Continuous glucose monitoring in pregnancies with type 1 diabetes: small increases in time-in-range improve maternal and perinatal outcomes.

BACKGROUND: Continuous glucose monitors provide detailed information regarding glycemic control in pregnant patients with type 1 diabetes. Little data have been published examining the association between continuous glucose monitor parameters and perinatal outcomes among gravidas with type 1 diabetes using continuous glucose monitors. OBJECTIVE: This study aimed to examine the association between perinatal outcomes and time-in-range as assessed by continuous glucose monitors used in pregnant individuals with type 1 diabetes. We hypothesized that higher time-in-range would be associated with lower risk of adverse perinatal outcomes. STUDY DESIGN: This multicenter retrospective cohort study included all gravidas with type 1 diabetes using continuous glucose monitors who delivered from 2020 to 2022 at 5 University of California sites. Only those with continuous glucose monitor target range set to 70 to 140 mg/dL (±10 mg/dL) were included. Time-in-range (%) was recorded at 12, 16, 20, 24, 28, and 32 weeks. The primary maternal and neonatal outcomes were preeclampsia and large for gestational age, defined as birthweight ≥95th percentile. Kruskal-Wallis tests were used to compare median time-in-range between those with and without the primary outcomes. Log-binomial regression was used to obtain risk ratios, with adjustment for microvascular disease and years with type 1 diabetes. RESULTS: A total of 91 patients were included. Most used an insulin pump (81%) and did not have diabetic microvascular disease (72%). Median time since diagnosis of type 1 diabetes was 16 years, and median periconception hemoglobin A1c was 6.7%. Compared with those with preeclampsia, normotensive gravidas had significantly higher time-in-range at nearly every time point. A similar pattern was observed for those with normal-birthweight infants compared with large-for-gestational-age infants. On adjusted analyses, every 5-unit increase in time-in-range at 12 weeks was associated with 45% and 46% reductions in the risks of preeclampsia and large for gestational age, respectively (preeclampsia: adjusted risk ratio, 0.55; 95% confidence interval, 0.30-0.99; large for gestational age: adjusted risk ratio, 0.54; 95% confidence interval, 0.29-0.99). CONCLUSION: Higher time-in-range is associated with lower risk of preeclampsia and large for gestational age. This association is observed early in gestation, when each 5-unit increase in time-in-range is associated with ∼50% reduction in the risk of these complications. These findings can be used to counsel patients regarding the risk of pregnancy complications at specific time-in-range values, and to encourage patients that even small improvements in time-in-range can have significant impact on pregnancy outcomes. Larger studies are needed to further explore these findings and to identify optimal time-in-range to reduce perinatal complication rates.

Chronic villitis as a distinctive feature of placental injury in maternal SARS-CoV-2 infection.

BACKGROUND: SARS-CoV-2 infection during pregnancy is associated with an increased risk for stillbirth, preeclampsia, and preterm birth. However, this does not seem to be caused by intrauterine fetal infection because vertical transmission is rarely reported. There is a paucity of data regarding the associated placental SARS-CoV-2 histopathology and their relationship with the timing and severity of infection. OBJECTIVE: This study aimed to determine if maternal SARS-CoV-2 infection was associated with specific patterns of placental injury and if these findings differed by gestational age at time of infection or disease severity. STUDY DESIGN: A retrospective cohort study was performed at the University of California San Diego between March 2020 and February 2021. Placentas from pregnancies with a positive SARS-CoV-2 test were matched with 2 sets of controls; 1 set was time-matched by delivery date and sent to pathology for routine clinical indications, and the other was chosen from a cohort of placentas previously collected for research purposes without clinical indications for pathologic examination before the SARS-CoV-2 outbreak. Placental pathologic lesions were defined based on standard criteria and included maternal and fetal vascular malperfusion and acute and chronic inflammatory lesions. A bivariate analysis was performed using the independent Student t test and Pearson chi-square test. A logistic regression was used to control for relevant covariates. Regions of SARS-CoV-2-associated villitis were further investigated using protein-based digital spatial profiling assays on the GeoMx platform, validated by immunohistochemistry, and compared with cases of infectious villitis and villitis of unknown etiology. Differential expression analysis was performed to identify protein expression differences between these groups of villitis. RESULTS: We included 272 SARS-CoV-2 positive cases, 272 time-matched controls, and 272 historic controls. The mean age of SARS-CoV-2 affected subjects was 30.1±5.5 years and the majority were Hispanic (53.7%) and parous (65.7%). SARS-CoV-2 placentas demonstrated a higher frequency of the 4 major patterns of placental injury (all P<.001) than the historic controls. SARS-CoV-2 placentas also showed a higher frequency of chronic villitis and severe chronic villitis (P=.03 for both) than the time-matched controls, which remained significant after controlling for gestational age at delivery (adjusted odds ratio, 1.52; 95% confidence interval, 1.01-2.28; adjusted odds ratio, 2.12; 95% confidence interval, 1.16-3.88, respectively). Digital spatial profiling revealed that programmed death-ligand 1 was increased in villitis-positive regions of the SARS-CoV-2 (logFC, 0.47; adjusted P value =.002) and villitis of unknown etiology (logFC, 0.58; adjusted P value =.003) cases, but it was conversely decreased in villitis-positive regions of the infectious villitis group (log FC, -1.40; adjusted P value <.001). CONCLUSION: Chronic villitis seems to be the most specific histopathologic finding associated with SARS-CoV-2 maternal infection. Chronic villitis involves damage to the vasculosyncytial membrane of the chorionic villi, which are involved in gas and nutrient exchange, suggesting potential mechanisms of placental (and perhaps neonatal) injury, even in the absence of vertical transmission. Surprisingly, changes in protein expression in SARS-CoV-2-associated villitis seem to be more similar to villitis of unknown etiology than to infectious villitis.

Risk Factors for Co-Twin Fetal Demise following Radiofrequency Ablation in Multifetal Monochorionic Gestations.

BACKGROUND: Umbilical cord occlusion via radiofrequency ablation (RFA) is utilized to maximize outcomes of the co-twin in complicated multifetal monochorionic (MC) gestations. However, post-procedure co-twin fetal demise is of concern. OBJECTIVE: The aim of this study was to determine risk factors for co-twin fetal demise following RFA. METHODS: This is a retrospective study of MC multiples that underwent RFA. Indications for RFA included twin reversed arterial perfusion (TRAP) sequence, selective fetal growth restriction (sFGR) type II, discordant lethal anomalies, and twin-twin transfusion syndrome (TTTS) with proximate placental cord insertion sites. The primary outcome was co-twin fetal demise. Bivariate analyses and multiple logistic regression modeling of identified risk factors were conducted. RESULTS: Of 36 patients studied, surgical indications were: TRAP (n = 15, 41.7%), sFGR (n = 10, 27.8%), discordant anomalies (n = 9, 25.0%), and TTTS (n = 2, 5.6%). Nine patients (25.0%) experienced a co-twin fetal demise. In multiple logistic regression analysis, fetal growth restriction (FGR) of one co-twin was associated with increased risk of co-twin fetal demise (OR = 10.85, 95% CI 1.03-114.48, p = 0.0474) and a preoperative diagnosis of TRAP was protective against fetal demise (OR = 0.06, 95% CI 0.00-0.84, p = 0.0368). CONCLUSION: Co-twin FGR was associated with an increased risk of post-RFA demise. When compared to other indications, patients with TRAP sequence were less likely to have a co-twin demise.

Survival Outcomes by Fetal Weight Discordance after Laser Surgery for Twin-Twin Transfusion Syndrome Complicated by Donor Fetal Growth Restriction.

INTRODUCTION: Management options for treatment of twin-twin transfusion syndrome (TTTS) with severe donor intrauterine growth restriction (IUGR) include fetoscopic laser surgery and umbilical cord occlusion (UCO). We studied perinatal survival outcomes in this select group after laser surgery, stratifying patients by preoperative estimated fetal weight (EFW) discordance. METHODS: In this retrospective study of monochorionic diamniotic twin gestations with TTTS and selective donor IUGR who underwent laser surgery (2006-2017), preoperative EFW discordance was calculated ([(larger twin - smaller twin)/(larger twin)] × 100) and cases were divided into discordance strata. Severe EFW discordance was defined as >35%. The primary outcome was 30-day donor twin neonatal survival. RESULTS: The 371 cases were distributed by discordance strata: ≤20% (74 [19.9%]), 21-25% (49 [13.2%]), 26-30% (68 [18.3%]), 31-35% (53 [14.3%]), 36-40% (51 [13.7%]), 41-45% (38 [10.2%]), >45% (38 [10.2%]). Donor 30-day survival declined as the discordance strata increased: 86.5, 85.7, 83.8, 75.5, 64.7, 63.2, and 65.8% (p = 0.0046); 30-day survival was inversely associated with severe discordance (>35%) (64.6 vs. 83.2%, p < 0.0001). DISCUSSION: In TTTS cases complicated by donor IUGR with severe growth discordance, laser surgery was associated with donor survivorship greater than 60% suggesting that, in this setting, laser surgery remains a reasonable alternative treatment to UCO.

Cerebrospinal fluid as vaginal discharge: ventriculoperitoneal shunt migration following Cesarean section.

Congenital hydrocephalus was once a permanently disabling and even fatal disease. With the advent of ventriculoperitoneal shunts, affected women are now surviving to their reproductive years and beyond. Pregnancy outcomes in this population are generally positive. However due to possible shunt complications, including infection, migration, and organ perforation, perinatal care for pregnant individuals with a ventriculoperitoneal shunt is complex and requires input from both obstetric and neurosurgical providers. We present the case of a 28-year-old G1P1 with a history of congenital hydrocephalus and ventriculoperitoneal shunt who presented to the emergency department at two months postpartum with clear fluid leaking from her vagina. The shunt's distal end had migrated and perforated the uterus causing cerebrospinal fluid to leak into the uterine cavity. Surgical repair was required of both the uterine hysterotomy and ventriculoperitoneal shunt, and the patient's symptoms ultimately resolved. Patients with a history of shunt placement who later undergo abdominal surgery, including cesarean section, are at risk for shunt complications. Shunt-dependent patients presenting in the post-partum period with new neurological or abdominopelvic complaints should undergo evaluation by a multidisciplinary team.

Hematometrocolpos following Low Transverse Cesarean Delivery Complicated by Uterine Dehiscence.

BACKGROUND: Hematometrocolpos is a rare complication following procedures performed on the female genital tract. While usually seen in adolescents with congenital anomalies including imperforate hymen and vaginal stenosis, it has also been described following obstetric vaginal lacerations. The incidence following cesarean delivery is unknown. CASE: This is a 43-year-old multigravida who underwent a low transverse cesarean delivery complicated by uterine dehiscence, as well as cervical and vaginal lacerations. The repair resulted in lower genital tract obstruction. She presented seven months afterwards with severe abdominopelvic pain and secondary amenorrhea, which resolved after vaginal dilation and excision of the vaginal scar. CONCLUSION: Systematic inspection of the upper vagina should be undertaken following complicated cesarean delivery with vaginal extension. Hematometrocolpos after cesarean delivery should be managed similar to a transverse vaginal septum.