Management and Interventions in Previable and Periviable Preterm Premature Rupture of Membranes: A Review.

Importance: Periviable and previable premature rupture of membranes (pPPROM) occurs in <1% of pregnancies but can have devastating consequences for the mother and the fetus. Understanding risk factors, possible interventions, and both maternal and neonatal outcomes will improve the counseling and care provided for these patients. Objective: The aim of this review is to describe the etiology, risk factors, management strategies, neonatal and maternal outcomes, and recurrence risk for patients experiencing pPPROM. Evidence Acquisition: A PubMed, Web of Science, and CINAHL search was undertaken with unlimited years searched. The search terms used included "previable" OR "periviable" AND "fetal membranes" OR "premature rupture" OR "PROM" OR "PPROM." The search was limited to English language. Results: There were 181 articles identified, with 41 being the basis of review. Multiple risk factors for pPPROM have been identified, but their predictive value remains low. Interventions that are typically used once the fetus reaches 23 to 24 weeks of gestation have not been shown to improve outcomes when used in the previable and periviable stage. Neonatal outcomes have improved over time, but survival without severe morbidity remains low. Later gestational age at the time of pPPROM and longer latency period have been shown to be associated with improved outcomes. Conclusions and Relevance: Periviable and previable premature rupture of membranes are uncommon pregnancy events, but neonatal outcomes remain poor, and routine interventions for PPROM >24 weeks of gestation have not proven beneficial. The 2 most reliable prognostic indicators are gestational age at time of pPPROM and length of the latency period.

Furosemide for postpartum blood pressure control in patients with hypertensive disorders.

Objective: diuretics have the potential to reduce intravascular volume, decrease blood pressure The aim of our study is to evaluate the effectiveness of furosemide in postpartum patients with pre-eclampsia and chronic hypertension with superimposed pre-eclampsia. Methods: This is a retrospective cohort study. Data was extracted from the record of patients who delivered between 2017 and 2020 and had chronic hypertension or, chronic hypertension with superimposed pre-eclampsia, gestational hypertension, or pre-eclampsia. Patients who received intravenous furosemide in the postpartum period were compared to those who did not. The groups were also analyzed for fetal growth restriction, and pregnancy outcomes comparing those who did receive furosemide and those who did not. Results: The furosemide group had a statistically significant longer postpartum length of stay (p < 0.0001), required more antihypertensive medications (p < 0.0001), medication increases (p < 0.0001), and emergent blood pressure treatment (p < 0.0001), than the group who did not. There was no difference between groups in hospital readmission, or fetal growth restriction. Conclusion: The postpartum length of stay and rates of readmission were not decreased in the group treated with intravenous furosemide. Future prospective studies that control for pregnancy comorbidities and severity of preeclampsia are needed to determine furosemide's effect on the volume status of the postpartum pre-eclamptic patient and determine its role in the treatment of these women.

Title: Is Mild Idiopathic Polyhydramnios Associated with an Increased Risk for an Intrauterine Fetal Demise? A Retrospective Cohort Study.

Objective: Antenatal fetal surveillance has been recommended for moderate/severe idiopathic polyhydramnios but not for mild idiopathic polyhydramnios. The purpose of this study is to determine if pregnancies with mild idiopathic polyhydramnios have an increased risk for an intrauterine fetal demise (IUFD). Methods: Medical records and amniotic fluid volume ultrasound data from 2016 to 2021 at a university medical center were examined. Pregnancies with fetal anomalies, fetal infection, isoimmunization, multiple gestation, maternal diabetes and oligohydramnios were excluded. Normal amniotic fluid volume was defined as an amniotic fluid index (AFI) <24 cm which was compared to mild idiopathic polyhydramnios, AFI of ≥24.0 cm-29.9 cm, and moderate/severe polyhydramnios which is an AFI ≥30 cm. Results: Of 12,725 patients meeting inclusion study criteria, there were 249 with idiopathic polyhydramnios (n = 249) which was associated with an increased odds of IUFD (aOR) of 3.27 (CI 1.50-7.15), NICU admission (aOR 1.28, CI 0.96-1.70), 5-minute APGAR score less than 7 (aOR 2.16, CI 1.52-3.07), and large for gestational age infant (LGA) (aOR 4.04, CI 2.83-5.78) compared to normal amniotic fluid volume (AFV). In the mild polyhydramnios group (n = 204, out of the 249 women with polyhydramnios) compared to the 12,476 pregnancies with normal AFV group, IUFD (aOR 3.38, CI 1.46-7.82), NICU admission (aOR 1.19, CI 0.87-1.64), 5-minute APGAR score less than 7 (aOR 1.68, CI 1.10-2.55) and LGA (aOR 3.87, CI 2.59-5.78). In moderate/severe polyhydramnios group (n = 45) compared to the normal AFV group, there was no increased odds of IUFD (aOR 2.78, CI 0.38-20.29) or NICU admission (aOR 1.74, CI 0.93-3.26) but an increased odds for a 5-minute APGAR score less than 7 (aOR 4.94, CI 2.57-9.53) and LGA fetus (aOR 4.80, CI 2.26-10.22). Conclusion: There is an increased odds of IUFD in pregnancies complicated by mild idiopathic polyhydramnios. Patients should be counseled on an increased odds of adverse pregnancy outcomes associated with idiopathic polyhydramnios, and in those pregnancies with mild idiopathic polyhydramnios, antenatal fetal surveillance should be considered.

Subchorionic Hemorrhage in the Second and Third Trimesters of Pregnancy: A Review.

Importance: Subchorionic hemorrhage (SCH) in the second and third trimesters of pregnancy can be associated with maternal morbidity and fetal morbidity/mortality. Management of SCH in the second or third trimesters can be complicated, especially in the setting of a large SCH that requires hospitalization and blood transfusion. Objective: The aim of this review is to describe SCH in second and third trimesters, risk factors, diagnosis, maternal and fetal outcomes, and management of this uncommon pregnancy complication. Evidence Acquisition: A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched. Results: There were 123 abstracts and/or articles reviewed, with 48 articles being the basis of review. The only known risk factors for SCH are maternal factor deficiency and anticoagulation therapy. The diagnosis is usually made by ultrasound imaging. Subchorionic hemorrhage in second and third trimesters has been associated with several adverse fetal outcomes including preterm birth, preterm prelabor rupture of membranes, fetal growth restriction, fetal demise, and neonatal pulmonary morbidity. There is no proven treatment for SCH, although there are several investigational therapies reported. Conclusions: Subchorionic hemorrhage can be complex and difficult to manage in the second and third trimesters. There are no recommendations or guidelines for management; however, serial growth ultrasounds, umbilical artery Doppler studies, and antenatal fetal testing should be considered particularly if the SCH is large or treatment requires a maternal blood transfusion. Relevance: Subchorionic hemorrhage in the second and third trimester is associated with poor fetal outcomes and maternal morbidity, especially if the SCH is significant.

Secondary Postpartum Hemorrhage Due to Retained Placenta Accreta Spectrum: A Case Report.

Background: Retained products of conception and placenta accreta spectrum are causes of postpartum hemorrhage. Placenta accreta spectrum is frequently managed with cesarean hysterectomy, but conservative approaches are emerging. We present a case of delayed postpartum hemorrhage secondary to a retained placenta increta. Case: A 29-year-old G3P2 presented with heavy vaginal bleeding 20 days postoperatively following an uncomplicated classical cesarean delivery at 27 5/7 weeks' gestation for preterm labor in the setting of a vasa previa. On workup, imaging showed retained products of conception and concern for placenta accreta. A hypervascular area in the lower uterine segment was identified at the time of postpartum laparotomy. Total abdominal hysterectomy was performed due to postpartum hemorrhage and clinical suspicion for placenta accreta spectrum disorder. Pathology confirmed a placenta increta. Conclusion: Diagnosis of placenta accreta spectrum in the remote postpartum period is uncommon but should be a considered etiology in delayed postpartum hemorrhage. Careful inspection and documentation of the placenta implantation site should occur in cesarean sections because placenta accreta spectrum disorders can remain unnoticed during delivery.

Spontaneous Uterine Vessel Rupture During Pregnancy or in the Puerperium: A Review of the Literature.

Importance: Spontaneous perinatal rupture of a uterine vessel is a rare occurrence that may lead to severe hemorrhage and requires prompt identification and management. Objective: The aim of this study was to examine the etiologies, locations, diagnostic tools, treatment options, and risks in subsequent pregnancies when spontaneous rupture of a uterine vessel occurs in pregnancy. Evidence Acquisition: A literature search was performed by university research librarians using the PubMed, CINAHL, and Web of Science search engines. Identified were 78 cases of perinatal spontaneous uterine vessel rupture and formed the basis for this review. Results: Increased uterine blood flow during pregnancy may alter the integrity of pelvic vessels leading to increased risk of spontaneous rupture. The uterine artery is the most common site of vessel rupture; the second most common site is the uterine-ovarian plexus. The most common presentation is abdominal or pelvic pain, maternal vital sign abnormalities, and an absence of vaginal bleeding. Exploratory laparotomy and embolization (interventional radiology) have been reported as management options. Conclusions: Spontaneous rupture of uterine vessels is a rare but potentially life-threatening complication of pregnancy that should be included in the differential diagnosis of pregnant patients presenting with an acute abdomen. Relevance: Our aim is to increase the awareness of spontaneous vessel rupture during pregnancy to improve detection, management, and perinatal outcomes.

Are the Diagnosis and Treatment of Acute Cystitis in the Premenopausal, Pregnant, and Postmenopausal Women the Same? A Review of the Literature.

Importance: Acute cystitis is a common condition diagnosed in women. The diagnosis and treatment of this condition change throughout a woman's life. Understanding the differences in diagnosis and treatment in premenopausal, pregnant, and postmenopausal woman increases the likelihood of treatment success and decreases risk of complications from untreated or suboptimally treated infections. Objective: The aim of this review is to describe the incidence, risk factor, pathophysiology, diagnosis, and management of acute cystitis and the similarities and differences of these aspects of the condition in the premenopausal, pregnant, and postmenopausal woman. Evidence Acquisition: A PubMed, Web of Science, and CINAHL search was undertaken with the years 1990 to 2020 searched. Results: There were 393 articles identified, with 103 being the basis of review. Multiple risk factors for acute cystitis have been identified and are largely consistent throughout a woman's lifetime with few exceptions. The diagnoses by group with common diagnostic tools, such as urinalysis, vary in specificity and sensitivity between these groups. Management also varies between groups, with pregnancy having specific limitations related to drug safety in regard to possible fetal effects posed by certain medications commonly used to treat acute cystitis. Conclusions: Acute cystitis not only varies in presentation throughout a woman's lifespan, but also in appropriate diagnosis and treatment. Treatment of acute cystitis does have some commonalities between the groups; however, there are contraindications unique to each group. These differences are paramount to not only ensuring appropriate treatment but also treatment success. Relevance: Acute cystitis is a common condition with different diagnostic and management recommendations throughout a woman's lifespan.

July Effect in Obstetric Outcomes.

OBJECTIVE: The July effect represents the month when interns begin residency and residents advance with increased responsibility. This has not been well studied in Obstetrics and Gynecology residencies and no study has been conducted evaluating obstetric outcomes. The purpose of this study was to evaluate the July effect on obstetric outcomes. Women who delivered between July and September (quarter 1) were compared to those delivering between April and June (quarter 4). METHODS: This retrospective cohort study compared outcomes of deliveries between quarter 1 and quarter 4 from 2017 to 2020. Outcomes evaluated were postpartum length of stay (LOS), postpartum readmission, wound complication, wound infection, blood transfusion, estimated blood loss, 3rd and 4th degree lacerations, 5 min APGAR scores, and cesarean delivery rates. RESULTS: There were 3693 deliveries in quarter 1 and 3107 deliveries in quarter 4. There was a higher incidence Of wound infection during the April-June period (N = 21; 0.68%) compared to July-September (N = 10; 0.27%; p = 0.0135). Although LOS for both periods were the same, the average postpartum LOS during July-September was slightly longer than April-June (1.7 days; SD = 1.1 vs 1.6 days; SD = 1.2; p = 0.0026). All other pregnancy outcomes were similar between the two groups. CONCLUSION: Overall, the July effect is minimal on obstetric complications. However, LOS between July and September may differ because all residents are less experienced in quarter 1. Wound infection rates were higher in April-June, perhaps because new PGY-1s went from assisting to primary on cesarean surgeries starting in the 4th quarter of the year.

Risk of vascular complications in prophylactic compared to emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of placenta accreta spectrum.

OBJECTIVE: To compare prophylactic and emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter placement in the management of placenta accreta spectrum (PAS). STUDY DESIGN: Retrospective chart review of all patients with PAS (January 2018 to January 2020) at a single tertiary center who underwent prophylactic or emergent REBOA for cesarean hysterectomy for PAS. RESULTS: A total of 16 pregnant patients with PAS underwent percutaneous REBOA placement by acute care surgeons in collaboration with a multi-disciplinary PAS team. The REBOA catheter was placed prophylactically in 11 cases and emergently in 5 cases. No complications occurred in the prophylactic placement group. In the emergent placement group, 3 of 4 surviving patients had vascular access site complications requiring intervention. CONCLUSION: A multidisciplinary approach for the management of PAS utilizing REBOA is feasible in the setting of both planned and emergent cesarean hysterectomy and can aid in the control of acute hemorrhage. The risk for vascular access site complications related to REBOA catheter placement is higher in the emergent setting compared to prophylactic placement.

Management of Critically Ill Pregnant Patients with COVID-19 Infection in a Rural State.

OBJECTIVE: There is limited data on the treatment of coronavirus disease 2019 (COVID-19) in pregnancy. Arkansas saw an increase in COVID-19 cases in June 2020. The first critically ill pregnant patient was admitted to our institution on May 21st, 2020. The objective of this study was to evaluate outcomes in critically ill pregnant women with COVID-19 at a single tertiary care center who received remdesivir and convalescent plasma (CCP). STUDY DESIGN: This is a retrospective observational review of critically ill pregnant women with COVID-19 who received remdesivir and CCP. This study was approved by the institutional review board (#261354). RESULTS: Seven pregnant patients with COVID-19 were admitted to the intensive care unit (ICU). All received remdesivir and CCP. Six received dexamethasone. The median ICU length of stay (LOS) was 8 days (range 3-17). Patient 1 had multi-organ failure requiring vasopressors, renal dialysis, and had an intrauterine fetal demise. Patients 4 and 6 required mechanical ventilation, were delivered for respiratory distress and were extubated at 2 and 1 days postpartum, respectively. The only common risk factor was obesity. There were no adverse events noted with remdesivir or CCP. CONCLUSION: There is little data regarding the use of remdesivir or CCP for the treatment of COVID-19 in pregnant women. In our cohort, these were well tolerated with no adverse events. Previously reported median ICU LOS in critically ill pregnant women with COVID-19 was 8 days (range 4-15).1 Our study found a similar ICU LOS (8 days; range 3-17). Patient 1 did not receive remdesivir or CCP until transport to our facility on hospital day 3. Excluding patient 1, median ICU LOS was 6.5 days (range 3-9). Our institution's treatment of pregnant women with critical illness with remdesivir, CCP and dexamethasone combined with delivery in select cases has thus far had good outcomes. KEY POINTS: · Combined therapy: remdesivir, CCP, dexamethasone.. · Remdesivir, CCP and dexamethasone was effective in treating critically ill pregnant women with COVID-19.. · No adverse events were associated with combined therapy.. · Delivery improved respiratory status..

Preconception, Antepartum, and Peripartum Care for the Woman With a Spinal Cord Injury: A Review of the Literature.

IMPORTANCE: Spinal cord injury (SCI) may result in temporary or permanent loss of sensory, motor, and autonomic function, presenting unique medical and psychosocial challenges in women during their childbearing years. OBJECTIVE: The aim of this study was to review the literature and describe the spectrum of pregnancy considerations, complications, and evidence-based obstetric practices in women with SCI. EVIDENCE ACQUISITION: A literature search was undertaken using the search engines of PubMed and Web of Science using the terms "spinal cord injury" or "spinal cord complications" and "pregnancy outcomes" or "pregnancy complications." The search was limited to the English language, and there was no restriction on the years searched. RESULTS: The search identified 174 abstracts, 50 of which are the basis for this review. Pregnancy in women who have experienced an SCI requires a multidisciplinary approach. Common complications during pregnancy include recurrent urinary tract infection, upper respiratory tract infection, hypertension, venous thromboembolism, and autonomic dysreflexia (AD), which is a potentially life-threatening complication. Obstetricians should avoid potential triggers and be familiar with acute management of AD. Postpartum complications include difficulty initiating and maintaining breastfeeding and increased risk of postpartum depression and other mental health issues. CONCLUSIONS AND RELEVANCE: Obstetricians caring for women with an SCI must be familiar with the unique challenges and complications that may occur during pregnancy and puerperium. RELEVANCE STATEMENT: An evidence-based literature review of the care of pregnant women with spinal cord injury.

Duration of the Third Stage of Labor and Estimated Blood Loss in Twin Vaginal Deliveries.

Objective The main aim of this study was to characterize the duration of the third stage of labor and estimated blood loss in twin vaginal deliveries. Study Design This was a retrospective case-control study. The data was collected from deliveries at the University of Arkansas for Medical Sciences in Little Rock, Arkansas, from January 2013 to June 2017. Women were identified who had twin gestation, were delivered vaginally, and whose maternal age was greater than 18 years old. Women were excluded if they had an intrauterine fetal demise, delivered either/both fetuses via cesarean, history of a previous cesarean or a fetus with a congenital anomaly. If a subject met criteria to be included in the study, the next normal singleton vaginal delivery was used as the control subject. Results There were 132 singleton vaginal deliveries and 133 twin vaginal deliveries analyzed. There was no significant difference in the length of the third stage of labor between twin and singleton vaginal deliveries except in the 95th percentile of the distribution. Mothers delivering twins had an increase in third-stage duration by 7.618 minutes (95% confidence interval [CI]: 0.73, 14.50; p = 0.03) compared with those who delivered singletons. The twin group had a higher estimated blood loss than singleton deliveries. The increase in blood loss in the twin group was 149.02 mL (95% CI: 100.2, 197.8), 257.01 mL (95% CI: 117.9, 396.1), and 381.53 mL (95% CI: 201.1, 562.1) at the 50th, 90th, and 95th percentiles, respectively. When the third stage of labor was at the 90th percentile or less in twin pregnancy (14 minutes), estimated blood loss was less than 1000 mL. Conclusion Twin pregnancy is a known risk factor for postpartum hemorrhage. As the duration of the third stage prolongs, the risk for hemorrhage also increases. We recommend delivery of the placenta in twin pregnancies by 15 minutes to reduce this risk. Key Points The third stage is longer in twin pregnancy at extremes.Twin placentas should be delivered by 15 minutes.Manually extract the placenta when third stage is prolonged.

Umbilical Cord Prolapse: A Review of the Literature.

IMPORTANCE: Umbilical cord prolapse is a rare occurrence and is a life-threatening emergency for the fetus. These events are unpredictable and unpreventable. Umbilical cord prolapse requires swift diagnosis and management for optimal outcome. OBJECTIVE: The aim of this review is to describe the incidence, risk factor, pathophysiology, diagnosis, and management of this rare but potentially life-threatening event. EVIDENCE ACQUISITION: A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched. RESULTS: There were 200 articles identified, with 53 being the basis of review. Multiple risk factors for a umbilical cord prolapse have been suggested including fetal malpresentation or abnormal lie, prematurity, multifetal gestation, and polyhydramnios. The diagnosis is largely made by examination and found after rupture of membranes, and most often, examination is prompted by fetal heart rate decelerations. The management of umbilical cord prolapse is expedited delivery; however, there are rare specific scenarios in which immediate delivery is not possible and efforts should be made to relieve cord compression. CONCLUSIONS: Rapid identification of an umbilical cord prolapse facilitates management and increases likelihood of an optimal outcome. The management is an expedited delivery with efforts to relieve cord compression until delivery can be achieved. RELEVANCE: Umbilical cord prolapse is a rare but a life-threatening obstetrical emergency.

Treatment of metastatic malignant melanoma during pregnancy with a BRAF kinase inhibitor.

BACKGROUND: Melanoma accounts for 8% of all malignancies encountered during pregnancy. BRAF kinase inhibitors have shown promise in the treatment of late-stage melanoma; however, there have been no studies and only one previous case report regarding its use in pregnancy. CASE: A 25-year-old woman, gravida 1, at 20 weeks of gestation presented to the clinic with a complaint of a lump on her neck and dyspnea. She had had a melanoma that was surgically treated 5 years prior to her pregnancy. A biopsy was performed and she was found to have metastatic melanoma. After multidisciplinary discussion, the patient was offered treatment with vemurafenib, a BRAF kinase inhibitor, and the mass reduced in size. CONCLUSION: Malignancy during pregnancy poses both medical and ethical dilemmas in the management and treatment of cancer. The treatment of late-stage melanoma in pregnancy with a BRAF kinase inhibitor may be an option.

Prevalence of Human Papillomavirus in Self-Collected Cervicovaginal Swabs in Young Women in the United States Between 2003 and 2012.

OBJECTIVE: To evaluate whether there was a change in prevalence of human papillomavirus (HPV) in the United States correlated with the introduction of HPV vaccines in both vaccinated and unvaccinated women. METHODS: We performed a retrospective review of prevalence data for women aged 18-29 years living in the United States using the National Health and Nutrition Examination Surveys, which is an ongoing series of cross-sectional surveys. Participants provided responses to standardized questions and self-collected cervicovaginal swabs in which a Linear Array HPV Assay was used to determine HPV prevalence. A total of 783 women from the prevaccine era (2003-2004) and 1,526 from the postvaccine era (2007-2012) were analyzed. RESULTS: Among women aged 18-29 years, the prevalence of vaccine-type HPV declined among women receiving one or more doses of vaccine (P=.003): 10.1% (95% confidence interval [CI] 7.1-13.8%) in the prevaccine era to 4.2% (95% CI 3.3-10.9%) in the postvaccine era. There was no change in prevalence of nonvaccine-type HPV among women receiving one or more doses of vaccine (P>.05). There was also no change in prevalence of vaccine-type HPV among unvaccinated women from the prevaccine era 10.1% (95% CI 7.1-13.8%) to 8.8% (95% CI 5.6-12.9%) in the postvaccine era (P=.4). Vaccine coverage increased to 31.5% of eligible women aged 18-29 years as of 2011-2012. CONCLUSION: Six years after introduction of HPV vaccination in the United States, there has been a decrease in the prevalence of vaccine-type HPV among women correlated with receiving one or more vaccine doses with no change in nonvaccine-type HPV. Furthermore, there has been no change in prevalence of vaccine-type HPV among unvaccinated women.