Vasa previa in singleton pregnancies: diagnosis and clinical management based on an international expert consensus.

BACKGROUND: There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. OBJECTIVE: This study aimed to systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions and a Delphi technique. STUDY DESIGN: A 4-round focus group discussion and a 3-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected on the basis of their publication record on vasa previa. First, we convened a focus group discussion panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A 3-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa, which the experts were asked to rate on a 5-point Likert scale (from "strongly disagree"=1 to "strongly agree"=5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of ≤3 were deemed to have had no consensus and were excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and nonconsensus statements were then aggregated. RESULTS: A total of 68 international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on 5 continents and have contributed to >80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, and 91% for the first, second, and third rounds, respectively, and 71% completed all 3 rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including the following: (1) although there is no agreement on the distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2-cm distance; (2) all pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; (3) when a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at approximately 32 weeks to rule out vasa previa; (4) outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; (5) asymptomatic patients with vasa previa should be delivered by scheduled cesarean delivery between 35 and 37 weeks of gestation; and (6) there was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. CONCLUSION: Through focus group discussion and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines.

Prenatally Diagnosed Vasa Previa: A Single-Institution Series of 96 Cases.

OBJECTIVE: To describe outcomes for a large cohort of women with prenatally diagnosed vasa previa, determine the percentage in patients without risk factors, and compare delivery timing and indications for singletons and twins. METHODS: This was a retrospective case series of women with prenatally diagnosed vasa previa delivered at a single tertiary center over 12 years. Potential participants were identified using hospital records and perinatal databases. Patients were included if vasa previa was confirmed at delivery and by pathologic examination. Maternal and newborn data were gathered from medical records. RESULTS: There were 77 singleton and 19 twin pregnancies with a prenatal diagnosis of vasa previa. There was one neonatal death from congenital heart disease. Perinatal management of recommended elective hospitalizations with corticosteroid administration and elective early delivery resulted in average gestational age for delivery in singletons at 34.7±1.6 weeks and 32.8±2.2 weeks for twins. Among the 77 singletons, delivery was elective in 48, as a result of contractions or labor in 21, bleeding in four, nonreassuring tracing in two, asymptomatic cervical shortening in one, and preeclampsia in one. Among 19 twins, delivery was elective in six and for contractions or labor in 13. Sixty-eight percent of twins compared with 37% of singletons had nonelective delivery (P<.05). Delivery occurred by 32 weeks of gestation in 6.4% of singletons and 26% of twins (P<.05) and by 34 weeks of gestation in 11% of singletons and 58% of twins (P<.001). Six neonates (5.2%) had major anomalies, all prenatally detected. Respiratory distress syndrome occurred in 57.1% of singletons and 65.7% of twins. Nineteen singletons (24.7%) had no risk factors for vasa previa. CONCLUSION: Planned preterm delivery for women with prenatally diagnosed vasa previa resulted in elective delivery for singletons in 62% and for twins 32%. Gestational age at birth on average was 34.7 weeks for singletons and 32.8 weeks of gestation for twins. Major anomalies were frequent as was respiratory distress syndrome. Elective delivery between 34 and 35 weeks of gestation for singletons is reasonable. As a result of the high rate of nonelective delivery in twins, delivery at 32-34 weeks of gestation may be risk-beneficial. The high rate of singletons without risk factors for vasa previa reinforces the recommendation to screen routinely for cord insertion site.

Nonstress testing at ≤ 32.0 weeks' gestation: a randomized trial comparing different assessment criteria.

OBJECTIVE: Comparison of time and outcomes of National Institutes of Child Health and Human Development defined fetal heart rate acceleration criteria at ≤ 32 weeks (≥ 10 beats/min, ≥ 10 seconds) compared with standard criteria (≥ 15 beats/min, ≥ 15 seconds). STUDY DESIGN: Singleton high-risk pregnancies that were referred for nonstress testing at ≤ 32 weeks' gestation were randomly assigned to 15 × 15 or 10 × 10 criteria. Data included nonstress test information, maternal data, and outcomes. RESULTS: One hundred forty-three women were randomly assigned to 15 × 15 (n = 71) or 10 × 10 (n = 72). The groups were similar in maternal and pregnancy characteristics. Median time to reactive nonstress testing was shorter in the 10 × 10 group (37.3 minutes) than the 15 × 15 group (41.3 minutes; P = .04). There were no serious adverse events. CONCLUSION: The time to attain a reactive nonstress testing at ≤ 32 weeks' gestation was 4 minutes shorter when the 10 × 10 criteria were used. There were no adverse events related to use of 10 × 10 nonstress testing criteria.

Prenatal diagnosis of fetal hepatoblastoma: case report and review of the literature.

Hepatoblastoma is the most common liver malignancy in childhood. The reported incidence is 11.2 cases per 1 million during the first year of life. Genetic predispositions include Beckwith-Wiedemann syndrome and familial polyposis. The prognosis depends on the extent of tumor spreading at the time of initial treatment, which typically includes chemotherapy and surgery. Imaging of hepatoblastoma has only rarely been reported prenatally. Here we report a recent case with a successful outcome and discuss issues of differential diagnosis and treatment.

Respiratory compromise after MgSO4 therapy for preterm labor in a woman with myotonic dystrophy: a case report.

BACKGROUND: MgSO4 is widely used for tocolysis. Serious complications are rare as long as dosing is carefully monitored. Adverse effects in muotonic dustrophy have not been previously described. CASE: A 35-year-old woman, gravida 1, para 0, was hospitalized with suspected mild myotonic dystrophy, polyhydramnios and preterm labor at 33 weeks. MgSO4 infusion rapidly resulted in respiratory compromise. Muscular strength returned to baseline after the infusion was stopped. Mother and infant proved to have myotonic dystrophy. CONCLUSION: The choice of tocolytic medication in maternal myotonic dystrophy is problematic. Beta-2 sympathomimetics have been reported to precipitate myotonia. This case illustrates the potential for MgSO4 to cause respiratory embarrassment. Indomethacin may be the tocolytic of choice in myotonic dystrophy.

Preventing needlestick injuries in obstetrics and gynecology: how can we improve the use of blunt tip needles in practice?

Surgical needlestick injuries are common in obstetrics and gynecology and can cause transmission of viral diseases including hepatitis and acquired immunodeficiency syndrome (AIDS). Strategies to reduce the rate of needlestick injuries include using instruments rather than fingers to retract tissue and grasp needles, double gloving, using surgical staplers for skin closure, and substituting blunt tip surgical needles for sharp tip needles where applicable. Studies have shown the use of blunt tip surgical needles to be remarkably effective in reducing needlestick injuries. Despite recommendations by the American College of Surgeons that blunt tip surgical needles be used routinely, at least for fascial closure, and by the Occupational Safety and Health Administration and the National Institute for Occupational Health and Safety that these devices be used whenever medically appropriate, use in obstetrics and gynecology appears to be limited. Potential barriers to use include availability, the "feel" of the needle as it penetrates tissue, and habit. We suggest that blunt tip surgical needles have the potential to replace traditional needles for many obstetric and gynecologic applications. If their use is to become more widespread, we must focus on availability, evaluation for specific applications, and physician education.

Oxytocin-associated rupture of an unscarred uterus in a primigravida.

BACKGROUND: Intrapartum rupture of the unscarred uterus is an uncommon event, usually associated with such risk factors as grand multiparity, malpresentation, history of gestational trophoblastic disease, or instrumented delivery. Rupture during first pregnancy is extremely rare. CASE: A 30-year-old primigravid woman was admitted for labor augmentation with oxytocin at 40.5 weeks of gestation. The oxytocin infusion rate was increased during the first and second stages of labor despite contractions occurring at a rate of 4-5 per 10 minutes. The uterus ruptured during second stage. Despite emergency cesarean delivery, the baby had evidence of severe asphyxia. CONCLUSION: This case of uterine rupture in a primigravida with no prior uterine surgery and a structurally normal uterus underscores the importance of careful contraction monitoring and judicious control of oxytocin infusion rates.

Vasa previa: the impact of prenatal diagnosis on outcomes.

OBJECTIVE: To evaluate outcomes and predictors of neonatal survival in pregnancies complicated by vasa previa and to compare outcomes in prenatally diagnosed cases of vasa previa with those not diagnosed prenatally. METHODS: We performed a multicenter study of 155 pregnancies complicated by vasa previa. Cases were obtained from the Vasa Previa Foundation and 6 large hospitals. Comparisons were made between groups based on prenatal diagnosis status and neonatal survival. RESULTS: The overall perinatal mortality was 36% (55 of 155). In 61 cases (39%), vasa previa was diagnosed prenatally; 59 of 61 (97%) infants from these pregnancies survived compared with 41 of 94 (44%) in cases not diagnosed prenatally (P <.001). Median 1- and 5-minute Apgar scores in cases diagnosed prenatally were 8 and 9, respectively, compared with 1 and 4 among survivors in cases not diagnosed prenatally (P <.001). More than half (24 of 41) of surviving neonates born to women without prenatal diagnosis required blood transfusions compared with 2 of 59 diagnosed prenatally (P <.001). Multivariable logistic regression analysis showed that the only significant predictors of neonatal survival were prenatal diagnosis (P <.001) and gestational age at delivery (P =.01). CONCLUSIONS: Good outcomes with vasa previa depend primarily on prenatal diagnosis and cesarean delivery at 35 weeks of gestation or earlier should rupture of membranes, labor, or significant bleeding occur.