudal vertebrate, phocomelia, hemimelia, syndactyly, and ectrodactyly. Based on human case reports of methotrexate exposure during pregnancy, a methotrexate embryopathy has been described that includes growth deficiency, microcephaly, hypoplasia of skull bones, wide fontanels, coronal or lambdoidal craniosynostosis, upswept frontal scalp hair, broad nasal bridge, shallow supraorbital ridges, prominent eyes, low-set ears, maxillary hypoplasia, epicanthal folds, short limbs, talipes, hypodactyly, and syndactyly. This syndrome may be associated with exposures between 6 and 8 weeks after conception and dose levels of 10 mg/week or greater. More recent case reports of methotrexate exposure for the misdiagnosis of ectopic pregnancy involve treatment before 6 weeks after conception and have raised the suggestion of a distinct syndrome due to such early exposures. Tetralogy of Fallot and perhaps other neural crest cell-related abnormalities may be features of this early syndrome. A disproportionality analysis of methotrexate and aminopterin case reports and series provides support for pulmonary atresia, craniosynostosis, and limb deficiencies as reported more often than expected in methotrexate-exposed children. Denominator-based data will be welcome to better define elements of a methotrexate embryopathy and possibly to distinguish an early exposure syndrome from anomalies traditionally associated with methotrexate exposure.

Teratology public affairs committee position paper: iodine deficiency in pregnancy.

Iodine deficiency is an important nutritional deficiency, with more than 2 billion people worldwide estimated to be at risk. The developing fetus and young children are particularly at risk. During pregnancy and lactation, iodine requirements increase, whether in iodine-poor or iodine-sufficient countries, making the mother and the developing fetus vulnerable. The American Thyroid Association (ATA) recommends 250 micrograms per day of iodine intake for pregnant and lactating women. The thyroid gland is able to adapt to the changes associated with pregnancy as long as sufficient iodine is present. Dietary intake is the sole source of iodine, which is essential to the synthesis of thyroid hormones. Iodine is found in multiple dietary sources including iodized salt, dairy products, seaweed, and fish. Prenatal vitamins containing iodine are a good source of iodine, but iodine content in multivitamin supplements is highly variable. Congenital hypothyroidism is associated with cretinism. Clinical hypothyroidism has been associated with increased risk of poor perinatal outcome including prematurity, low birth weight, miscarriage, preeclampsia, fetal death, and impaired fetal neurocognitive development. Subclinical hypothyroidism is also associated with poor pregnancy outcomes and potential fetal neurocognitive deficits, but the data are more variable than those for clinical hypothyroidism. We concur with the ATA recommendation that all pregnant and lactating women should ingest (through diet and supplements) 250 micrograms of iodine daily. To achieve this goal, we recommend that all pregnant and lactating women take daily iodine supplementation of 150 micrograms.

Folic acid in early pregnancy: a public health success story.

Folate is a water-soluble B vitamin that must be obtained in the diet or through supplementation. For >50 yr, it has been known that folate plays an integral role in embryonic development. In mice, inactivation of genes in the folate pathway results in malformations of the neural tube, heart, and craniofacial structures. It has been shown that diets and blood levels of women who had a fetus with a neural tube defect are low for several micronutrients, particularly folate. Periconceptional use of folic acid containing supplements decreased recurrent neural tube defects in the offspring of women with a previously affected child and the occurrence of a neural tube defect and possibly other birth defects in the offspring of women with no prior history. Based on these findings, the U.S. Public Health Service recommended that all women at risk take folic acid supplements, but many did not. Mandatory food fortification programs were introduced in numerous countries, including the United States, to improve folate nutritional status and have resulted in a major decrease in neural tube defect prevalence. The success story of folate represents the cooperation of embryologists, experimentalists, epidemiologists, public health scientists, and policymakers.

A Case of Retroperitoneal Synovial Sarcoma in Pregnancy Treated with Antepartum Doxorubicin plus Ifosfamide Chemotherapy.

We report a case of a 25-year-old pregnant woman diagnosed with a large, unresectable retroperitoneal synovial sarcoma. Successful neoadjuvant treatment with doxorubicin plus ifosfamide prepartum and continuing postpartum resulted in significant disease response allowing for later tumor resection. Following the first prepartum chemotherapy cycle, a decreased amniotic fluid index was noted, representing a potential complication of chemotherapy. Induction of labor was performed at 33 weeks gestation with excellent outcome in the newborn. This case highlights the complex medical decision-making process in the setting of cancer diagnosed during pregnancy, balancing oncologic and obstetric concerns, and to our knowledge is only the second reported case of synovial sarcoma treated with neoadjuvant cytotoxic chemotherapy in the antepartum period.

Impact of Doula-Led Lactation Education on Breastfeeding Outcomes in Low-Income, Minoritized Mothers.

Prenatal education may improve breastfeeding outcomes among low-income women. Our objective was to assess breastfeeding intentions and knowledge among women participating in doula-facilitated prenatal education classes from August 2016 to October 2017. Breastfeeding knowledge and infant feeding intentions were assessed before and after the classes. Breastfeeding rates were assessed at birth, 2-4 weeks postpartum, and 6-8 weeks postpartum. Paired t-tests tests were conducted. A total of 121 racially diverse, low-income women were enrolled. Intentions to breastfeed increased pre- to post-intervention (p = 0.007). Breastfeeding knowledge scores increased pre- to post-intervention (p <.001); specifically, among women who were exclusively breastfeeding or breastfeeding while supplementing with formula at birth (p < .001 and p = 0.046, respectively). Doula-facilitated breastfeeding education may help improve breastfeeding outcomes for low-income women.

Pregnancy in systemic lupus erythematosus.

OBJECTIVES: Systemic lupus erythematosus (SLE) is a chronic illness that often affects women of reproductive age. The objectives of this article are to review the impact of SLE on pregnancy and current management strategies, including commonly used therapies. METHODS: We conducted a review of available literature on the clinical course of SLE, diagnosis, management and pregnancy complications. RESULTS: SLE has a variable clinical course characterized by flares and periods of remission and can present unique challenges in the management of obstetric patients. Pregnancy in patients with SLE is associated with multiple risks, including fetal loss, preterm birth, fetal growth restriction, and hypertensive disease. With advancements in disease treatment, many women have favorable pregnancy outcomes, but appropriate preconception counseling and disease management remain important tools in reducing complications. CONCLUSION: Given the implications SLE can have on women of reproductive age and in pregnancy, understanding the disease course and management is important in order to optimize pregnancy outcomes.

Current landscape of prenatal genetic screening and testing.

Pregnant patients should be offered the option of prenatal genetic screening and diagnostic testing. The type of screening and testing offered to a patient may depend on various factors including but not limited to age, family history, fetal findings, exposures, and patient preferences. Prenatal screening is available for a variety of genetic conditions including aneuploidy, congenital abnormalities, and carrier status. Diagnostic testing options include karyotype, prenatal microarray, as well as next-generation sequencing. The various options differ in methodology, accuracy, timing and indication for testing, and information they provide. Given that the technologies related to prenatal testing are rapidly evolving and improving, the array of available screening and testing modalities are increasing. This article reviews the current offerings in prenatal screening and diagnosis.

Teratogen update: Antithyroid medications.

OBJECTIVE: Thyroid disorders including hyperthyroidism are common during pregnancy. Untreated hyperthyroidism can result in adverse outcomes for pregnancy. METHODS: Iodine, propylthiouracil (PTU), carbimazole (CMZ), and methimazole (MMI) are common medications for hyperthyroidism treatment. The literature regarding antithyroid medication use in pregnancy and breastfeeding is reviewed. RESULTS: Animal studies for PTU have suggested congenital anomalies while animal studies for MMI have only indicated adverse outcomes at higher doses than used in humans. Epidemiological studies have noted an increased risk of congenital anomalies for PTU less often than CMZ or MMI but the epidemiological evidence remains mixed. A pattern of anomalies has been described for CMZ and MMI, from both case and epidemiological studies, including choanal atresia, aplasia cutis congenita, and other facial, heart, gastrointestinal, and skin anomalies. Closer examination of cases indicates that a few cases of the anomalies have occurred without exposure to CMZ or MMI and outside of the proposed critical period. PTU has a small risk of hepatotoxicity which rarely results in liver transplantation and death. Some authors have suggested that PTU be prescribed in early pregnancy and switched to MMI in late pregnancy. Untreated hyperthyroidism, from either a lack of medications or switching medications during the first trimester, may also increase the chance of congenital anomalies. Multiple case studies and larger epidemiological studies have failed to provide clear, consistent outcomes for the use of PTU, CMZ, and MMI in pregnancy. MMI and PTU both enter the breastmilk in small amounts. CONCLUSION: Additional research is needed to assist in the medical management and exposure counseling of pregnant and breastfeeding women with hyperthyroidism.