Subchorionic Hematomas and Adverse Pregnancy Outcomes among Twin Pregnancies.

OBJECTIVE: This study estimates the association of a first trimester finding of subchorionic hematoma (SCH) with third trimester adverse pregnancy outcomes in women with twin pregnancies. STUDY DESIGN: Retrospective cohort study of twin pregnancies prior to 14 weeks at a single institution from 2005 to 2019, all of whom had a first trimester ultrasound. We excluded monoamniotic twins, fetal anomalies, history of fetal reduction or spontaneous reduction, and twin-to-twin transfusion syndrome. Ultrasound data were reviewed, and we compared pregnancy outcomes after 24 weeks in women with and without a SCH at their initial ultrasound 60/7 to 136/7 weeks. Regression analysis was used to control for any differences in baseline characteristics. RESULTS: A total of 760 women with twin pregnancies met inclusion criteria for the study, 68 (8.9%) of whom had a SCH. Women with SCH were more likely to have vaginal bleeding and had their initial ultrasound at earlier gestational ages. On univariate analysis, SCH was not significantly associated with gestational age at delivery, preterm birth, birthweight of either twin, low birthweight percentiles of either twin, fetal demise, or preeclampsia. SCH was associated with placental abruption on univariate analysis, but not after controlling for vaginal bleeding and gestational age at the time of the initial ultrasound (adjusted odds ratio: 2.00, 95% confidence interval: 0.63-6.42). Among women with SCH, SCH size was not associated with adverse pregnancy outcomes. CONCLUSION: In women with twin pregnancies, the finding of a first trimester SCH is not associated with adverse pregnancy outcomes >24 weeks.

Acute pulmonary complications in the setting of high risk gestational trophoblastic neoplasia and induction of chemotherapy.

Gestational trophoblastic neoplasia (GTN) consists of rare malignancies of the placenta with a known propensity to metastasize to the lungs. GTN is treated with chemotherapeutic agents known to cause lung injury, further placing patients at risk for serious pulmonary events. In the literature, only a few reports of these complications and their management have been described. Here, we present two cases of GTN with pulmonary complications in the hopes of providing guidance in management. Management of these acute complications had to be balanced between continuation of life-saving therapy to reduce disease burden versus further exacerbation existing pulmonary disease. A review of the English language literature on pulmonary complications in GTN and chemotherapy was performed. In these two cases, we identified key steps that were critical in management: inpatient chemotherapy, early intervention and transfer to an intensive unit when needed, multidisciplinary teams, and altering regimens to reduce lung toxicity. Sequelae of pulmonary injury secondary to chemotherapy can be similar to those secondary to metastases. Because consistent criteria for chemotherapy-induced lung injury has not been established, the true incidence of lung injury that is directly related to chemotherapy versus metastatic disease cannot always be parsed out, making management of these complications difficult. There is also a lack of centralized care for a rare disease like GTN and regional differences in incidence, which can lead to inconsistent treatment decisions. It therefore remains important to illuminate rarely seen complications and their management in the hopes of providing guidance to future clinicians.

Stratified risk of pregnancy loss for women with a viable singleton pregnancy in the first trimester.

OBJECTIVE: Calculate the risk of miscarriage in women with a viable (defined as presence of fetal heart rate on ultrasound) first trimester singleton pregnancy and to create a model for stratified risk-assessment for pregnancy loss based on significant risk factors. STUDY DESIGN: Retrospective cohort study of unselected women with singleton pregnancies in a large obstetrical practice who presented for prenatal care prior to 14 weeks over a three-year period. All women underwent a formal first-trimester ultrasound, and we only included women with viable pregnancies with fetal heart activity seen on that ultrasound. Our primary outcome was pregnancy loss prior to 20 weeks. Statistical modeling was used to create a risk-assessment tool from adjusted likelihood ratios of pregnancy loss based on risk factors independently associated with this outcome. RESULTS: From January 2015-December 2017, 2,446 women met the inclusion criteria for the study and 132 (5.4%) had a pregnancy loss <20 weeks. On regression analysis, the independent risk factors for pregnancy loss were earlier gestational age (aOR 0.72, 95% CI 0.65-0.80) and increasing number of prior miscarriages (aOR 1.56, 95% CI 1.32-1.83). Using these risk factors, we calculated the stratified risk of pregnancy loss, which ranged from 0.8% in women at 13 weeks of gestation with no prior miscarriages to 33.7% in women at six weeks of gestation with three or more prior miscarriages. CONCLUSION: In first trimester singleton pregnancies, the overall risk of pregnancy loss <20 weeks after confirmation of fetal heart activity is 5.4%, but can be stratified for each woman and ranges from 0.8% to 33.7% based on the gestational age and number of prior pregnancy losses.

Age-associated trends of vulvar cancer in the US.

OBJECTIVE: Medical societies have over the years moved away from recommending routine pelvic examinations in older, asymptomatic women above age 65. Consequently, vulvar examination is a largely neglected component of the physical examination, unless sent to a specialist for gynecological evaluation. In recognition of these recommendations, we analyzed US trends in vulvar cancer incidence, age, and stage at diagnosis, survival, and association with human papillomavirus (HPV). METHODS: Cases of vulvar and cervical cancer from 1992 to 2014 were extracted from the National Cancer Institute's Surveillance, Epidemiology, and End Results and Centers for Disease Control's data on age at diagnosis, stage of disease, and HPV-association were analyzed and compared. Incidence and mortality rates were extracted and calculated. RESULTS: From 1992-2014, there was a 14.3% increase in vulvar cancer rates. The absolute average incidence rate was 2.25, with HPV still being seen in vulvar carcinomas in women 65 years and above. Cervical cancer mortality rates declined by 34.2%, while vulvar cancer death rates were unchanged. We show increased intervals for cervical cancer screening is associated with later stage vulvar cancer detection. The proportion of vulvar cancer cases diagnosed in women age <50 steadily decreased, from 42.05% of cases in 1992-1996 to 19.75% of total cases in 2012-2015. Meanwhile, vulvar cancer cases diagnosed in women > 65 yo increased from 36.62% of cases in 1992-1996 to 49.82% of cases in 2012-2015. CONCLUSION: The incidence of vulvar cancer increases with age, with the median age of diagnosis 67 years, with HPV (+) tumors occurring into 70's and 80's. Though medical societies do not routinely recommend an external genital examination in women 65 years and above, we show this is a missed opportunity to improve cancer outcomes in some older females.

Video Summary:http://links.lww.com/MENO/A678.

Exercise-Induced Sustained Ventricular Tachycardia without Structural Heart Disease: A Case Report.

BACKGROUND Exercise-induced ventricular tachycardia (VT) has been widely reported in patients with preexisting structural heart disease or underlying ischemia and is attributed to reentry tachycardia and abnormal automaticity. However, studies regarding exercise-induced VT in individuals without evident structural heart disease are still limited. CASE REPORT A 51-year-old woman came to our practice for a treadmill stress echocardiogram. The patient experienced only mild chest discomfort and was otherwise asymptomatic. Cardiovascular risk factors were significant only for obesity and positive family history of coronary artery disease in the mother. During the exercise stress test, the patient developed wide complex VT with multiple capture beats accompanied by nausea and dizziness, which lasted approximately 2 minutes before resolving spontaneously. Subsequent evaluation with magnetic resonance imaging, transthoracic echocardiography, and coronary angiography revealed an absence of apparent structural heart disease. CONCLUSIONS Exercise-induced VT in the absence of structural heart disease, although rare, can pose a life-threatening event and requires different considerations for management. The benefits of currently available therapeutic options have yet to be elucidated for this subset of patients. Thus, we assert that there is a need for further investigation on the approach of exercise-induced VT in patients without structural heart disease.

Association Between First-Trimester Subchorionic Hematomas and Pregnancy Loss in Singleton Pregnancies.

OBJECTIVE: To assess the association of a first-trimester subchorionic hematoma with pregnancy loss in women with singleton pregnancies. METHODS: We conducted a retrospective cohort study of all women with singleton pregnancies presenting for prenatal care before 14 weeks of gestation over a 3-year period at a single obstetric practice. All patients had routine first-trimester ultrasound scans. We reviewed ultrasound data from the first ultrasound scan performed between 6 0/7 and 13 6/7 weeks of gestation and compared rates of pregnancy loss before 20 weeks in women with and without a subchorionic hematoma. Logistic regression analysis was used to control for potential confounding variables. RESULTS: From January 2015 to December 2017, a total of 2,446 women met inclusion criteria, 451 (18.4%) of whom had subchorionic hematomas. Women with subchorionic hematomas had their first ultrasound scans at an earlier gestational age (8 5/7 vs 9 6/7 weeks of gestation, P<.001) and were more likely to have vaginal bleeding (33.3% vs 8.1%, P<.001). Maternal age, race, use of in vitro fertilization, body mass index, prior number of losses, and medical comorbidities did not differ between the groups. On univariable analysis, subchorionic hematoma was associated with an increased risk of pregnancy loss before 20 weeks of gestation (7.5% vs 4.9%, P=.026); however, after adjusting for gestational age and vaginal bleeding, this association was no longer significant (adjusted odds ratio 1.13, 95% CI 0.74-1.74). In the 451 women with subchorionic hematomas, no characteristics of the subchorionic hematoma, including size by volume, largest diameter, presence of vaginal bleeding, and presence of an additional subchorionic hematoma, were associated with pregnancy loss. Post hoc power analysis showed we had 80% power to detect an increase in pregnancy loss before 20 weeks of gestation from 4.9% in women with no subchorionic hematoma to 8.3% in women with subchorionic hematoma. CONCLUSION: In this cohort of women with singleton pregnancies, subchorionic hematoma before 14 weeks of gestation was not independently associated with pregnancy loss before 20 weeks of gestation.

Association Between First-Trimester Subchorionic Hematomas and Adverse Pregnancy Outcomes After 20 Weeks of Gestation in Singleton Pregnancies.

OBJECTIVE: To assess the association of first-trimester subchorionic hematomas with pregnancy outcomes after 20 weeks of gestation in women with singleton pregnancies. METHODS: We conducted a retrospective cohort study of all women with singleton pregnancies presenting for prenatal care before 14 weeks of gestation over a 3-year period at a single obstetric practice. All patients underwent routine first-trimester ultrasound examinations. We compared rates of adverse pregnancy outcomes at more than 20 weeks of gestation in women with and without a subchorionic hematoma on the initial ultrasound examination, excluding women with pregnancy loss before 20 weeks of gestation. RESULTS: From January 2015 to December 2017, a total of 2,172 women met the inclusion criteria for the study, 389 (17.9%) of whom had a subchorionic hematoma (mean largest diameter 2.1±1.4 cm). Women with subchorionic hematomas had their first ultrasound examination at earlier gestational ages (8 5/7 vs 9 6/7 weeks, P<.001) and were more likely to have vaginal bleeding at the time of the ultrasound examination (31.9% vs 7.9%, P<.001). Maternal age, race, use of in vitro fertilization, body mass index, and medical comorbidities did not differ between the groups. On univariable analysis, subchorionic hematoma was not associated with any pregnancy outcomes at more than 20 weeks of gestation, including gestational age at delivery, preterm birth, birth weight, birth weight less than the 10th percentile for gestational age, gestational hypertension, preeclampsia, placental abruption, intrauterine fetal death at more than 20 weeks of gestation, cesarean delivery, blood transfusion, and antepartum admissions. On regression analysis including subchorionic hematoma, vaginal bleeding, and gestational age at ultrasound examination, vaginal bleeding was independently associated with preterm birth at less than 37 weeks of gestation and birth weight less than the 10th percentile. Subchorionic hematoma was not independently associated with pregnancy outcomes. This study had 80% power to detect a 5% absolute difference in the frequency of preterm birth; that is, from 10% to 15%. CONCLUSION: In singleton pregnancies, a first-trimester subchorionic hematoma is not associated with adverse pregnancy outcomes at more than 20 weeks of gestation.