Outcomes following Placement and Removal of Transvaginal Cerclage in at Risk Pregnancies: A Single Center Experience.

Objective: The objective of this study was to estimate the time between removal of cerclage and delivery, stratified by indication for cerclage placement (elective or non-elective). Additionally, delivery within 72 hours after cerclage removal was compared between elective and non-elective cerclage placement, as well as between ultrasound-indicated and physical examination-indicated cerclage placement. Design: A single-center retrospective cohort study. Participants/Materials, Setting, and Methods. Clinical information of 72 pregnant women who underwent transvaginal cerclage over a 4-year period was obtained. Comparisons were made between elective (history-indicated) and non-elective (ultrasound or physical examination-indicated) cerclage placement. Comparisons were also made between physical examination-indicated and ultrasound-indicated cerclage. Results: Compared to those who had a non-elective cerclage, women undergoing elective cerclage were more likely to have history of cervical treatment (44% vs. 15%, p = 0.02), and spontaneous preterm delivery (92% vs. 61%, p = 0.003). There was no difference in the rate of delivery ≤72 hours following cerclage removal between women who had elective cerclage and those who had non-elective cerclage (46% vs. 58%, p = 0.47). Women who had an elective cerclage were more likely to have elective cerclage removal ≥36 weeks (71.8% vs. 39.4%, p = 0.01), compared to those who had undergone non-elective cerclage. The rate of delivery ≤72 hours following removal of cerclage was greater in women who had a physical examination-indicated cerclage compared to women who had ultrasound-indicated cerclage (80% vs. 39%, p = 0.04). Among women who had an elective cerclage, there was no difference in the rate of delivery at ≤72 hours between those who had elective cerclage removal at 36 weeks compared to those electively removed at 37 weeks (31% vs. 58%, p = 0.30). No complications such as fetal demise, iatrogenic amniotic membrane rupture, hemorrhage, or cervical laceration were reported within this cohort. Conclusion: Cerclage indication should be considered prior to scheduling elective cerclage removal. Women who had an elective cerclage are most likely to get it electively removed at 36 weeks compared to their counterparts who had a non-elective cerclage. Furthermore, women who had a physical examination-indicated cerclage are most likely to deliver within 72 hours of cerclage removal.

Spontaneous septostomy in a monochorionic-diamniotic twin gestation.

Monochorionic twin gestations are associated with a greater incidence of neonatal morbidity and mortality when compared with their dichorionic counterparts. In turn, monochorionic-monoamniotic (MCMA) gestations carry greater risks compared with monochorionic-diamniotic (MCDA) gestations. While the true incidence of spontaneous septostomy of the dividing membranes (SSDM) in MCDA twins is unknown, SSDM has been demonstrated to be associated with increased morbidity and mortality, due to functional transition from a MCDA gestation to a MCMA gestation. We report a case of SSDM in a mid-trimester MCDA gestation, review the literature, and describe how to identify and manage this complication.

Adolescence and risk of preterm birth in multifetal gestations.

OBJECTIVE: The objective of this study is to evaluate if adolescence confers additional risk for preterm delivery in multifetal gestations. METHODS: This is a retrospective review of all twin and triplet deliveries from 8/2008 to 12/2012 at two Detroit Hospitals. Outcomes in adolescent mothers aged 19 or younger (n = 59) were compared with adult controls aged 20-34 (n = 350). RESULTS: Mean gestational age at delivery in adolescents was 31.3 (SD: 5.8) weeks versus 34.2 (SD: 4.3) weeks in adults (p < .001). On multivariable analysis, adolescence was associated with preterm delivery (adjusted odds ratio [aOR], 2.3; 95% confidence intervals [95% CI], 1.1-4.7, p = .02) and early-preterm delivery (aOR, 2.2; 95% CI 1.2-4; p = .01). Adjusted rates of preterm and early-preterm delivery were markedly higher in adolescents compared with controls. Being an adolescent was also a significant risk factor for iatrogenic preterm delivery (aOR, 2.4; 95% CI 1.1-5.5; p = .04). CONCLUSIONS: Adolescents pregnant with twins or triplets deliver 3 weeks, on average, before adults and are at markedly increased risk of preterm and early-preterm delivery.

Outcomes in subsequent pregnancies after wedge resection for interstitial ectopic pregnancy: a retrospective cohort study.

OBJECTIVE: The objective of this study is to evaluate pregnancy outcomes in patients with a history of wedge resection for interstitial ectopic pregnancy (WRIEP). METHODS: Retrospective cohort study of pregnancies with a history of WRIEP from 2000 to 2013 at two inner city hospitals in Detroit, MI. Pregnant-matched controls (1:3) were selected and included patients with history of surgically treated tubal ectopic pregnancy and delivered patients without history of ectopic pregnancy. Pregnancy outcomes, including a composite, were compared among the groups. RESULTS: Eighty-three cases of interstitial pregnancy were identified. Sixty-three (75.9%) underwent WRIEP from which 19 (30.2%) had a subsequent pregnancy and 11 (57.9%) carried it ≥20 weeks. No difference in subsequent pregnancy outcomes including the composite was found among patients with prior WRIEP and patients with history of surgically treated tubal ectopic pregnancy except for a longer interpregnancy interval. Compared with delivered patients without a history of ectopic pregnancy, no difference in late obstetric outcomes was found including the composite, gestational age at delivery in weeks (38.2 versus 38.1, p = .955), preterm delivery rate (30% versus 21%, p = .674), and proportion of term vaginal (40% versus 52%, p = .721) or cesarean deliveries (60% versus 30%, p = .137). The most common indication for cesarean among patients with a history of WRIEP was a history of such (5/6, 83.3%) and there were no cases of abnormal placentation. CONCLUSION: Findings suggest that a history of WRIEP is not associated with increased risk of adverse pregnancy outcomes.

Genomic detection of a familial 382 Kb 6q27 deletion in a fetus with isolated severe ventriculomegaly and her affected mother.

Terminal deletions of the chromosome 6q27 region are rare genomic abnormalities, linked to specific brain malformations and other neurological phenotypes. Reported cases have variable sized genomic deletions that harbor several genes including the DLL1 and TBP. We report on an inherited 0.38 Mb terminal deletion of chromosome 6q27 in a 22-week fetus with isolated bilateral ventriculomegaly and her affected mother using microarray-based comparative genomic hybridization and fluorescent in situ hybridization (FISH). The deleted region harbors at least seven genes including DLL1 and TBP. The affected mother had a history of hydrocephalus, developmental delay, and seizures commonly associated with DLL1 and TBP 6q27 deletions. This deletion is one of the smallest reported isolated 6q27 terminal deletions. Our data provides additional evidence that haploinsufficiency of the DLL1 and TBP genes may be sufficient to cause the ventriculomegaly, seizures, and developmental delays associated with terminal 6q27 deletions, indicating a plausible role in the abnormal development of the central nervous system.

Risk-profiles and outcomes of multi-foetal pregnancies in adolescent mothers.

In this retrospective review of 468 mothers with a multi-foetal pregnancy in Detroit, we describe the risk-profiles and the obstetrical, maternal and foetal outcomes of multi-foetal pregnancy in 59 (13%) adolescents. Overall, most mothers were African American, did not have private insurance and all were unmarried. For most mothers, this was their first pregnancy (59.3%) and their first delivery (69.5%). Almost 50% presented to triage at least once during their pregnancy. Anaemia (78%) and hypertensive disorders (18.6%) were common in this age group. The majority of adolescents delivered preterm as 81.4% were <37 weeks and 49% were <34 weeks. Furthermore, the majority of infants (79%) had low birth weights (median: 1975 g, range: 365-3405 g). This contemporary report emphasises the need for multidisciplinary prenatal management and specialist supervision, as multi-foetal pregnancies in adolescents pose real risks and impact obstetrical, maternal and neonatal outcomes.

Secondary Postpartum Hemorrhage due to Spontaneous Uterine Artery Rupture after Normal Vaginal Delivery Managed by Selective Arterial Embolization.

Secondary postpartum hemorrhage due to an intraperitoneal bleed following a vaginal delivery is extremely rare. We present a case of spontaneous rupture of the uterine artery following a normal vaginal delivery with a delayed presentation, which resulted in significant morbidity. This case discusses the presentation and management of this rare obstetrical emergency. The report also discusses the role of selective arterial embolization in management of secondary postpartum hemorrhage.

Outcomes following intra-amniotic instillation with indigo carmine to diagnose prelabor rupture of membranes in singleton pregnancies: a single center experience.

OBJECTIVE: To evaluate clinical outcomes of women with singleton pregnancies that underwent intra-amniotic dye instillation (amniodye test) following equivocal diagnosis of prelabor rupture of membranes (PROM). METHOD: Records of 34 pregnant women who underwent amniodye test for equivocal PROM were reviewed. Comparisons of characteristics, amniotic fluid (AF) cultures, AF interleukin (IL)-6 concentrations, and placenta pathology results between women who tested positive and those who tested negative were performed. A sub-analysis of women who were amniodye test-negative was also performed. RESULTS: (1) Commonest indication for amniodye test was a typical history of PROM with positive conventional tests and persistently normal AF volume, (2) amniodye test-positive women had a shorter procedure-to-delivery interval (p = 0.008), and a greater proportion of histologic acute chorioamnionitis (p = 0.04) and funisitis (p = 0.01) than amniodye-negative women, and (3) in addition to similarities to women with amniodye-positive test, amniodye test-negative women who delivered <34 weeks, had a greater proportion of women with risk for preterm birth (p = 0.04), than their counterparts who delivered between 34 0/7 and 36 6/7 weeks. CONCLUSION: Equivocal diagnosis of PPROM should warrant an amniodye test to avoid iatrogenic intervention in women with intact amniotic membranes. AF analysis should be performed in amniodye test-negative women.

Fetal cardiac axis in non-anomalous pregnancies: does fetal gender or maternal body mass index (BMI) matter?

OBJECTIVES: To determine if cardiac axis obtained at an early ultrasound study (11-15 weeks) differs from that obtained at a late ultrasound study (18-22 weeks) in the same fetus and to evaluate the impact of fetal gender and/or maternal body mass index (BMI). METHODS: Cardiac axes of 324 non-anomalous fetuses at 11-15 weeks gestation were measured, with follow-up measurements obtained at 18-22 weeks. Comparisons were performed based on gestational age period, fetal gender and obese/non-obese maternal status. RESULTS: (1) Mean fetal cardiac axis did not change between 11 and 15 weeks; p = 0.8, (2) mean fetal cardiac axis was more levorotated at 11-15 weeks than measurements obtained at 18-22 weeks; 48.1 ± 7.1° versus 43.7 ± 8.9°; p < 0.0001, (3) male fetuses had less levorotated cardiac axis than female fetuses in late ultrasound studies but there was no difference between them at early ultrasound studies; 18-22 weeks male fetus, 42.7 ± 9.3° versus female fetus, 45.2 ± 8.3°; p = 0.02 and 11-15 weeks male fetus, 48.1 ± 7.0° versus female fetus, 48.4 ± 7.4°, p = 0.7, respectively, and (4) similar trends with the overall study population were observed in the comparison between fetuses of obese and non-obese women. CONCLUSION: Fetal cardiac axis remains stable at 11-15 weeks, becoming less levorotated at 18-22 weeks. This may be attributed to increments in fetal lung volume. The differences in cardiac axis measurements between male and female fetuses examined at 18-22 weeks may also be attributable to differences in increment of fetal lung volume during this gestational age period.

Optimal visualization of the fetal four-chamber and outflow tract views with transabdominal ultrasound in the morbidly obese: Are we there yet?

BACKGROUND: To compare optimal visualization of the four-chamber and outflow-tract views of the fetal heart on sonographic examination between morbidly obese (body mass index [BMI] ≥ 40 kg/m(2) ) and nonobese (BMI < 25 kg/m(2) ) pregnant women. METHODS: In this retrospective cohort study, we included records and images from 509 pregnant women who had first undergone sonographic examination between 18 and 36 weeks' fetal gestational age. RESULTS: Compared with the nonobese women, morbidly obese women had lower optimal visualization of the four-chamber and outflow-tract heart views: four-chamber view, morbidly obese, 83/186 (44.6%), versus nonobese, 283/323 (87.6%), and outflow-tract view, morbidly obese, 80/186 (43%) versus nonobese, 258/290 (89%); p < 0.0001 for each comparison. Similar outcomes were observed when the results from each subcategory of morbidly obese women (ie, BMI 40-49.9, 50-59.9, and ≥60 kg/m(2) ) were compared with that from nonobese women; p < 0.0001 for each comparison. These outcomes remained the same regardless of whether this comparison was made among those who had their examination before or at 19 weeks' or more gestational age. Among the morbidly obese women, there was no difference in optimal visualization of the four-chamber or outflow-tract views regardless of whether the examination was performed at <23 weeks' or at ≥23 weeks' gestational age: four-chamber view <23 weeks, 44.8% (78/174), versus four-chamber view ≥23 weeks, 41.7% (5/12); p = 0.8, and outflow-tract view <23 weeks, 43.1% (75/174), versus outflow-tract view ≥23 weeks, 41.7% (5/12); p = 0.9. After controlling for maternal age and race, the odds of visualizing the four-chamber and outflow-tract views in the morbidly obese were reduced compared with those in their nonobese counterparts: odds ratio (OR) for four-chamber, 0.13; 95% confidence interval (CI), 0.08-0.21, and OR for outflow-tract, 0.11; 95% CI, 0.07-0.17. CONCLUSIONS: Optimal visualization of the fetal four-chamber and outflow-tract views was achieved in less than 50% of morbidly obese women, compared with almost 90% in nonobese women.

Asymptomatic "placental prolapse" with cervical funneling in a patient with complete placenta previa.

We describe the transvaginal sonographic findings in a patient with complete placenta previa and increased risk of preterm birth owing to a prior history of mid-trimester pregnancy loss in whom we observed a short cervix and prolapse of the placenta and fetal membranes into the endocervical canal. We believe that this could lead to antepartum hemorrhage and mandate close observation when diagnosed. We introduced the term "placental prolapse" to describe our finding.

The clinical relevance of fetal MRI in the diagnosis of Type IV cystic sacrococcygeal teratoma--a review.

The introduction of fetal magnetic resonance imaging (MRI) has improved the prenatal evaluation of uterine, placental and fetal anatomy. However, its utilization has mostly been restricted to fetal central nervous system anomalies. We review how adjunct fetal MRI was performed and diagnosis of cystic type IV sacrococcygeal teratoma was made. We also discuss the clinical relevance of fetal MRI in differentiating this lesion from other selected abdominal/pelvic cystic malformations and lesions.

Passage of decidual cast following poor compliance with oral contraceptive pill.

BACKGROUND: Decidual cast describes the spontaneous sloughing of endometrium as an entire piece while retaining the shape of the endometrial cavity. It may be associated with increased serum progesterone levels and must be considered as a differential diagnosis in a patient who passes tissue per vagina while on progesterone containing hormonal contraception. CASE: A 13-year-old adolescent with a history of menorrhagia since menarche, presented to the pediatric emergency room with worsening abdominal pain and heavy vaginal bleeding stopping her oral contraceptive pill 10 days prior to presentation. Her symptoms resolved spontaneously following passage of tissue per vagina which was later by histopathology to be a decidual cast. CONCLUSION: Decidual cast is a rare pathological entity that may be a side effect of progesterone-containing hormonal contraceptives, requiring patient education before use.

Endocan, a putative endothelial cell marker, is elevated in preeclampsia, decreased in acute pyelonephritis, and unchanged in other obstetrical syndromes.

OBJECTIVE: Endocan, a dermatan sulphate proteoglycan produced by endothelial cells, is considered a biomarker for endothelial cell activation/dysfunction. Preeclampsia is characterized by systemic vascular inflammation, and endothelial cell activation/dysfunction. Therefore, the objectives of this study were to determine whether: (1) plasma endocan concentrations in preeclampsia differ from those in uncomplicated pregnancies; (2) changes in plasma endocan concentration relate to the severity of preeclampsia, and whether these changes are specific or observed in other obstetrical syndromes such as small-for-gestational age (SGA), fetal death (FD), preterm labor (PTL) or preterm prelabor rupture of membranes (PROM); (3) a correlation exists between plasma concentration of endocan and angiogenic (placental growth factor or PlGF)/anti-angiogenic factors (soluble vascular endothelial growth factor receptor or sVEGFR-1, and soluble endoglin or sEng) among pregnancies complicated by preeclampsia; and (4) plasma endocan concentrations in patients with preeclampsia and acute pyelonephritis (both conditions in which there is endothelial cell activation) differ. METHOD: This cross-sectional study included the following groups: (1) uncomplicated pregnancy (n = 130); (2) preeclampsia (n = 102); (3) pregnant women without preeclampsia who delivered an SGA neonate (n = 51); (4) FD (n = 49); (5) acute pyelonephritis (AP; n = 35); (6) spontaneous PTL (n = 75); and (7) preterm PROM (n = 64). Plasma endocan concentrations were determined in all groups, and PIGF, sEng and VEGFR-1 plasma concentrations were measured by ELISA in the preeclampsia group. RESULTS: (1) Women with preeclampsia had a significantly higher median plasma endocan concentration than those with uncomplicated pregnancies (p = 0.004); (2) among women with preeclampsia, the median plasma endocan concentration did not differ significantly according to disease severity (p = 0.1), abnormal uterine artery Doppler velocimetry (p = 0.7) or whether diagnosis was made before or after 34 weeks gestational age (p = 0.3); (3) plasma endocan concentration in women with preeclampsia correlated positively with plasma anti-angiogenic factor concentrations [sVEGFR-1: Spearman rho 0.34, p = 0.001 and sEng: Spearman rho 0.30, p = 0.003]; (4) pregnancies complicated by acute pyelonephritis with bacteremia had a lower median plasma endocan concentration than pregnancies complicated by acute pyelonephritis without bacteremia (p = 0.004), as well as uncomplicated pregnancies (p = 0.001); and (5) there was no significant difference in the median plasma endocan concentration between uncomplicated pregnancies and those complicated by FD, delivery of an SGA neonate, PTL or preterm PROM (other members of the "great obstetrical syndromes"; each p > 0.05). CONCLUSION: Median maternal plasma endocan concentrations were higher preeclampsia and lower in acute pyelonephritis with bacteremia than in uncomplicated pregnancy. No significant difference was observed in the median plasma endocan concentration between other great obstetrical syndromes and uncomplicated pregnancies. The difference in the direction of change of endocan in preeclampsia and acute pyelonephritis with bacteremia may be consistent with the view that both disease entities differ in pathogenic mechanisms, despite their associations with systemic vascular inflammation and endothelial cell activation/dysfunction.

von Hippel-Lindau disease and pregnancy: what an obstetrician should know.

BACKGROUND: von Hippel-Lindau disease is an autosomal dominant genetic disorder that presents with a variable constellation of symptoms and signs due to formation of hemangioblastomas and cysts. We address the management of pregnancies associated with this disorder from an obstetric perspective. CASE: A 26-year-old known to have type 2A von Hippel-Lindau disease with a significant surgical history secondary to disease manifestations was managed from early pregnancy to delivery. A literature review to determine the best evidence-based care from an obstetric perspective, addressing patient management preconceptionally, in the antepartum period (including antepartum surgical care), during labor and delivery (including type of analgesia/anesthesia,mode of delivery), and the postpartum period, as well as contraception, was performed. CONCLUSIONS: A pregnant woman with von Hippel-Lindau disease should be managed in conjunction with a multidisciplinary team. Routine clinical and radiological imaging should be continued within safe parameters of pregnancy. Mode of delivery, analgesia/anesthesia, and postpartum care (including birth control) should be determined based on each patient's disease phenotype and individual risk-to-benefit ratio on a case-by-case basis.