Evaluation of classic and novel ultrasound signs of placenta accreta spectrum.

OBJECTIVES: Improvement in the antenatal diagnosis of placenta accreta spectrum (PAS) would allow preparation for delivery in a referral center, leading to decreased maternal morbidity and mortality. Our objectives were to assess the performance of classic ultrasound signs and to determine the value of novel ultrasound signs in the detection of PAS. METHODS: This was a retrospective cohort study of women with second-trimester placenta previa who underwent third-trimester transvaginal ultrasound and all women with PAS in seven medical centers. A retrospective image review for signs of PAS was conducted by three maternal-fetal medicine physicians. Classic signs of PAS were defined as placental lacunae, bladder-wall interruption, myometrial thinning and subplacental hypervascularity. Novel signs were defined as small placental lacunae, irregular placenta-myometrium interface (PMI), vascular PMI, non-tapered placental edge and placental bulge towards the bladder. PAS was diagnosed based on difficulty in removing the placenta or pathological examination of the placenta. Multivariate regression analysis was performed and receiver-operating-characteristics (ROC) curves were generated to assess the performance of combined novel signs, combined classic signs and a model combining classic and novel signs. RESULTS: A total of 385 cases with placenta previa were included, of which 55 had PAS (28 had placenta accreta, 11 had placenta increta and 16 had placenta percreta). The areas under the ROC curves for classic markers, novel markers and a model combining classic and novel markers for the detection of PAS were 0.81 (95% CI, 0.75-0.88), 0.84 (95% CI, 0.77-0.90) and 0.88 (95% CI, 0.82-0.94), respectively. A model combining classic and novel signs performed better than did the classic or novel markers individually (P = 0.03). An increasing number of signs was associated with a greater likelihood of PAS. With the presence of 0, 1, 2 and ≥ 3 classic ultrasound signs, PAS was present in 5%, 24%, 57% and 94% of cases, respectively. CONCLUSIONS: We have confirmed the value of classic ultrasound signs of PAS. The use of novel ultrasound signs in combination with classic signs improved the detection of PAS. These findings have clinical implications for the detection of PAS and may help guide the obstetric management of patients diagnosed with these placental disorders. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Pregnancy and postpartum outcomes in a universally tested population for SARS-CoV-2 in New York City: a prospective cohort study.

OBJECTIVE: To describe differences in outcomes between pregnant women with and without coronavirus dsease 2019 (COVID-19). DESIGN: Prospective cohort study of pregnant women consecutively admitted for delivery, and universally tested via nasopharyngeal (NP) swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) using reverse transcription-polymerase chain reaction. All infants of mothers with COVID-19 underwent SARS-CoV-2 testing. SETTING: Three New York City hospitals. POPULATION: Pregnant women >20 weeks of gestation admitted for delivery. METHODS: Data were stratified by SARS-CoV-2 result and symptomatic status, and were summarised using parametric and nonparametric tests. MAIN OUTCOME MEASURES: Prevalence and outcomes of maternal COVID-19, obstetric outcomes, neonatal SARS-CoV-2, placental pathology. RESULTS: Of 675 women admitted for delivery, 10.4% were positive for SARS-CoV-2, of whom 78.6% were asymptomatic. We observed differences in sociodemographics and comorbidities among women with symptomatic COVID-10 versus asymptomatic COVID-19 versus no COVID-19. Caesarean delivery rates were 46.7% in symptomatic COVID-19, 45.5% in asymptomatic COVID-19 and 30.9% in women without COVID-19 (P = 0.044). Postpartum complications (fever, hypoxia, readmission) occurred in 12.9% of women with COVID-19 versus 4.5% of women without COVID-19 (P < 0.001). No woman required mechanical ventilation, and no maternal deaths occurred. Among 71 infants tested, none were positive for SARS-CoV-2. Placental pathology demonstrated increased frequency of fetal vascular malperfusion, indicative of thrombi in fetal vessels, in women with COVID-19 versus women without COVID-19 (48.3% versus 11.3%, P < 0.001). CONCLUSION: Among pregnant women with COVID-19 at delivery, we observed increased caesarean delivery rates and increased frequency of maternal complications in the postpartum period. Additionally, intraplacental thrombi may have maternal and fetal implications for COVID-19 remote from delivery. TWEETABLE ABSTRACT: COVID-19 at delivery: more caesarean deliveries, postpartum complications and intraplacental thrombi.

Endocervical hyaluronan and ultrasound-indicated cerclage.

OBJECTIVE: To investigate whether, at the time of ultrasound-indicated cerclage, the endocervical concentration of hyaluronan (HA), 27-kDa heat shock protein (HSP-27) and/or interleukin-8 (IL-8) would predict pregnancy outcome. METHODS: Endocervical samples, obtained from 40 women undergoing ultrasound-indicated cerclage at 15 + 3 to 25 + 0 weeks' gestation, were assayed by enzyme-linked immunosorbent assay for HA, HSP-27 and IL-8. All subjects had a cervical length of < 1.5 cm or dramatic cervical length change on serial endovaginal ultrasound, no uterine contractions or tenderness, no fever and intact membranes and underwent a modified Shirodkar cerclage. RESULTS: The median HA level was 10.0 ng/mL in the 12 women who delivered at < 37 weeks' gestation as opposed to 39.7 ng/mL in the 28 women delivering at 37-41 weeks (P = 0.017). Median HSP-27 and IL-8 concentrations were not significantly different in these groups. CONCLUSION: A higher endocervical HA level at the time of ultrasound-indicated cerclage is associated with a longer interval before birth.

Prenatal diagnosis of gastrointestinal anomalies with ultrasound. What have we learned?

The use of routine obstetric ultrasound has been shown to accurately diagnose fetal gastrointestinal anomalies, both during and after the midtrimester. These are among the most accurately diagnosed of all anomalies, comprising 5-7% of all fetal anomalies. From a review of the literature it is clear that the use of routine ultrasound allows: (1) the detection of multiple anomalies that are often present and affect outcome significantly, (2) preparation for delivery at a tertiary center where neonatal surgical experience will allow optimal outcome, and (3) decisions about mode and timing of delivery in cases where this is important, i.e., cases of omphalocele and gastroschisis.

An ethical justification for emergency, coerced cesarean delivery.

OBJECTIVE: To provide an ethical justification for emergency coerced cesarean delivery without a court order when a pregnant woman refuses cesarean delivery. METHODS: Ethical analysis is conducted of the existing literature and an ethical justification illustrated by a clinical example. RESULTS: Absolute and near-absolute objections to coerced cesarean delivery fail for lack of adequate arguments to show that the woman's autonomy is not constrained by obligations to the at-term fetal patient. The ethical justification for emergency coerced cesarean delivery requires that three criteria be satisfied: 1) high reliability of the prognostic judgment that on balance cesarean delivery is expected to prevent serious infant morbidity or mortality, 2) lack of physical resistance that could significantly increase the risks of maternal or fetal harm from coerced cesarean delivery, and 3) insufficient time to consider a court order. CONCLUSION: The obstetrician may justifiably coerce emergency cesarean delivery without a court order only when these three criteria are satisfied on a case-by-case basis.

Cesarean delivery for intrapartum fetal heart rate abnormalities: incorporating survey data into clinical judgment.

OBJECTIVE: To identify the descriptive clinical practice of maternal-fetal medicine specialists when faced with severe intrapartum fetal heart rate (FHR) abnormalities (as determined by continuous electronic fetal monitoring). METHODS: All regular members of the Society of Perinatal Obstetricians (maternal-fetal medicine specialists) were sent a survey questionnaire on the topic of cesarean delivery for intrapartum FHR abnormalities. The time from observation of FHR abnormalities to making the decision to proceed to cesarean delivery was the main outcome measure. Time was allowed for intrauterine resuscitative maneuvers to alleviate the abnormal pattern. Legislative definitions of consensus and strong consensus were applied to the data. Analysis of covariance was performed to determine the effect of physician demographic factors on the times reported. RESULTS: Four hundred thirty-one of 704 (61.2%) questionnaires were returned. Consensus was identified for deciding on cesarean delivery (after intrauterine resuscitation) 1) after 30 minutes for cases of repetitive late and severe variable decelerations, 2) after 10 minutes in cases of fetal bradycardia, and 3) in all scenarios with decreased beat-to-beat variability of the FHR. Consensus was identified for deciding on cesarean delivery in five of eight intrapartum FHR pattern abnormalities. CONCLUSION: The descriptive clinical practice of maternal-fetal medicine specialists demonstrated in this study should be considered in prudential clinical judgment.

Fetal seizures: further observations.

BACKGROUND: Previous reports of ultrasonographically diagnosed seizure activity in utero have described fetuses with obvious, gross, tonic-clonic movements of trunk and extremities. CASES: Three fetuses with akinesia deformation sequence are described: two with arthrogryposis multiplex congenita and one with Pena-Shokeir syndrome. Each was demonstrated by serial real-time ultrasound examinations to have joint contractures, absent fetal breathing motions, and lack of gross movements other than sonographically evident subtle seizure activity. CONCLUSION: Fetal seizure activity can be subtle when seen in the presence of fetal anomalies that limit joint movement. The prognosis remains poor.

Intrapartum management of multiple gestation.

The intrapartum management of multiple gestation continues to challenge the obstetric profession. In general, attempted vaginal delivery is appropriate for vertex-vertex twins. The options of external version, breech delivery, and cesarean delivery are analyzed for vertex-nonvertex twins. Special considerations in the intrapartum management of multiple gestation include monoamniotic twins, conjoined twins, and triplet pregnancies.

Fetal transfusion therapy.

Rapid advances are occurring in the diagnosis and treatment of the fetus with a red blood cell or platelet cytopenia. Noninvasive methods of monitoring the alloimmunized pregnancy, invasive methods such as amniocentesis and cordocentesis, and intrauterine transfusion therapy of both red cells and platelets, are being further refined to allow the prompt recognition and treatment of fetal cytopenias. Specialized centers have now accrued a large experience in the management of the fetus severely affected by alloimmunization. Advances in ultrasound, blood banking techniques, and genetic engineering technology have spurred the most recent advances. The indications for diagnosis, timing and frequency of invasive procedures for treatment, and technical considerations regarding preparation of blood products and volume of transfusion, are outlined in this review. Polymerase chain reaction (PCR) determination of fetal Rh(D) genotype by chorionic villus sampling or amniocentesis in the first or second trimesters is a recent clinically useful advance. The advent of hematopoietic stem cell transplantation and the potential for gene therapy are exciting advances in the treatment and prevention of hematopoietic diseases, including, but not limited, to the fetal cytopenias.

Is routine ultrasound screening for all patients?

The issue of routine ultrasound screening is addressed through an analysis of previous randomized trials in Europe and the United States. Potential benefits of offering ultrasound examination to low risk patients are explored, including detection of anomalies, diagnosis of multiple gestation, and reduction in induced labors for erroneous diagnoses of postdatism. The most recent US routine antenatal diagnostic imaging ultrasound (RADIUS) study is summarized and analyzed. Principles of obstetric ethics as applied to the use of routine ultrasound examination are developed and discussed. The responsibilities of those involved in providing such services are described. It is our opinion that routine ultrasonography has a favorable risk to benefit ratio and suggest that it should be offered.

Routine obstetric ultrasound.

A detailed review of the literature reveals that routine obstetric ultrasound has value in providing more accurate gestational dating and in the diagnosis of fetal anomalies. The recent RADIUS study, which has concluded that routine obstetric ultrasound is of no clinical benefit, is critically analyzed, focusing on four areas: the applicability of the results to the general population, the appropriateness of the outcome parameters, the quality of the ultrasound provided, and the issue of excessive cost. Finally, an ethical analysis of the role of routine obstetric ultrasonography is provided, focusing on the principles of beneficence and respect for autonomy. The offering obstetric ultrasound is necessary in both beneficence-based and autonomy-based ethical analyses, and the use of routine ultrasound is supported from an analysis of the scientific data.

Vascularity of uterine myomas: assessment by color and pulsed Doppler ultrasound.

OBJECTIVE: To evaluate the effects of different clinical and anatomical factors on the vascularity of uterine myomas METHODS: The study group included 195 patients, 153 premenopausal and 42 postmenopausal. Four hundred five myomas, 316 in the first group and 89 in the second, were studied by color Doppler ultrasound. Differences in the visualization of blood flow and resistance index (RI) were analyzed according to several factors, including: menopausal status, phase of menstrual cycle, duration of menopause, size and location of the myomas, and secondary changes within the myomas. RESULTS: The size of myomas was the most important single factor in determining both visualization of blood flow and RI. A higher blood flow visualization rate (BFVR) and a lower RI were found: (1) in the premenopausal compared with the postmenopausal patients (P < 0.05), (2) in the group of larger myomas compared with the group of smaller myomas (P < 0.0001), and (3) in submucosal and subserosal myomas compared with intramural myomas (P < 0.05). Other above-mentioned factors did have some, but not significant, influence on the visualization of blood flow and resistance to blood flow. CONCLUSION: Differences in the vascularity and resistance to blood flow in uterine myomas may limit the clinical use of color Doppler ultrasound.

Twin-twin transfusion syndrome: an update.

Twin-twin transfusion syndrome leads to high rates of perinatal morbidity and mortality due to its poorly understood etiology and difficult diagnosing and treatment. Current therapies are suboptimal and have not been tested through randomized controlled trials. Parent counseling at the time of diagnosis includes informing on poor chance of double survival, relatively high chance of long term neurologic handicap, almost certain prematurity, and the probability of cesarean delivery. Improvement in therapies awaits a better scientific understanding of the etiology of this condition.

Changes in survival of twins delivered after twin-twin transfusion syndrome versus preterm singletons over the calendar years 1970-1994.

OBJECTIVE: The use of serial amniotic fluid volume reduction for the treatment of twin-twin transfusion syndrome (TTTS) became available about 1986 and may account for a recent increase in survival of TTTS twins. To determine whether the increase in survival has been due to advances in neonatal care rather than the advent of amnioreduction, the current study evaluated whether increases in survival of preterm TTTS twins were greater than increases in survival of preterm singletons from studies before 1986 compared to studies after 1986. METHODS: Medline literature search identified all reported cases of TTTS and all reports of severely preterm neonatal survival. Studies were divided into groups according to gestational age at birth (27 weeks) and midyear of each study (1986). Comparison was performed of the increase in survival from pre-1986 studies to post-1986 studies between preterm singletons and TTTS twins. RESULTS: When comparing studies from before 1986 to after 1986, there was no difference in the increase in survival between preterm (>27 weeks) TTTS twins (67-92%) and preterm (>27 weeks) singletons (79-91%) (p = NS). When comparing studies from before 1986 to after 1986, there was a greater increase in survival among severely preterm (

Alloimmune thrombocytopenia.

For the fetuses who are at risk for antenatal or postnatal sequelae from AIT, prevention and treatment are now possible. This requires the attention of the obstetrician to factors in the patient's history and early referral to a center experienced in the diagnosis and management of fetal AIT.