Stage I Twin-Twin Transfusion Syndrome: Outcomes of Expectant Management and Prognostic Features.

OBJECTIVE: This article describes the natural history of stage I twin-twin transfusion syndrome (TTTS) including risk of progression to higher stage TTTS and pregnancy outcomes, and to identify risk factors for progression. STUDY DESIGN: Retrospective cohort study of monochorionic diamniotic (MCDA) twin pregnancies from 2006 to 2016 with expectantly managed Quintero stage I TTTS. RESULTS: A total of 30 MCDA twin pregnancies with expectantly managed stage I TTTS were identified. Of these, eight (26.7%) progressed to higher stage TTTS. Median gestational age (GA) at diagnosis for those that progressed was 18.9 ± 2.9 weeks versus 21.4 ± 3.4 weeks in those that remained stable (p = 0.06). Presence of an arterioarterial (A-A) anastomosis was assessed for 20/30 patients, and eight A-A were identified. Of those, 7/8 (87.5%) remained stable. In the complete cohort, a tiny or transiently visible bladder was noted in seven donor twins. Of these, 4/7 (57.1%) progressed. Excluding one termination, 47/58 (81.0%) fetuses survived. CONCLUSION: With expectant management of stage I TTTS, nearly three-fourths of pregnancies remain stable and most have survival of ≥ 1 twin. A-A anastomoses were not associated with progression to higher stage TTTS, whereas earlier GA at diagnosis or a small or intermittently visible donor bladder may herald greater risk of progression.

Polyhydramnios Affecting a Recipient-like Twin: Risk of Progression to Twin-Twin Transfusion Syndrome and Outcomes.

OBJECTIVE: The significance of polyhydramnios of one twin in the absence of oligohydramnios of the cotwin in monochorionic diamniotic (MCDA) twin pregnancies (polyhydramnios affecting a recipient-like twin [PART]) is unknown. Our aim is to assess the risk of progression to twin-twin transfusion syndrome (TTTS) with PART, progression to ≥ stage II TTTS, and neonatal survival. STUDY DESIGN: This study was a retrospective cohort study of MCDA twin pregnancies with PART evaluated at a referral center from 2008 to 2015. RESULTS: Sixty-four MCDA twin pregnancies with PART were identified. Fifteen (23.4%) progressed to TTTS, including 10 (15.6%) who progressed to ≥ stage II TTTS. Three pregnancies were terminated and one underwent selective reduction by radiofrequency ablation. Overall survival was 113 out of 128 (88.3%). Of those who remained stable, 91.8% (N = 45) had survival of both neonates. In multivariate analysis, the presence of arterioarterial (A-A) anastomosis by in utero Doppler ultrasound was associated with decreased risk of progression to TTTS (odds ratio: 0.12, p = 0.03, 95% confidence interval: 0.02-0.78). CONCLUSION: Most MCDA twin pregnancies with PART do not progress to TTTS and have a favorable prognosis. Progression rates are higher than observed in uncomplicated MCDA twins; however, so close surveillance is warranted. The presence of an A-A anastomosis appears to confer decreased risk of progression to TTTS.

Outcomes of nonsurgical versus surgical treatment of cesarean scar pregnancies in the first trimester.

PURPOSE: To compare outcomes of nonsurgical versus surgical treatment of Cesarean scar pregnancies (CSP) in the first trimester and identify optimal treatment methods for CSP. METHODS: Retrospective cohort study of all women diagnosed and treated with CSP in the first trimester at a single tertiary care center from 2000-2012. Main outcome measures were need for additional treatments, hemorrhage, or emergent hysterectomy. Future pregnancy outcomes were considered secondarily. RESULTS: Twenty-three cases of CSP treated in the first trimester were confirmed including 12 treated surgically and 11 treated nonsurgically. Of the nonsurgical patients, none treated with a combination of intrasac potassium chloride (KCl) and systemic methotrexate (MTX) required further treatment versus 5/8 (62%) of those treated with a single agent (p = 0.18). One patient who was treated with intrasac KCl alone experienced hemorrhage. Of the nine patients treated with suction dilation and curettage (D&C), two (22%) required additional intervention, but none experienced major complications. Nonsurgical therapy had a higher rate of needing further intervention (45%) than surgical therapy (17%) (p = 0.19). There was one recurrent CSP in 11 subsequent deliveries with no uterine ruptures or hysterectomies. CONCLUSIONS: We have described nonsurgical and surgical treatments of first trimester CSP with a low rate of major complications and no emergent hysterectomies. Of the nonsurgical therapies, single-agent treatment with either systemic MTX or intrasac KCl was associated with high rates of needing additional treatment and should be avoided. Our method of ultrasound-guided suction D&C resulted in no major hemorrhage and is a reasonable surgical treatment option.

Outcome of cesarean scar pregnancies diagnosed sonographically in the first trimester.

OBJECTIVES: The purpose of this study was to determine the outcome of cesarean scar pregnancies diagnosed during the first trimester. METHODS: We retrospectively identified all cesarean scar implantation pregnancies diagnosed by sonography before 14 weeks' gestation between 2000 and 2012 at our institution. We reviewed the patients' sonograms and medical records and recorded sonographic findings and pregnancy outcomes. RESULTS: Thirty-four cases met study entry criteria. Ten patients presented with no embryonic cardiac activity, of whom 7 underwent interventions, and 3 were expectantly managed. One of the former 7 and none of the latter 3 required hysterectomy for bleeding. Among the 24 patients with embryonic cardiac activity, 8 were managed expectantly: 5 (62.5%) ultimately delivered a live-born neonate, 3 (60.0%) of whom required hysterectomy due to placenta accreta; and 3 had fetal demise. Sixteen of the 24 underwent interventions, 2 opting for gravid hysterectomy (10 and 11 weeks' gestation, respectively) and 14 treated by a minimally invasive method: intrasac potassium chloride injection (3 cases); intrasac potassium chloride injection plus intramuscular methotrexate (4 cases); sonographically guided dilation and curettage (6 cases); and laparascopic resection (1 case). None of the latter 14 subsequently required hysterectomy. CONCLUSIONS: If a woman has a first-trimester diagnosis of a cesarean scar implantation pregnancy and embryonic cardiac activity is present, expectant management offers the possibility of delivering a live-born neonate (62.5% in our study) but carries a substantial likelihood of hysterectomy at delivery due to placenta accreta (37.5% in our study), whereas minimally invasive therapy that interrupts the pregnancy largely eliminates the need for hysterectomy.

Trends in reported resident surgical experience in hysterectomy.

STUDY OBJECTIVE: To compare differences in trends in reported surgical experience of residents in obstetrics and gynecology in the United States insofar as abdominal, vaginal, and laparoscopic hysterectomy. DESIGN: Retrospective analysis of the national case log reports from the Accreditation Council for Graduate Medical Education (ACGME) for obstetrics and gynecology cases logged as "surgeon" from 2002 to 2012 (Canadian Task Force classification III). SETTING: AGCME-accredited residency programs in obstetrics and gynecology. PARTICIPANTS: Eleven thousand five hundred and eight graduating residents in obstetrics and gynecology (n = 11 508). MEASUREMENTS AND MAIN RESULTS: Since 2008, when the ACGME began reporting the 4-year cumulative hysterectomy case load statistics for graduating residents in obstetrics and gynecology, there has been no significant change in the mean (SD) number of hysterectomies performed by residents from 118.1 (38.0) cases in 2008-2009 to 116.1 (31.0) cases in 2011-2012 (p = .16; 95% confidence interval [CI], -0.78 to 4.78). During the past decade, however, the total number of reported abdominal hysterectomies consistently decreased from 89.1 (34.2) cases in 2002-2003 to 59.1 (21.0) cases in 2011-2012 (28% decrease; p <.001; 95% CI, 27.7-32.3). The number of vaginal hysterectomies also trended down from 34.9 (19.2) cases to 19.4 (9.0) cases (40% decrease; p <.001; 95% CI, 14.3-16.7). The ACGME did not report the number of laparoscopic hysterectomies performed by residents until 2008-2009, when residents reported performing 23.4 (17.0) cases. From 2008 to 2012, this number increased to 38.5 (20.0) cases (72% increase; p <.001; 95% CI, 13.6-16.6). The proportion of reported laparoscopic hysterectomies performed with robotic assistance was not separately reported. CONCLUSIONS: Although the overall number of hysterectomies reported by residents has remained stable since 2008, the predominant modes of hysterectomy during the past decade have changed substantially, with laparoscopic hysterectomy comprising an increasingly large proportion of resident experience. As laparoscopic hysterectomy has become more common, reported cases of abdominal and vaginal hysterectomies have decreased. Additional statistics on the percentage of laparoscopic hysterectomies performed using robotic assistance would be valuable to additionally analyze the effect of this new technology on resident training.