Transient Idiopathic Polyhydramnios: Maternal and Perinatal Outcomes: Maternal and Perinatal Outcomes.

OBJECTIVES: To compare maternal and perinatal outcomes in pregnancies with transient and persistent idiopathic polyhydramnios to those with normal amniotic fluid volume. METHODS: This retrospective cohort study included subjects delivering a singleton pregnancy between January 1, 2015, and June 30, 2020, with sonography ≥26 weeks' gestation demonstrating transient or persistent idiopathic polyhydramnios (amniotic fluid index [AFI] ≥24.0 cm) or normal AFI (referent group). The primary maternal outcome was a composite of spontaneous preterm delivery <37 weeks, cesarean delivery for malpresentation, abnormal labor progress, or nonreassuring fetal status, operative vaginal delivery, hemorrhage requiring transfusion, and umbilical cord prolapse. The primary perinatal outcome was a composite of birthweight >4500 g, fetal or neonatal death, 5-minute Apgar score <7, and neonatal intensive care unit admission for >24 hours. RESULTS: Patients with transient polyhydramnios (n = 259) exhibited maternal outcomes similar to those of the referent group (n = 435) but had significantly increased odds for the primary perinatal outcome (odds ratio [OR] 1.70, 95% confidence interval [CI] 1.15-2.53; P = .008) and for birthweight ≥4500 g (OR 8.70, 95% CI 1.89-40.0; P = .005). Persistent polyhydramnios (n = 176) was significantly associated with both the primary maternal (OR 1.93, 95% CI 1.27-2.95, P = .002) and primary perinatal outcome (OR 2.15, 95% CI 1.40-3.30; P < .001), and individually with cesarean delivery for abnormal labor (OR 3.22, 95% CI 1.55-6.68; P = .002) and birthweight ≥4500 g (OR 8.97, 95% CI 1.84-43.6; P = .007). CONCLUSIONS: Transient idiopathic polyhydramnios does not impact maternal outcomes but is associated with increased odds of newborn birthweight >4500 g. Persistent polyhydramnios is associated with both adverse maternal and perinatal outcomes.

Second-Trimester Ultrasound-Measured Umbilical Cord Insertion-to-Placental Edge Distance: Determining an Outcome-Based Threshold for Identifying Marginal Cord Insertions.

OBJECTIVES: We sought to study potential diagnostic criteria for marginal placental cord insertions as determined by associations with obstetric outcomes. METHODS: This single-center retrospective cohort investigation included singleton gestations delivering from January 1, 2012, to December 31, 2016, and having a standard or detailed fetal ultrasound examination from 18 weeks to 21 weeks 6 days. Cord insertion-to-placental edge distances were used to create a referent comparison group and 3 patient groups: greater than 3.0 cm (comparison); greater than 2.0 to 3.0 cm (group 1); greater than 1.0 to 2.0 cm (group 2); and 1.0 cm or less (group 3). The primary outcome consisted of any one of spontaneous delivery before 37 weeks, fetal growth restriction, oligohydramnios, placental abruption, or intrauterine fetal demise. RESULTS: The numbers of participants and mean distances ± SDs for the comparison group and groups 1 to 3, respectively, were 628 and 4.68 ± 1.17 cm, 106 and 2.52 ± 0.26 cm, 131 and 1.60 ± 0.29 cm, and 77 and 0.36 ± 0.37 cm, respectively. The primary outcome was significantly associated only with cord insertion-to-placental edge distances of 1.0 cm or less (adjusted odds ratio, 3.05; 95% confidence interval, 1.73-5.38). CONCLUSIONS: Marginal cord insertions may be diagnosed when the cord insertion-to-placental edge distance is 1.0 cm or less.

U.S. acute care hospital shootings, 2012-2016: A content analysis study.

BACKGROUND: Healthcare workers experience a disproportionately high frequency of workplace assaults. Incidents involving firearms are of particular concern. OBJECTIVE: To provide detailed characterizations of recent hospital shootings to better inform prevention and mitigation strategies. METHODS: Quantitative content analysis of reports involving hospital shootings resulting in casualties derived from web searches for each year from 2012-2016. Data were abstracted independently by two investigators, with differences resolved by consensus. Data were compared between subgroups by chi-square test, Fisher's exact test, or Kruskal-Wallis test, as appropriate. RESULTS: Eighty-eight shootings occurred in 86 hospitals resulting in 121 firearms-related casualties, including 54 victims and 67 perpetrators. Case fatality rates were 55.6% (n = 30) and 70.1% (n = 47), respectively. The most frequent sites involved were the emergency department, (n = 27, 30.3%), patient room (n = 19, 21.3%), and parking lot (n = 13, 14.6%). Grudge (n = 17, 19.3%), suicide (n = 14, 15.9%), and mental instability (n = 13, 14.8%) were the most common explanations for these shootings. Four inadvertent discharges occurred and were more likely to involve a female perpetrator (p = 0.03). Shootings were most frequent during summer (p = 0.03) and winter (p = 0.04). CONCLUSIONS: Out study findings on location and seasonal patterns can guide the development or improvement of prevention and mitigations strategies for hospital shootings.

Cervical varices: An unusual source of first-trimester hemorrhage.

Endocervical varices are a rare cause of obstetrical hemorrhage. Usually presenting in the second and third trimesters, bleeding varices often require pregnancy termination or indicated preterm birth via cesarean delivery. Our patient experienced variceal hemorrhage at 12 weeks' gestation in a dichorionic twin pregnancy conceived through in vitro fertilization. A low-lying placenta resolved at 19 weeks followed by variceal regression at 22 weeks' gestation. Endocervical varices causing first-trimester hemorrhage may regress with resolution of a coexisting low placental implantation, permitting planned vaginal delivery, despite progressive hemodynamic changes of pregnancy. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:218-221, 2018.

Clinical pitfalls in misoprostol-based medical management of first-trimester induced and presumed spontaneous abortion.

When administered inappropriately, first-trimester misoprostol management of induced or spontaneous abortion can result in loss or damage of a continuing pregnancy. Despite these serious consequences, such misoprostol exposures continue to occur. Unfortunately, contributing factors and preventive measures receive little attention. We describe the cases of 4 women in whom misoprostol was inappropriately administered during management of induced and presumed spontaneous abortion. In each case, careful adherence to published clinical guidance could have avoided the exposures.

Cervical Evaluation in Pregnancy: Proper Measurement, Evaluation, and Management.

Preterm birth is the leading cause of perinatal morbidity and mortality in developed nations. The heterogeneous causes of spontaneous preterm birth make prediction and prevention difficult. The primary importance of transvaginal cervical sonography and cervicovaginal fetal fibronectin lies in their high negative predictive values in assessing risk for preterm birth. Cervical length may be useful in identifying women who are candidates for cervical cerclage or progesterone therapy for preterm birth prevention. Together, cervical length and fibronectin can be used in the triaging of women symptomatic for preterm labor.

First-trimester chorionic bump--Association with fetal aneuploidy in a high-risk population.

PURPOSE: To determine the relationship between the first-trimester chorionic bump and fetal aneuploidy. METHODS: This retrospective cohort study included all singleton pregnancies with chromosomal analysis and sonographic examination performed between 5 0/7 and 13 6/7 weeks from January 1, 2010 through August 15, 2015. Interobserver and intraobserver agreement for identifying a chorionic bump was evaluated by the Kappa statistic. Pregnancies with and without a chorionic bump were compared regarding patient characteristics and fetal karyotypes. RESULTS: Six hundred ninety subjects were included, 16 (2.3%) having a bump. The kappa coefficients for interobserver agreement were 0.88 (95% confidence interval [CI]: 0.71-1.00) and 0.94 (95% CI: 0.82-1.00); those for intraobserver agreement were 0.81 (95% CI: 0.61-1.00) and perfect agreement. One hundred seventeen fetuses (16.9%) were aneuploid, of which five (4.3%) had a bump. The odds of aneuploidy in the presence of a chorionic bump were higher than those in the absence of a chorionic bump, although this difference was not statistically significant (odds ratio [OR] 2.3, 95% CI: 0.8-6.7). In subgroup analyses, odds of aneuploidy were four times higher in the bump group than in the no bump group among those with a sonographically isolated bump (OR 4.5, 95% CI: 1.5-13.5) and 15 times higher among those with an isolated bump and increased first-trimester aneuploidy risk (OR 15.0, 95% CI 2.4-93.3). CONCLUSIONS: Agreement in identifying chorionic bumps is near-perfect. A sonographically nonisolated chorionic bump is not associated with significant additional aneuploidy risk, whereas a sonographically isolated chorionic bump confers a significantly increased likelihood of aneuploidy in high-risk fetuses. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:3-7, 2017.

Workplace Violence in Health Care-It's Not "Part of the Job".

IMPORTANCE: While health care workers comprise just 13% of the US workforce, they experience 60% of all workplace assaults. This violence is the second leading cause of fatal occupational injury. Women comprise 45% of the US labor force but 80% of health care workers, the highest proportion of females in any industry. OBJECTIVE: The purpose was to describe the prevalence, forms, and consequences of health care workplace violence (WPV). The role and components of prevention programs for avoiding or mitigating violence are discussed, including opportunities for participation by obstetrician-gynecologists. EVIDENCE ACQUISITION: A search of PubMed from 1990 to February 1, 2016, identified relevant manuscripts. Additional studies were found by reviewing the manuscripts' references. Government Web sites were visited for relevant data, publications, and resources. RESULTS: Health care WPV continues to rise despite an overall decrease in US WPV. While workers are most likely to be assaulted by clients or patients, they are most frequently bullied and threatened by coworkers. All incidents are markedly underreported in the absence of physical injury or lost work time. Sequelae include physical and psychological trauma, adverse patient outcomes, and perceived lower quality of care. CONCLUSIONS: The human, societal, and economic costs of health care WPV are enormous and unacceptable. Comprehensive prevention, planning, and intervention offer the best means of mitigating risks. As women's health physicians and health care workers, obstetrician-gynecologists should be encouraged to participate in such efforts.

The chorionic bump: Etiologic insights from two pathologic pregnancies.

The clinical significance and etiology of the chorionic bump remain unclear. We describe two pregnancies characterized by chorionic bumps, which subsequently were diagnosed with a complete mole and trisomy 18, respectively. We hypothesize that placental pathology, including edema and hydropic villi, may contribute to or cause the sonographic finding of some chorionic bumps. An association between chorionic bumps and aneuploidy awaits future study. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:452-454, 2016.

Biophysical and Biochemical Screening for the Risk of Preterm Labor: An Update.

The heterogeneous causes of spontaneous preterm birth make prediction and prevention difficult. Recently developed biochemical and biophysical tests add significantly to clinicians' ability to evaluate and treat women at risk for spontaneous preterm birth. The primary importance of transvaginal cervical sonography and cervicovaginal fetal fibronectin lies in the high negative predictive values of the tests for preterm delivery risk. Cervical length may be useful in identifying women who are candidates for cervical cerclage or progesterone therapy for preterm birth prevention. Together, cervical length and fibronectin can be used in the triaging of women symptomatic for preterm labor.

Noninvasive prenatal testing: impact on genetic counseling, invasive prenatal diagnosis, and trisomy 21 detection.

PURPOSE: The aim of this study was to compare rates of genetic counseling, invasive prenatal diagnosis, and trisomy 21 detection among women at increased risk for aneuploidy, before versus after the availability of noninvasive prenatal testing (NIPT). METHODS: This institutional review board-exempt retrospective study included all women who had an ultrasound (US) examination between 10 0/7 and 21 6/7 weeks' gestation and were eligible for NIPT (ie, age ≥35 years, US findings suggestive of increased aneuploidy risk, positive aneuploidy screen, prior trisomic fetus, parental balanced translocation with increased risk for trisomy 13 or 21) between June 1, 2012 and February 1, 2013. NIPT was performed by a single laboratory after patients received genetic counseling. We also identified a comparison group of women evaluated between December 1, 2010 and November 30, 2011, who would have been eligible for NIPT had it been available. The two groups were compared for maternal demographics, aneuploidy risk factors, rates of genetic counseling, invasive diagnostic procedures, and trisomy 21 detection. RESULTS: The before-NIPT and after-NIPT groups contained 1,464 and 1,046 subjects, respectively. All 33 fetuses with trisomy 21 in the two groups were identified by positive aneuploidy screening. After the introduction of NIPT, genetic counseling for aneuploidy risk increased (adjusted odds ratio [aOR], 1.77 [1.49-2.11]; p < 0.0001) and the overall invasive diagnosis (aOR, 0.42 [0.32-0.55]; p < 0.0001), including amniocentesis (aOR, 0.37 [0.27-0.52], p < 0.0001), decreased, whereas the prenatal diagnosis of trisomy 21 remained similar (88% versus 100%; p = 0.86). CONCLUSIONS: NIPT in clinical practice uses more genetic counseling resources but requires significantly fewer invasive procedures to maintain the detection rates of trisomy 21.

Prenatal sonographic diagnosis of placenta accreta--impact on maternal and neonatal outcomes.

PURPOSE: To compare maternal and neonatal outcomes of prenatally diagnosed versus undiagnosed cases of placenta accreta. METHODS: This retrospective study included all pathology-proven placentas accreta/increta/percreta from a single tertiary center from January 1, 2005 to December 31, 2012. Outcomes were compared between prenatally diagnosed and undiagnosed cases. RESULTS: Thirty-six cases of abnormal implantations were identified, of which 19 (53%) were prenatally diagnosed by ultrasound. Prenatal detection was more likely with a percreta (7/19 versus 2/17, p = .07), parity (18/19 versus 9/17, p = .01), prior cesarean (17/19 versus 4/17, p = .0001), shorter cesarean-conception interval (22.8 ± 21.4 versus 108 ± 7.6 months, p = .01), and spontaneous conception (19/19 versus 12/17, p = .03). Cases diagnosed prenatally more frequently received steroids for fetal maturity (13/20 versus 3/19, p = .003), delivered by cesarean (19/19 versus 11/17, p = .01) under general anesthesia (14/19 versus 4/17, p = .002) with a cell saver (5/19 versus 0/17, p = .06). There were no statistically significant differences by group in maternal blood loss, transfusion, intensive care admission or length of stay, operative injury, or severe composite morbidity (reoperation, coagulopathy, thromboembolism, wound infection, multiorgan failure, transfusion reaction, fistula, or chest compressions). There were no statistically significant differences in 5-minute Apgar <7, neonatal intensive care unit admission or length of stay, or severe composite morbidity. CONCLUSION: Prenatally undiagnosed accretas are less complex than prenatally diagnosed cases, but associated with statistically similar outcomes, suggesting benefit to prenatal recognition.

May-Thurner syndrome complicating pregnancy: a report of four cases.

BACKGROUND: May-Thurner syndrome is a common anatomic variant associated with deep venous thrombosis. There are few reports describing implications for and management in pregnancy. CASES: We performed a retrospective review and description of 4 women with May-Thurner syndrome receiving complete or consultative obstetrical care in our practice. Presentations included (1) previous stroke from presumed paradoxical embolus, (2) chronic lower extremity venous congestion treated prepregnancy with stenting, (3) prior iliac thrombosis treated with thrombolysis, anticoagulation, and stenting, and (4) active third trimester iliac thrombosis. The first 3 patients received prophylactic anticoagulation, while the fourth was fully anticoagulated. CONCLUSION: May-Thurner is an underappreciated cause of deep venous thrombosis in reproductive-aged women. Awareness may lead to improved recognition, treatment, and fewer long-term sequelae.

Two- and three-dimensional prenatal sonographic diagnosis of Alagille syndrome.

We describe a case of Alagille syndrome diagnosed by second-trimester ultrasound. Features included the characteristic prominent chin, single umbilical artery, and hemivertebrae. Three-dimensional imaging demonstrated classic butterfly vertebrae, which were not otherwise appreciable. Alagille syndrome may be detected by second-trimester ultrasound in the at-risk fetus.

Promoting preconception, pregnancy, and postpartum care following bariatric surgery: a best practice planning toolkit for patients and their physicians.

Most bariatric procedures are performed in reproductive-aged women. Managing sequelae of postoperative anatomic and physiologic changes can be complex, particularly in women. Standardizing preconception, pregnancy, and postpartum management may limit practice variation and improve pore. We therefore provide a clinical toolkit consisting of physician checklists and corresponding written patient educational material to achieve these goals.

Second-trimester prenasal and prefrontal skin thickening - association with MECP2 triplication syndrome.

MECP2 triplication syndrome is a rare and usually lethal genetic disorder characterized by progressive neurologic and cognitive regression. None of the four reported cases describe prenatal sonographic features of affected offspring. We report a second-trimester fetus with marked prefrontal and prenasal skin thickening, retrognathia, and later, third-trimester mild cerebral ventriculomegaly. Amniocyte karyotype was normal male, but newborn whole-genome oligonucleotide microarray showed duplication and triplication of chromosome Xq28 containing the MECP2 gene. Comparative genomic hybridization may be diagnostic in fetuses with prefrontal and prenasal skin thickening, additional sonographic findings, and normal karyotype.

Roux-en-Y gastric bypass-associated bowel obstruction complicating pregnancy-an obstetrician's map to the clinical minefield.

Over 80% of patients undergoing bariatric surgery are women, approximately half of whom are of reproductive age. The most common procedure in the United States is the Roux-en-Y gastric bypass. Small bowel obstruction is one of many recognized postoperative complications. For such a serious condition, this entity presents with remarkable subtlety and is easily misdiagnosed, particularly in pregnant women. The consequences of late recognition can be life-threatening to both mother and fetus. We aim to decrease preventable maternal and perinatal morbidity and mortality by revealing diagnostic and therapeutic missteps related to Roux-en-Y gastric bypass-associated small bowel obstruction.

The birds and the beans: a low-fidelity simulator for chorionic villus sampling skill acquisition.

Because no simulation models are described for chorionic villus sampling (CVS), we sought to design and construct a CVS training simulator. Using materials available from our labor floor and local supermarket, we built and demonstrated a practical model for learning transabdominal and transcervical CVS. The simulator can be used to teach single- or dual-operator transabdominal CVS and traditional transcervical CVS. Aspirated "villi" immediately inform the teacher and learner of successful procedures. No image degradation or sonographically visible tracks resulted from use, permitting more than one trainee to benefit from a model. This model for transabdominal and transcervical CVS provides realistic imaging, tactile sensations, and immediate feedback.

First trimester transabdominal chorionic villus sampling--does the needle matter?

PURPOSE: To compare first-trimester transabdominal chorionic villus samples (TA-CVS) when obtained by 20-gauge amniocentesis versus lancet needles. METHODS: This is a retrospective study of all women with viable singleton pregnancies undergoing TA-CVS from 01/01/2009 to 03/31/2011. All CVS were performed by a single operator using a freehand technique and amniocentesis needles from 01/01/2009 to 08/31/2010 and lancet needles from 09/01/2010 to 03/31/2011. All samples were processed by the same laboratory. RESULTS: There were no differences between groups regarding maternal age, weight, gestational age at CVS, indication for CVS, uterine position, or placental location. Lancet needles were associated with significantly larger samples (median 18 [range 3-40] versus 7 [range 1-33] mg, p < 0.0001), more successful in situ hybridization (96% versus 74.2%, p = 0.03), and faster result reporting (median 7 [range 5-12] versus 9 [range 6-26] days, p = 0.002). CONCLUSIONS: Needle type may be clinically important when selecting 20-gauge TA-CVS needles.