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.

Peripartum Hypertensive Crisis Simulation and Education Initiative among Rural Emergency Departments.

OBJECTIVE: To determine whether the introduction of hypertensive bundles through simulation and education would result in the timely assessment and treatment of a simulated patient in a peripartum hypertensive crisis. METHODS: This prospective observational pilot study evaluates the use of simulation and education on hypertension bundled care for peripartum patients in eight rural hospitals. Unannounced simulation exercises were conducted at each hospital. Emergency department staff response was assessed with a checklist. Primary outcomes included time to first antihypertensive medication administered, time to registered nurse assessment, and time to physician assessment. After the initial simulation, nurse educators conducted an in-person didactic on the management of peripartum hypertensive crisis, providing each hospital with materials for local bundle initiation and implementation for hypertensive emergency. The nurse educators conducted the same simulation at the individual sites 3 to 4 months later. Time of intervention improvement pre- and posteducation training scores were analyzed for each of these using a paired t test followed by a Wilcoxon signed-rank test. The average time of intervention improvement among delivering hospitals versus nondelivering hospitals was compared. RESULTS: Eight training simulation and training sessions were conducted at four delivering and four nondelivering hospitals. Seventy-three healthcare workers attended training. The average time decreased from pre- to postsimulation at all of the hospitals (this was not statistically significant, however). The average reduction in time for first nurse assessment was 1.25 ± 10.05 minutes (P = 0.99). The average reduction in time to physician assessment was 4.88 ± 14.74 minutes (P = 0.45). The average reduction of time to administration of first hypertensive medication was 12.0 ± 25.79 minutes (P = 0.15). The average times for nurse or physician assessment and time to first hypertension medication administration were similar between delivering and nondelivering hospitals. CONCLUSIONS: Our study demonstrates a trend toward improved treatment of a peripartum hypertensive emergency through bundled care and simulation. The training reduced the time to first medication given and improved the selection process for the preferred hypertensive medication. The time from nurse care to physician assessment also was reduced. Education in bundled peripartum hypertension care may improve patient outcomes by decreasing hypertension-related maternal morbidity and mortality.

Longitudinal assessment of obstetrics and gynecology resident perceptions and comfort following cerclage placement simulation.

BACKGROUND: Utilization of simulation training in medical education has increased over time, particularly for less common scenarios and procedures. Simulation allows trainees to practice in a low-stress environment and eliminates patient risk. Cerclage placement has become less frequent, which limits obstetrics and gynecology (OB/GYN) exposure to cerclage placement during training. This exposes an area of training requiring simulation in OB/GYN resident education. OBJECTIVE: To evaluate resident reception to cerclage simulation, their self-reported comfort with and ability to troubleshoot difficult cerclage placement immediately and 12 months following didactic education and simulation. METHODS: In 2019, 18/20 (90%) OB/GYN residents in our university program underwent didactic teaching and simulation in cerclage placement using a pelvic model with removable cervix. Residents completed a survey immediately and 12 months following simulation. Wilcoxon signed-rank test was used to analyze resident self-report of comfort with cerclage placement and skill techniques for navigating difficult placement before and after simulation training. Descriptive statistics were analyzed as means and standard deviations. RESULTS: Eighteen of twenty (90%) residents participated in the education session in cerclage placement. All 18 (100%) completed a postsimulation survey and 17/18 (94%) completed a survey 12 months later. All reported improved comfort with cerclage placement and statistically significant improvement in knowledge on techniques for troubleshooting difficult placement after simulation. All residents reported that the simulation enhanced their learning and recommended the simulation for future educational opportunities. CONCLUSIONS: Cerclage simulation was well-received by OB/GYN residents in learning and practicing cerclage placement. Residents demonstrated improved comfort with placement following simulation.

Management of pregnancies complicated by placenta accreta spectrum utilizing a multidisciplinary care team in a rural state.

PURPOSE: To compare maternal and neonatal outcomes following the development of a multidisciplinary care team for the management of pregnancies complicated by placenta accreta spectrum (PAS) in a rural state. METHODS: This is a retrospective cohort study evaluating pregnancies managed before PAS team care management formation (2010-2015) and after (2016-2020) in a university medical center. Maternal and neonatal outcomes were analyzed. Patients were grouped by delivery date to either before or after dedicated PAS team formation. Maternal and neonatal outcomes were analyzed. Frequencies and percentages were reported for categorical measures while means and standard deviations were computed for continuous measures. Wilcoxon rank-sum test was used for continuous variables while Chi-square or Fisher's exact was used for categorical measures. FINDINGS: There were 82 patients with PAS managed at our institution (29 in Pre-PAS team group and 53 in Post-PAS team group). The number of units of packed red blood cells (PRBCS) transfused intraoperatively was significantly higher in the Pre-PAS care team group (6.52 vs. 3.26, p = .0057). The total number of units PRBCS transfused (9.93 vs. 3.51, p = .0014) and total number of cryoprecipitate transfused (0.77 vs. 0.08, p = .0225) during the entire hospital stay were increased in the Pre-PAS team group. Median neonatal 1 min and 5 min APGAR scores were lower in the Pre-PAS care team group (2 vs 6 at 1 min, p = .0035; 6 vs. 7at 5 min, p = .0301). CONCLUSIONS: Management of PAS by a dedicated, multidisciplinary team results in less blood transfusion requirements and improved maternal and neonatal outcomes.

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..

Spontaneous Renal Rupture During Pregnancy: A Contemporary Literature Review and Guide to Management.

IMPORTANCE: Spontaneous renal rupture is a rare pregnancy complication, which requires a high index of suspicion for a timely diagnosis to prevent a poor maternal or fetal outcome. OBJECTIVE: This review highlights risk factors, pathophysiology, symptoms, diagnosis, management, and complications of spontaneous renal rupture in pregnancy. EVIDENCE ACQUISITION: A literature search was carried out by research librarians using the PubMed and Web of Science search engines at 2 universities. Fifty cases of spontaneous renal rupture in pregnancy were identified and are the basis of this review. RESULTS: The first case of spontaneous renal rupture in pregnancy was reported in 1947. Rupture occurs more commonly on the right side and during the third trimester. Pain was a reported symptom in every case reviewed. Treatment usually consists of stent or nephrostomy tube placement. Conservative management has been reported. CONCLUSIONS: When diagnosed early and managed appropriately, maternal and fetal outcomes are favorable. Preterm delivery is the most common complication. RELEVANCE: Our aim is to increase the awareness of spontaneous renal rupture in pregnancy and its associated complications in order to improve an accurate diagnosis and maternal and fetal outcomes.

Cesarean Delivery Management of Stillbirth: In-Depth Analysis of 75 Cases in a Rural State.

OBJECTIVE: To analyze the characteristics surrounding women who underwent cesarean delivery for stillbirth management in the rural, southern US state of Arkansas. METHODS: This was a planned secondary analysis of a retrospective descriptive study evaluating mode of delivery following the stillbirth of singleton pregnancies without anomalies or aneuploidy delivered in our state between July 2015 and June 2019. Data were extracted from a statewide reproductive health monitoring system and reviewed by the first three authors. Summary statistics were presented as means and standard deviations for continuous measures and frequencies and percentages for categorical variables. RESULTS: There were 861 patients diagnosed as having stillbirth between July 2015 and June 2019 in 44 hospitals in Arkansas. Seventy-five of those patients (8.7%) underwent cesarean delivery and are the basis for this analysis. Common indications for cesarean delivery were prior cesarean delivery (41%), malpresentation (18.7%), and abruption or hemorrhage (13.1%). Sixty-five percent of patients had a prior cesarean delivery. The most common complications were infection and hemorrhage, which accounted for 64.3% of known complications. The overall complication rate was 18.7% among stillbirths delivered via cesarean. CONCLUSIONS: This study demonstrates that cesarean delivery remains a common mode of delivery for management of stillbirth and that there is maternal morbidity associated with an abdominal delivery because 22.7% of the women undergoing a cesarean had an operative complication. It also highlights that prior cesarean delivery remains a common indication for a repeat abdominal delivery following a stillbirth despite the lack of fetal benefit.

Fetal intracranial hemorrhage associated with maternal coagulopathy and vitamin K deficiency after biliary drain placement: A case report and literature review.

INTRODUCTION: Fetal intracranial hemorrhage (ICH) is a rare but serious prenatal diagnosis. Predisposing factors include maternal trauma and fetal coagulation dysfunction. Maternal vitamin K deficiency has been described as an etiology. We present a case of maternal vitamin K deficiency associated with fetal ICH after percutaneous biliary drain (PBD) placement in a complicated cholecystectomy with injury to the common bile duct. CASE PRESENTATION: A 21-year-old woman, G2P1, presented at 23 weeks and 3 days of gestation with epigastric pain, nausea and vomiting. Right upper quadrant ultrasound diagnosed cholelithiasis. The patient was managed conservatively and discharged. She returned four days later, at 24 weeks of gestation, with worsening symptoms and ultrasound showing acute cholecystitis. She underwent laparoscopic cholecystectomy. Increasing bilirubin and imaging showed a transected biliary duct that required percutaneous biliary drain (PBD) placement. The patient was discharged and followed up at a high-risk obstetric clinic. Prenatal ultrasound showed bilateral ventriculomegaly with features of ICH. Maternal vitamin K deficiency was confirmed with PIVKA-II testing. The patient received vitamin K supplementation with normalization of the coagulopathy. Delivery occurred at 36 weeks of gestation via cesarean delivery after preterm premature rupture of membranes for fetal macrocrania. The neonate was discharged to a hospice. DISCUSSION: Maternal and neonatal etiologies for ICH include malabsorption and coagulopathy. Maternal vitamin K deficiency should be considered when coagulopathy is present. This case highlights that maternal vitamin K deficiency due to biliary diversion and malabsorption increases the risk of fetal ICH, which impacts pregnancy and neonatal outcomes.

Can maternal characteristics on admission for preterm prelabor rupture of membranes predict pregnancy latency?

BACKGROUND: Latency duration after preterm prelabor rupture of membranes has been an area of investigation for many years. Previously described factors associated with latency include gestational age at the time of rupture, cervical dilation of >1 cm, vaginal bleeding at the time of presentation, and oligohydramnios. However, little is known about the impact of composite maternal factors and presenting symptoms on the duration or prediction of the latency period. OBJECTIVE: This study aimed to determine whether maternal factors and subjective presenting symptoms can predict pregnancy latency after preterm prelabor rupture of membranes. STUDY DESIGN: This is a retrospective observational study of singleton pregnancies complicated by preterm prelabor rupture of membranes for over 3 years at a single institution utilizing a uniform management protocol. Maternal demographics, obstetrical data, maternal subjective symptoms and physical examination findings on admission, amniotic fluid volume assessment, presence of contractions, and maternal perception of feeling unwell were collected and analyzed. Clinical characteristics were summarized with mean and standard deviation for continuous measures and frequency and percentages for categorical variables. For skewed variables, medians with 25th and 75th percentiles were reported. Cumulative latency duration (ie, survival time) was estimated with a Kaplan-Meier model. Multivariable Cox proportional hazards regression model with backward variable selection was used to determine the effects of maternal factors on latency duration. RESULTS: Of the 212 patients available for analysis, there was a considerable variability in the latency duration with values ranging between 0 and 119 days. Factors related to latency duration included maternal age, parity, gestational age at rupture, cervical dilation, amniotic fluid volume, and contractions. Advancing maternal age (P=.012), increased gestational age at rupture (P<.0001), cervical dilation of ≥3 (vs 0; P<.0001), anhydramnios or oligohydramnios (vs normal amniotic fluid; P<.0001), cramping (P=.012), and painful contractions (P=.015) were associated with a shorter latency duration. Utilizing these statistically significant factors, we constructed a nomogram to predict latency for 1-day, 1-week, and overall median latency duration. CONCLUSION: Maternal factors and presenting symptoms can predict pregnancy latency after preterm prelabor rupture of membranes. We created a nomogram for clinical use that provides a visual display of the probability of pregnancy latency. This tool may be useful for counseling and providing additional information on expectations for providers and patients with pregnancies complicated by preterm prelabor rupture of membranes.

Hospital Annual Delivery Volume and Presence of Graduate Medical Education Influence Mode of Delivery after Stillbirth.

OBJECTIVES: To evaluate the statewide experience in mode of delivery for pregnancies complicated by stillbirth by annual delivery volume and presence of graduate medical education programs. METHODS: This is a descriptive study of all stillbirths without known congenital anomalies or aneuploidy born in our state from July 1, 2015 to June 30, 2019. Stillbirths were ascertained by the State Reproductive Health Monitoring System, a population-based surveillance system. Stillbirths were identified by the State Reproductive Health Monitoring System from medical facilities and fetal death certificates; trained staff abstracted records. All of the stillbirths with a gestational age of >20 weeks or a birth weight of >500 g if birth weight was unknown and without congenital anomalies or aneuploidy were eligible for this study. RESULTS: There were 861 stillbirths from July 2015 through June 2019, 75 (8.7%) of which were delivered by cesarean section. Low-volume hospitals (<1000 deliveries) experienced a higher proportion of their stillbirths delivered by cesarean compared with high-volume hospitals (>1000 deliveries; 13.4% vs 5.5%; P < 0.0001). Before adjusting for maternal characteristics, stillbirths delivered at high-volume hospitals had a 59% lower risk of delivery by cesarean section compared with those delivered at low-volume hospitals (relative risk [RR] 0.41, 95% confidence interval 0.20-0.86, P = 0.02). The cesarean cohort had a higher proportion of Black mothers (44% vs 31.3%, P = 0.025), greater parity (P < 0.0001), and greater gravidity (P < 0.0001) compared with the vaginal group. The gestational age at delivery for stillbirths delivered by cesarean was much higher compared with those who were delivered vaginally (34.8 weeks vs 28.6 weeks; P < 0.0001). The RR of the cesarean delivery of a stillbirth at teaching institutions compared with nonteaching institutions was significantly reduced (RR 0.45, 95% confidence interval 0.28-0.73, P = 0.0011). CONCLUSIONS: Annual hospital delivery volumes and residency teaching programs in obstetrics influence the mode of delivery in the management of stillbirth. Advancing gestational age, Black race, and parity are associated with an increased risk of cesarean delivery after stillbirth.

Prenatal diagnosis of Fetal notochord syndrome: A case report and review of the literature.

INTRODUCTION: Split notochord syndrome is a rare disorder characterized by fistula formation between the gastrointestinal tract and skin on the dorsum. Prenatal diagnosis is difficult and most cases are diagnosed postnatally. CLINICAL FINDINGS AND DIAGNOSIS: A 29-year-old woman, gravida 3 para 2, was referred for fetal cystic chest mass on prenatal ultrasound for congenital pulmonary airway malformation (CPAM). Fetal magnetic resonance imaging (MRI) suggested foregut duplication, and this was confirmed on postnatal thoracotomy with mass excision. A spine dysraphism was suspected on prenatal ultrasound, but was not confirmed on fetal MRI at the time of the study. Neonatal MRI noted vertebral abnormalities, confirming split notochord syndrome. Retrospective examination of the fetal MRI images detected a dysraphism and confirmed the prenatal ultrasound findings. OUTCOME: At 17 months of life, the child had mild symptoms of neurogenic bowel, but was meeting all milestones without neurodevelopmental delays. We present a mild form of split notochord syndrome. CONCLUSION: Split notochord syndrome is difficult to diagnose prenatally and should be considered when a fetal cystic chest mass is found on ultrasound. Detailed vertebrae assessment may improve detection.

Telemedicine in Low-Risk Obstetrics.

Telemedicine has been used to expand access to routine prenatal care for patients in rural areas and areas without enough obstetrician/gynecologists. Telemedicine can be used to reduce face-to-face visits, to increase patient autonomy and satisfaction, for behavioral modification, and to aid in smoking cessation. Patients and providers alike find telemedicine a useful adjunct to routine care.

Torsion in the Gravid and Nongravid Uterus: A Review of the Literature of an Uncommon Diagnosis.

IMPORTANCE: Uterine torsion is an uncommon but life-threatening clinical situation that requires a high index of suspicion for diagnosis. OBJECTIVE: The aim of this study was to review literature and determine the etiology, presentation, diagnosis, and management of uterine torsion in the gravid and nongravid patients. EVIDENCE ACQUISITION: A literature search was undertaken by our research librarian using the search engines PubMed and CINAHL. The search terms used were "uterine torsion" OR (uterus and torsion). The search was limited to the English language, but the years searched were unlimited. RESULTS: The search identified 177 articles, 91 of which are the basis for this review. There have been 41 cases or gravid uterine torsion, their characteristics, and symptoms published since 2006. Torsion is rare in nongravid patients, but can still occur. CONCLUSION AND RELEVANCE: Uterine torsion is rare, can affect all ages, and can have significant implications for women. Prompt recognition allows for timely intervention and can mitigate harm.

Diagnosis and Management of Placental Mesenchymal Disease. A Review of the Literature.

OBJECTIVE: To review what is currently known about placental mesenchymal dysplasia (PMD) including imaging techniques for diagnosis and differentiation from a molar pregnancy, genetics, maternal/fetal effects, and management. EVIDENCE ACQUISITION: A literature search by research librarians at 2 universities was undertaken using the search engines PubMed and Web of Science. The search terms used were "etiology" OR "cause" OR "risk" OR "risks" OR "epidemiology" OR "diagnosis" OR "therapy" OR "prognosis" OR "management" AND "placental mesenchymal dysplasia" OR "placenta" AND "mesenchymal dysplasia." No limit was put on the number of years searched. RESULTS: The etiology of PMD remains uncertain, although there are a number of theories on causation. An elevated maternal serum α-fetoprotein level, slightly elevated human chorionic gonadotropin level, normal karyotype, multicystic lesions on ultrasound, and varying degrees of flow within cysts using color Doppler (stained-glass appearance) are helpful in making the diagnosis. On pathologic examination of the placenta, PMD is differentiated from molar pregnancy by the absence of trophoblastic hyperplasia. Fetal complications of PMD include hematologic disorders, Beckwith-Wiedemann syndrome, liver tumors, fetal growth restriction, preterm delivery, and intrauterine fetal demise. Maternal complications include gestational hypertension, preeclampsia, HELLP (hemolysis, elevated liver function tests, low platelets) syndrome, and eclampsia. CONCLUSIONS: Accurate diagnosis of PMD is imperative for appropriate management and surveillance to minimize adverse maternal and fetal outcomes. RELEVANCE: The importance of a correct diagnosis of PMD is important because it can be misdiagnosed as a partial molar pregnancy or a complete mole with coexisting normal fetus, and this can result in inappropriate management.

Implementation of Low-Cost Obstetric Hemorrhage Simulation Training Models for Resident Education.

INTRODUCTION: Simulation is beneficial training for low frequency high acuity events such as management of obstetric hemorrhage. Our objective was to evaluate perceived competency in management of obstetric and pelvic hemorrhage following training with low fidelity task trainers using inexpensive and common medical supplies. MATERIALS AND METHODS: This was a prospective observational study of training residents for management of obstetric and pelvic hemorrhage using a brief didactic instruction and low-cost task trainers with inexpensive common medical supplies. Participants practiced placement of a uterine tamponade balloon, uterine packing with gauze, pelvic parachute packing and temporary abdominal closure. Following training, participants completed a self-report survey regarding perceived competency with each technique. The Wilcoxon Signed-Rank Test was used to compare results before and after training. RESULTS: Eighteen of 23 residents completed the training and completed the survey on perceived competencies. There was a statistically significant improvement in perceived competency for all participants before and after training, with scores improving by 1.5 points for Bakri placement, from 1.94 to 3.44 (p < 0.001), improving by 1.67 points for uterine packing, from 1.78 to 3.44 (p < 0.001), improving by 1.95 for pelvic parachute packing, from 1.16 to 3.11 (p < 0.001), and improving by 1.89 for temporary abdominal closure, from 1.22 to 3.11 (p < 0.001). CONCLUSIONS: Low-cost supplies and task trainers can be utilized to simulate postpartum hemorrhage and improve perceived competency in managing obstetric and pelvic hemorrhage. Similar training programs can be used in small community programs with limited resources.

Late Abdominal Pregnancies (≥20 Weeks Gestation): A Review from 1965 to 2012.

BACKGROUND: Information about the diagnosis and management of late abdominal pregnancies (≥20 weeks gestation) is limited to case reports and small case series. METHODS: We performed a literature review of abdominal pregnancies ≥20 weeks gestation from 1965 to November 2012. Excluded were abdominal ectopic pregnancies that did not primarily implant in the peritoneal cavity, including tubal, ovarian, and intraligamentary pregnancies, and those prior to 20 weeks gestation. RESULTS: The 31 cases identified were at 30.4 ± 7.4 weeks at diagnosis and 33 ± 8.3 weeks at delivery. The most common sites of placental implantation were uterus or adnexa (47.8%), bowel (30%), and the potential spaces surrounding the uterus (8.7%). There were 5 cases of an intra-abdominal abscess in the 14 patients in whom the placenta had been left in situ. Maternal outcomes were documented in 26 cases with 7 deaths; 27 fetal outcomes were documented in 22 cases with 3 fetal deaths (13.6%). CONCLUSION: An abdominal ectopic pregnancy is an uncommon but serious event and should be considered in all patients until intrauterine gestation is confirmed. Management should be undertaken by an experienced surgical team in a tertiary care facility.

Postpartum use of long-acting reversible contraception in a military treatment facility.

OBJECTIVE: To determine the rate at which long-acting reversible contraception (LARC) is desired immediately postpartum and utilized within 12 weeks of delivery at our institution. METHODS: This prospective cohort study analyzed 400 consecutive postpartum patients between January 2009 and March 2009. We followed contraceptive desire prior to discharge and actual contraception utilized within 12 weeks postpartum. Patient demographics and LARC utilization was analyzed to determine characteristics predictive of use. RESULTS: There was complete follow-up information on 329 (82.3%) of the studied women. Thirty-three percent (132/400) desired LARC immediately postpartum, and overall LARC utilization at 12 weeks was 31% (100/329). Demographic characteristics predictive of LARC desire and utilization included age <25 years (adjusted RR=1.53, 95% CI 1.17-1.92) and African-American ethnicity (adjusted RR=1.39, 95% CI 1.03-1.78). CONCLUSION: In our institution, LARC is highly desired and utilized within 12 weeks postpartum with African-American ethnicity and age <25 years predictive of use.

Postpartum insertion of levonorgestrel--intrauterine system at three time periods: a prospective randomized pilot study.

BACKGROUND: The study was conducted to determine the feasibility of levonorgestrel-intrauterine system (LNG-IUS) insertion at three different times postpartum. STUDY DESIGN: From August 2009 to January 2010, all women desiring LNG-IUS for postpartum contraception were offered enrollment into our study and randomized to three insertion times: immediate (within 10 min of placenta delivery), early (10 min to 48 h postpartum) or interval (≥6 weeks postpartum). RESULTS: Forty-six women met inclusion criteria and were analyzed. There was no difference in utilization rates at 3 and 6 months between groups (p=.931). Expulsion rates were significantly higher and pain during insertion was significantly lower in the immediate and early groups (p<.001) when compared to the interval group. CONCLUSION: Insertion of LNG-IUS ≤48 h postpartum is feasible in our institution and may be associated with similar utilization at 6 months, increased expulsion rates and decreased pain at insertion when compared to placement after 6 weeks.