Morbidity of Repeat Cesarean Delivery after a Trial of Labor as Compared with Elective Repeat Cesarean Delivery.

OBJECTIVE: This study aimed to evaluate if a secondary repeat cesarean after a trial of labor (TOLAC) without uterine rupture is associated with increased morbidity as compared with a scheduled elective repeat cesarean delivery (ERCD). STUDY DESIGN: This was a retrospective cohort study of repeat cesarean delivery (CD) in a single obstetrical practice between 2005 and 2022. Patients were included if they had a singleton pregnancy at term with one prior CD and had a repeat CD this pregnancy resulting in live birth. Patients were excluded if they had a prior myomectomy, more than one prior CD, uterine rupture in a prior or current pregnancy, or placenta previa in this pregnancy. We compared baseline characteristics and outcomes between patients who had a repeat cesarean after TOLAC and ERCD. The primary outcome was a composite of maternal morbidity that included hysterectomy, blood transfusion, cystotomy, bowel injury, intensive care unit admission, thrombosis, reoperation, or maternal mortality. RESULTS: A total of 930 women met inclusion criteria. A total of 176 (18.9%) patients intended to labor and 754 (81.1%) planned an ERCD. There was no difference in the primary outcome between patients with a repeat cesarean after TOLAC compared with patients with ERCD (2.8 vs. 1.2%, p = 0.158). Patients with repeat cesarean after labor had significantly more 1-minute Apgar scores less than 7, but no difference in 5-minute Apgar scores. We were powered to detect a difference in the primary outcome from 1.2% in the ERCD group to 3.3% in the repeat cesarean after labor group. Results did not differ when we analyzed patients who intended to TOLAC versus patients who actually labored prior CD. CONCLUSION: For women with one prior CD the morbidity of repeat cesarean after labor is not more than the morbidity of planned repeat CD. Our study can be helpful in delivery planning counseling for patients with one prior CD. KEY POINTS: · Uterine rupture is a known risk of TOLAC.. · This study aimed to understand morbidity associated with labor.. · No added morbidity of repeat cesarean after labor is inferred in this study..

Association Between Mental Health and Reproductive System Disorders in Women: A Systematic Review and Meta-analysis.

Importance: Reproductive system and mental health disorders are commonly comorbid in women. Although the causes of this overlap remain elusive, evidence suggests potential shared environmental and genetic factors associated with risk. Objective: To investigate the comorbidity between psychiatric and reproductive system disorders, both as broad diagnostic categories and among specific pairs of diagnoses. Data Source: PubMed. Study Selection: Observational studies published between January 1980 and December 2019 assessing prevalence of psychiatric disorders in women with reproductive system disorders and prevalence of reproductive system disorders in women with psychiatric disorders were included. The study did not include psychiatric and reproductive disorders triggered by life events (eg, trauma, infection, surgery) to address potential confounding. Data Extraction and Synthesis: A search yielded 1197 records, of which 50 met the inclusion criteria for the qualitative and 31 for the quantitative synthesis in our study. A random-effects model was used for data synthesis and Egger test and I2 to assess study bias and heterogeneity. Data were analyzed from January to December 2022. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. Main Outcomes and Measures: Psychiatric and reproductive system disorders. Results: A total of 1197 records were identified, of which 50 met the inclusion criteria for qualitative and 31 for quantitative synthesis. Diagnosis of a reproductive system disorder was associated with a 2- to 3-fold increased odds of having a psychiatric disorder (lower bound odds ratio [OR], 2.00; 95% CI, 1.41-2.83; upper bound OR; 2.88; 95% CI, 2.21-3.76). The analysis focused on specific diagnoses described in the literature and found that polycystic ovary syndrome was associated with increased odds of depression (population-based studies OR, 1.71; 95% CI, 1.19-2.45; clinical studies OR, 2.58; 95% CI, 1.57-4.23) and anxiety (population-based studies OR, 1.69; 95% CI, 1.36-2.10; clinical studies OR, 2.85; 95% CI, 1.98-4.09). Chronic pelvic pain was also associated with both depression (OR, 3.91; 95% CI, 1.81-8.46) and anxiety (OR, 2.33; 95% CI, 1.33-4.08). Few studies investigated risk of other reproductive system disorders in women with psychiatric disorders, or reverse associations (risk of reproductive system disorder among women with a psychiatric diagnosis). Conclusions and Relevance: In this systematic review and meta-analysis, a high rate of reported co-occurrence between psychiatric and reproductive disorders overall was observed. However, data for many disorder pairs were limited. The available literature focused overwhelmingly on affective disorders in polycystic ovary syndrome, overlooking a substantial portion of disease overlap. As such, the associations between the majority of mental health outcomes and conditions of the female reproductive system are largely unknown.

Maternal Morbidity with Repeated Cesarean Deliveries.

OBJECTIVE: This study aimed to estimate the association between adverse maternal outcomes and the number of repeated cesarean deliveries (CDs) in a single obstetrical practice. STUDY DESIGN: Retrospective cohort study of all CDs between 2005 and 2020 in a single maternal fetal medicine practice. We used electronic records to get baseline characteristics and pregnancy/surgical outcomes based on the number of prior CDs. We performed two subgroup analyses for women with and without placenta previa. Chi-square for trend and one-way analysis of variance (ANOVA) were used. RESULTS: A total of 3,582 women underwent CD and met inclusion criteria. Of these women, 1,852 (51.7%) underwent their first cesarean, 950 (26.5%) their second, 382 (10.7%) their third, 191 (5.3%) their fourth, 117 (3.3%) their fifth, and 84 (2.3%) their sixth or higher CDs. The incidence of adverse outcomes (placenta accreta, uterine window, uterine rupture, hysterectomy, blood transfusion, cystotomy, bowel injury, need for a ventilator postpartum, intensive care unit admission, wound complications, thrombosis, reoperation, and maternal death) increased with additional CDs. However, the absolute rates remained low. In women without a placenta previa, the likelihood of adverse outcome did not differ across groups. In women with a placenta previa, adverse outcomes increased with increasing CDs. However, the incidence of placenta previa did not increase with increasing CDs (<5% in each group). The incidence of a uterine dehiscence increased significantly with additional CDs: first, 0.2%; second, 2.0%; third, 6.6%; fourth, 10.3%; fifth, 5.8%; and sixth or higher, 10.4% (p < 0.001). CONCLUSION: Maternal morbidity increases with CDs, but the absolute risks remain low. For women without placenta previa, increasing CDs is not associated with maternal morbidity. For women with placenta previa, risks are highest, but the incidence of placenta previa does not increase with successive CDs. The likelihood of uterine dehiscence increases significantly with increasing CDs which should be considered when deciding about timing of delivery in this population. KEY POINTS: · Maternal morbidity increase with each CD.. · Absolute adverse outcomes remains low in highest order CDs.. · In women without placenta previa, there is no added morbidity with additional CDs..

Screening for preterm birth in twin pregnancies.

Twins represent 3.2% of all live births. However, they account for 20% of all preterm deliveries, with 60% delivered before 37 weeks and 10.7% before 32 weeks of gestation. Twin pregnancies have a 5 times higher risk of early neonatal and infant death related to prematurity. Monochorionic twins have a higher incidence of both indicated and spontaneous preterm delivery than dichorionic twins. Additional risk factors include a history of preterm delivery and cervical surgery. The transvaginal cervical length before 24 weeks is the best factor to predict preterm birth, independent of other risk factors.

Predictors of Early Preterm Birth Despite Vaginal Progesterone Therapy in Singletons with Short Cervix.

OBJECTIVE: This study aimed to identify the incidence of and risk factors for early preterm birth (PTB) (delivery <34 weeks) in women without prior PTB and current short cervix (≤20 mm) prescribed vaginal progesterone. STUDY DESIGN: Retrospective cohort study of singletons without prior PTB diagnosed with short cervix (≤20 mm) between 180/7 and 236/7 weeks. Women who accepted vaginal progesterone and had delivery outcomes available were included. Demographic/obstetric history, cervical length, and pregnancy characteristics compared between women with early PTB versus delivery ≥34 weeks. Multiple logistic regression analysis used to identify predictors; odds ratio for significant factors used to generate a risk score. Risk score and risk of early PTB assessed with receiver operating characteristic curve (ROCC). Perinatal outcomes compared by risk score. RESULTS: Among 109 patients included, 29 (27%) had a spontaneous PTB <34 weeks. In univariate analysis, only gestational age at ultrasound, presence funneling, and mean cervical length were significantly different between those with and without early sPTB. With multiple logistic regression analysis, only gestational age at diagnosis (odds ratio [OR]: 0.66; 95% confidence interval [CI]: 0.46-0.96; p = 0.028) and index cervical length (OR: 0.84; 95% CI: 0.76-0.93; p = 0.001) remained significantly associated with early PTB. ROCC for the risk score incorporating cervical length and gestational age was predictive of early PTB with an AUC of 0.76 (95% CI: 0.67-0.86; p < 0.001). A high-risk score was predictive of early PTB with a sensitivity of 79%, specificity of 75%, positive predictive value of 54%, and negative predictive value of 91%. Women with a high-risk score had worse perinatal outcomes compared with those with low-risk score. CONCLUSION: A total of 27% of patients with short cervix prescribed vaginal progesterone will have a sPTB < 34 weeks. Patients at high risk for early PTB despite vaginal progesterone therapy may be identified using gestational age and cervical length at diagnosis of short cervix. Given the narrow window for intervention after diagnosis of short cervix, this has important implications for clinical care.

Risk factors for positive postpartum depression screen in women with private health insurance and access to care.

Objective: To determine risk factors for a positive postpartum depression screen among women with private health insurance and 24/7 access to care.Study design: Retrospective cohort study of all patients delivered by a single MFM practice from April 2015 to September 2016. All patients had private health insurance and 24/7 access to care. All patients were scheduled to undergo the Edinburgh Postnatal Depression Scale (EPDS) at their 6-week postpartum visit and a positive screen was defined as a score of 10 or higher, or a score greater than zero on question 10 (thoughts of selfharm). Using logistic regression, risk factors for postpartum depression were compared between women with and without a positive screen.Results: Of the 1237 patients delivered, 1113 (90%) were screened with the EPDS. 81 patients (7.3, 95%CI 5.9-9.0%) of those tested had a positive screen. On regression analysis, risk factors associated with a positive screen were nulliparity (aOR 1.8, 95%CI 1.1, 2.9), cesarean delivery (aOR 1.7, 95%CI 1.1, 2.8), non-White race (aOR 2.0, 95%CI 1.1, 3.5), and a history of depression or anxiety (aOR 4.6, 95%CI 2.6, 8.1). Among the 100 women with a history of depression or anxiety, selective serotonin reuptake inhibitor (SSRI) use in the postpartum period was not associated with a reduced risk of a positive screen (25.5% in those taking an SSRI versus 18.4% of those not taking an SSRI, p = .39).Conclusions: Among women with private health insurance and access to care, the incidence of a positive screen for postpartum depression is approximately 7%. The use of an SSRI did not eliminate this risk. All women should be screened for postpartum depression.

Pregnancy outcomes in viable pregnancies with a septate uterus compared with viable pregnancies after hysteroscopic uterine septum resection.

BACKGROUND: Septate uterus is one of the more common Müllerian anomalies and is the anomaly most amenable to surgical correction. It is currently uncertain if hysteroscopic septum resection reduces the incidence of adverse pregnancy outcomes. OBJECTIVE: The purpose of this study was to compare pregnancy outcomes in women who had reached at least 20 weeks gestation with those women with a uterine septum and those women who had undergone septum resection before pregnancy. STUDY DESIGN: Retrospective cohort study of women with a history of uterine septum who were cared for by a large maternal-fetal medicine practice from 2005-2018. We included women with singleton pregnancies at >20 weeks gestation. Baseline characteristics and pregnancy outcomes were compared between women with a history of a hysteroscopic uterine septum resection and women with an unresected septum. Regression analysis was performed to control for differences in baseline characteristics. The analysis was repeated in nulliparous women only. RESULTS: A total of 109 women (163 pregnancies) were included. In the entire population, pregnancy outcomes did not differ between the groups, aside from a higher rate of cesarean delivery in the resected septum group. In the 63 nulliparous women, septum resection was associated with later gestational ages at delivery (39.1 vs 37 weeks; P=.030), decreased preterm birth <37 weeks gestation (4.5% vs 31.6%; adjusted odds ratio, 0.154; 95% confidence interval, 0.027-0.877), and an increased incidence of cesarean delivery in women who attempted vaginal delivery (30.6% vs 0%; P=.012). There was no difference in the rates of small for gestational age, preeclampsia, blood transfusion, retained placenta, or morbidly adherent placenta. CONCLUSION: In nulliparous women with viable pregnancies, hysteroscopic resection of a uterine septum is associated with a decreased incidence of preterm birth and an increased incidence of cesarean delivery. These findings need to be confirmed in a well-designed randomized trial before uterine septum resection is recommended routinely.

Suture Compared With Staple Closure of Skin Incision for High-Order Cesarean Deliveries.

OBJECTIVE: To compare wound complication rates in tertiary or higher-order cesarean delivery based on wound closure technique. METHODS: We performed a retrospective cohort study of all tertiary or higher-order cesarean deliveries performed by one group practice in a large academic medical center from 2005 to 2017. We excluded patients with a vertical skin incision. Although the study was not randomized, wound closure type was relatively uniform in this practice and based on time period: before 2011, the preferred closure was staple closure; after 2011, subcuticular suture closure was preferred. All patients received preoperative antibiotics and closure of subcutaneous tissue 2 cm deep or greater. The primary outcome was a wound complication, defined as a wound infection requiring antibiotics or a wound separation requiring wound packing or reclosure any time up to 6 weeks after delivery. Regression analysis was used to control for any significant differences at baseline between the groups. RESULTS: There were 551 patients with tertiary or higher-order cesarean delivery, 192 (34.8%) of whom had staple closure and 359 (65.2%) of whom had suture closure. Suture closure was associated with a significantly lower rate of wound complication (4.7% [17/359, 95% CI 3.0%-7.5%] vs 11.5% [22/192, 95% CI 7.7%-16.7%], P=.003). On regression analysis controlling for the number of prior cesarean deliveries and the participation of a resident in the closure, suture closure remained independently associated with a lower risk of a wound complication (adjusted odds ratio 0.44, 95% CI 0.23-0.86). CONCLUSION: For women undergoing their third or higher-order cesarean delivery, suture closure is associated with a lower rate of wound complications.

Cervical Pessary and Vaginal Progesterone in Twin Pregnancies With a Short Cervix.

OBJECTIVE: To evaluate cervical pessary as an intervention to prevent preterm birth in twin pregnancies with a short cervix. METHODS: This was a retrospective cohort study of twin pregnancies managed by a single maternal-fetal medicine practice from 2005 to 2015. We included patients at 28 weeks of gestation or less who were diagnosed with a cervical length less than 20 mm. At the time of diagnosis, all patients were prescribed vaginal progesterone. Starting in 2013, they were also offered pessary placement in addition to vaginal progesterone. We compared outcomes between patients who received a pessary and matched women in a control group in a one-to-three ratio. Women in the control group were matched to women in the case group according to cervical length and gestational age (within 5 mm and 1 week, respectively, of the case patient at the time of pessary placement). We excluded patients with cerclage, monochorionic-monoamniotic placentation, major fetal congenital anomalies discovered before or after birth, patients with twin-twin transfusion syndrome, and patients for whom there were no appropriate controls. Chi-square, Fisher exact, and Student's t tests were used, as appropriate. Regression analysis was performed to control for significant differences at baseline. RESULTS: Twenty-one patients received a cervical pessary, and they were compared with 63 matched women in the control group. As expected (as a result of matching), baseline gestational age (25.7±2.1 compared with 25.9±2.1 weeks of gestation, P=.671) and cervical length (10.9±3.6 mm compared with 11.9±4.5 mm, P=.327) were similar between the groups. Patients with a pessary had a significantly lower incidence of delivery at less than 32 weeks of gestation (1/21 [4.8%] compared with 18/63 [28.6%], adjusted P=.05), longer interval to delivery (65.2±16.8 compared with 52.1±24.3 days, adjusted P=.025), and a lower incidence of severe neonatal morbidity (2/21 [9.5%] compared with 22/63 [34.9%], adjusted P=.04). CONCLUSION: For twin pregnancies with a short cervix, the addition of a cervical pessary to vaginal progesterone is associated with prolonged pregnancy and reduced risk of adverse neonatal outcomes. A large randomized trial should be performed to verify these retrospective findings.

Abnormal Biochemical Analytes Used for Aneuploidy Screening and Adverse Pregnancy Outcomes in Twin Gestations.

OBJECTIVE: The objective of this study was to determine if first- and second-trimester biochemical markers for aneuploidy have an association with adverse pregnancy outcomes in twin gestations. STUDY DESIGN: A retrospective cohort study of patients who presented with dichorionic diamniotic twin gestations was performed. Patients with first-trimester low pregnancy-associated plasma protein A (PAPP-A) or low free ß human chorionic gonadotropin (ß-hCG), or second-trimester elevated α-fetoprotein (AFP), elevated inhibin A, elevated hCG, or low unconjugated estradiol were identified. The rates of adverse pregnancy outcomes were compared between patients with or without abnormal analytes with p < 0.05 used as significance. RESULTS: In this study, 340 pregnancies were included. Patients with a low PAPP-A had an increased risk for delivery < 37 weeks. Patients with an elevated second-trimester hCG had an increased risk for spontaneous delivery < 28 weeks and neonatal intensive care unit (NICU) admission. Patients with an elevated inhibin A had an increased risk of spontaneous delivery at < 37 and NICU admission. Patients with an elevated AFP had an increased risk of a NICU admission. CONCLUSION: Certain abnormal aneuploidy markers are associated with an increased risk of adverse pregnancy outcomes in twin gestations.

Effect of Resident Participation on Outcomes in High-Order Cesarean Deliveries.

OBJECTIVE: To estimate the effect of resident participation on outcomes in women undergoing high-order cesarean deliveries. METHODS: We performed a retrospective cohort study of patients in one obstetric practice undergoing a third- or greater order cesarean delivery from 2005 to 2014. Patients with placenta previa, accreta, or failed vaginal birth after cesarean delivery were excluded. We compared outcomes between patients whose operations were performed by two attendings with patients whose operations were performed by one attending and one resident. Regression analysis was performed to control for differences at baseline. RESULTS: Three hundred seventy patients were included, 189 (51%) of whom had two attendings and 181 (49%) of whom had one attending and one resident. The mean operative time was slightly but significantly less in the two=attending group (60.9±17.3 compared with 62.5±18.3 minutes, adjusted P=.038). Otherwise, there were no significant differences in measured outcomes between the groups, including wound complications, blood loss (estimated and drop in hemoglobin), blood transfusion, major maternal morbidity (hysterectomy, cystotomy, bowel injury, intensive care unit admission, thrombosis, reoperation, death), postoperative endometritis, and postoperative days in the hospital. Among patients in the resident group, there was no difference in outcomes between cases performed by a junior (first or second year) resident compared with a senior (third or fourth year) resident. CONCLUSION: Resident participation does not negatively affect outcomes in patients undergoing high-order cesarean deliveries. Residents should be included in these complicated cases because they can obtain a significant learning experience without compromising patient safety.

The effect of maternal obesity on outcomes in patients undergoing tertiary or higher cesarean delivery.

OBJECTIVE: To estimate the association between maternal obesity and adverse outcomes in patients without placenta previa or accreta undergoing a tertiary or higher cesarean delivery. STUDY DESIGN: Retrospective cohort of patients cared for by a single MFM practice undergoing a tertiary or higher cesarean delivery from 2005 to 2013. Patients attempting vaginal delivery and patients with placenta accreta and/or placenta previa were excluded. We estimated the association of maternal obesity (prepregnancy BMI ≥ 30 kg/m(2)) and maternal outcomes. The primary outcome was a composite of severe maternal morbidity (uterine rupture, hysterectomy, blood transfusion, cystotomy requiring repair, bowel injury requiring repair, intensive care unit admission, thrombosis, re-operation, or maternal death). RESULTS: Three hundred and forty four patients met inclusion criteria, 73 (21.2%) of whom were obese. The composite outcome was significantly higher in the obese group (6.8% versus 1.8%, p = 0.024, aOR 4.36, 95% CI 1.21, 15.75). The incidence of several individual adverse outcomes were also increased in obese women, including blood transfusion (4.1% versus 0.7%, p = 0.033, aOR 7.36, 95% CI 1.19, 45.34), wound separation or infection (20.5% versus 5.9%, p < 0.001, aOR 4.05, 95% CI 1.75, 9.36) and 1-min Apgar score less than 7 (6.8% versus 1.9%, p = 0.024, aOR 4.40, 95% CI 1.21, 15.94). CONCLUSIONS: In patients undergoing a tertiary or higher cesarean delivery without placenta previa or accreta, obesity increases the risk of adverse outcomes. Obese patients are at risk for blood transfusion, low 1-min Apgar scores and postoperative wound complications.

Is MSAFP still a useful test for detecting open neural tube defects and ventral wall defects in the era of first-trimester and early second-trimester fetal anatomical ultrasounds?

INTRODUCTION: To evaluate whether maternal serum α-fetoprotein (MSAFP) improves the detection rate for open neural tube defects (ONTDs) and ventral wall defects (VWD) in patients undergoing first-trimester and early second-trimester fetal anatomical survey. MATERIAL AND METHODS: A cohort of women undergoing screening between 2005 and 2012 was identified. All patients were offered an ultrasound at between 11 weeks and 13 weeks and 6 days of gestational age for nuchal translucency/fetal anatomy followed by an early second-trimester ultrasound at between 15 weeks and 17 weeks and 6 days of gestational age for fetal anatomy and MSAFP screening. All cases of ONTD and VWD were identified via query of billing and reporting software. Sensitivity and specificity for detection of ONTD/VWD were calculated, and groups were compared using the Fisher exact test, with p < 0.05 as significance. RESULTS: A total of 23,790 women met the criteria for inclusion. Overall, 15 cases of ONTD and 17 cases of VWD were identified; 100% of cases were diagnosed by ultrasound prior to 18 weeks' gestation; none were diagnosed via MSAFP screening (p < 0.001). First-trimester and early second-trimester ultrasound had 100% sensitivity and 100% specificity for diagnosing ONTD/VWD. DISCUSSION: Ultrasound for fetal anatomy during the first and early second trimester detected 100% of ONTD/VWD in our population. MSAFP is not useful as a screening tool for ONTD and VWD in the setting of this ultrasound screening protocol.

Pregnancy outcomes in patients with prior uterine rupture or dehiscence.

OBJECTIVE: To report obstetric outcomes in a series of women with prior uterine rupture or prior uterine dehiscence managed with a standardized protocol. METHODS: Series of patients delivered by a single maternal-fetal medicine practice from 2005 to 2013 with a history of uterine rupture or uterine dehiscence. Uterine rupture was defined as a clinically apparent, complete scar separation in labor or before labor. Uterine dehiscence was defined as an incomplete and clinically occult uterine scar separation with intact serosa. Patients with prior uterine rupture were delivered at approximately 36-37 weeks of gestation or earlier in the setting of preterm labor. Patients with prior uterine dehiscence were delivered at 37-39 weeks of gestation based on obstetric history, clinical findings, and ultrasonographic findings. Patients with prior uterine rupture or uterine dehiscence were followed with serial ultrasound scans to assess fetal growth and lower uterine segment integrity. Outcomes measured were severe morbidities (uterine rupture, hysterectomy, transfusion, cystotomy, bowel injury, mechanical ventilation, intensive care unit admission, thrombosis, reoperation, maternal death, perinatal death). RESULTS: Fourteen women (20 pregnancies) had prior uterine rupture and 30 women (40 pregnancies) had prior uterine dehiscence. In these 60 pregnancies, there was 0% severe morbidity noted (95% confidence interval [CI] 0.0-6.0%). Overall, 6.7% of patients had a uterine dehiscence seen at the time of delivery (95% CI 2.6-15.9%). Among women with prior uterine rupture, the rate was 5.0% (95% CI 0.9-23.6%), whereas among women with prior uterine dehiscence, the rate was 7.5% (95% CI 2.6-19.9%). CONCLUSION: Patients with prior uterine rupture or uterine dehiscence can have excellent outcomes in subsequent pregnancies if managed in a standardized manner, including cesarean delivery before the onset of labor or immediately at the onset of spontaneous preterm labor.

Natural history of vasa previa across gestation using a screening protocol.

OBJECTIVES: The purpose of this study was to estimate the prevalence and persistence rate of vasa previa in at-risk pregnancies using a standardized screening protocol. METHODS: We conducted a descriptive study of patients with a diagnosis of vasa previa from a single ultrasound unit between June 2005 and June 2012. Vasa previa was defined as a fetal vessel within 2 cm of the internal cervical os on transvaginal sonography. Screening for vasa previa using transvaginal sonography with color flow mapping was performed routinely in the following situations: resolved placenta previa, prior pregnancy with vasa previa, velamentous insertion of the cord in the lower uterine segment, placenta succenturiata in the lower uterine segment, and twin gestations. RESULTS: A total of 27,573 patients were referred to our unit for fetal anatomic surveys over the study period. Thirty-one cases of vasa previa were identified, for an incidence of 1.1 per 1000 pregnancies. Twenty-nine cases had full records available for analysis. Five patients (17.2%) had migration and resolution of the vasa previa. When the diagnosis was made during the second trimester (<26 weeks), there was a 23.8% resolution rate (5 of 21); when the diagnosis was made in the third trimester, none resolved (0 of 8 cases). Of the 24 pregnancies (5 twin gestations and 19 singleton gestations) with persistent vasa previa, there was 100% perinatal survival and a median length of gestation of 35 weeks (range, 27 weeks 5 days-36 weeks 5 days). No known missed cases were identified over the study period. CONCLUSIONS: The use of standardized screening for vasa previa based on focused criteria was found to be effective in diagnosing vasa previa, with a 100% survival rate. Vasa previa diagnosed during the second trimester resolves in approximately 25% of cases.

First-trimester aneuploidy risk assessment: the impact of comprehensive counseling and same-day results on patient satisfaction, anxiety, and knowledge.

We evaluated the added benefit of a comprehensive counseling protocol for first-trimester aneuploidy risk assessment. We performed a prospective cohort study surveying patients referred for first-trimester aneuploidy risk assessment. We compared responses between women who underwent serum testing done in advance of their ultrasound such that their final risk assessment was given to them the same day as their ultrasound (comprehensive) versus women who underwent serum testing the same day as their ultrasound and who therefore received their final risk assessment later (standard). Response rate was 94.8%. The comprehensive group was significantly more likely to receive counseling in accordance with recommended American College of Obstetricians and Gynecologists (ACOG) guidelines, had significantly greater reduction in anxiety and increased satisfaction, and was more likely to report an increased understanding of their results. The comprehensive group scored significantly higher on test-style questions about aneuploidy risk assessment. Comprehensive aneuploidy risk assessment counseling including same-day results is associated with increased patient understanding and satisfaction, decreased anxiety, and increased adherence to ACOG guidelines.

Effect of increased body mass index on first-trimester ultrasound examination for aneuploidy risk assessment.

OBJECTIVE: To estimate whether body mass index (BMI) affects the evaluation of nuchal translucency or the nasal bone during first-trimester ultrasound examination for aneuploidy risk assessment. METHODS: Six hundred ninety-four women with singleton gestations undergoing first-trimester aneuploidy risk-assessment ultrasound examinations were identified. Weight categories were defined as normal (body mass index [BMI] less than 25), overweight (25-29.9), and obese (at or above 30). chi, chi for trend, Student t test, one-way analysis of variance, and Pearson correlation were used for statistical analysis where appropriate to estimate the effect of BMI on first-trimester ultrasound examination. P<.05 was considered statistically significant. RESULTS: Increasing BMI was significantly associated with an inadequate nasal-bone assessment (3% compared with 12.7%, P<.001), increased ultrasound examination time (15.23+/-8.09 minutes compared with 17.01+/-7.97 minutes, P=.028), and an increased need to perform a transvaginal ultrasound examination (23% compared with 41.8%, P<.001). Prior abdominal surgery was not significantly associated with nasal-bone assessment inadequacy (7.8% compared with 4.4%, P=.125), the need to perform transvaginal ultrasound examination (33.6% compared with 28.6%, P=.279), or longer examination time (16.22+/-8.6 minutes compared with 15.92+/-7.8 minutes, P=.704). CONCLUSION: In singleton pregnancies, increased BMI is not associated with suboptimal visualization of nuchal translucency, but it is associated with a longer time to perform the first-trimester ultrasound examination for aneuploidy risk assessment, increased need for transvaginal ultrasound examination for nuchal-translucency visualization, and a lower likelihood of obtaining an adequate nasal-bone image. Previous abdominal surgery did not affect the ability to visualize the nasal bone. LEVEL OF EVIDENCE: II.

Spontaneous resolution of an adrenal mass seen on ultrasound at 17 weeks gestation.

We report a congenital neuroblastoma with findings at 17 weeks gestation that was managed expectantly; this represents the earliest reported finding of a congenital neuroblastoma we could find in the English literature.