Extensive fundal placenta accreta spectrum (PAS) in a nulliparous patient with an unscarred uterus and systemic lupus erythematosus (SLE) necessitating cesarean hysterectomy at delivery.

Placenta accreta spectrum (PAS) defined by various degrees of abnormally invasive placentation is strongly associated with severe maternal morbidity and maternal mortality, mainly reflecting maternal hemorrhage. Predisposing factors for this condition include: multiparity, placenta previa, previous uterine surgeries (previous curettage, cesarean delivery, and myomectomy), smoking and previous PAS. Prenatal sonographic findings associated with PAS include the presence of placenta previa, loss of the hypoechoic retroplacental sonolucency, myometrial thinning, interruption of the irregularity of the bladder wall, excessive vascularity of the uterovesical plane, placental lacunae, increased placental vascularity, bridging vessels with vascularity extending from the placental bed across the uterine wall into the bladder or other pelvic organs. PAS is very rare among nulliparous patients, especially those without previous uterine surgery. We describe an unusual case of PAS in a nulliparous patient with an unscarred uterus and systemic lupus erythematosus in whom a fundal placenta with PAS and thinned and areas of absent myometrium suspected at midtrimester sonography, sustained uterine atony and severe hemorrhage at delivery, necessitated massive blood transfusion and subtotal hysterectomy. Both mother and infant did well. Pathology confirmed PAS and marked uterine thinning. Although PAS most commonly is associated with placenta previa and the presence of previous cesarean delivery, this case emphasizes the need for alertness of at times subtle prenatal sonographic findings of PAS irrespective of placental location even among nulliparous patients, especially those with systemic lupus erythematosus.

Reverse diastolic flow of the fetal middle cerebral artery associated with placental chorangiomatosis and asymptomatic concealed placental abruption.

Reverse diastolic flow of the fetal middle cerebral artery is a rare, yet ominous finding which has been associated with adverse perinatal outcomes including: intracranial hemorrhage, growth restriction, fetal-maternal hemorrhage, severe anemia, hydrops, hepatic anomaly, subsequent stillbirth, and early neonatal death. We report a case in which following notation of a nonreassuring fetal heart rate at 32 weeks' gestation, sonographic documentation of persistent reverse diastolic flow of the fetal middle cerebral artery was noted in association with sonographic findings of vascular placental dysmorphology and an asymptomatic concealed placental abruption. Subsequent fetal heart rate tracing consistent with uteroplacental insufficiency led to immediate Cesarean birth of an anemic yet nonacidotic, nonhypoxic neonate, who did well following management of respiratory distress syndrome and partial exchange transfusion. Placental abruption was confirmed at delivery. Histopathology of the placenta confirmed the presence of localized chorangiomatosis ("wandering" chorangioma). The association of reverse diastolic flow of the fetal middle cerebral artery, placental chorangiomatosis and placental abruption has not been reported previously. We conclude that in the presence of prenatal sonographic findings of placental dysmorphology and or placental abruption, insonation of the fetal middle cerebral artery should be performed to assess the possibility of increased peak systolic velocity and possible reverse diastolic flow, both associated with fetal anemia and increased likelihood of an adverse perinatal outcome.

Prevalence of Positive Cervical Cancer Screening Tests Past the Age of 65 Years With Prior Adequate Negative Screening.

OBJECTIVES: Cervical cancer screening recommendations suggest that cessation can be offered above the age of 65 years if specific prior negative screening criteria are met. We investigated the prevalence of abnormal results in individuals who continue screening despite satisfying the American Society for Colposcopy and Cervical Pathology guidelines for cessation. MATERIALS AND METHODS: In this retrospective study, medical records 2008-2019 from a single urban hospital-based clinic were queried. Charts were manually reviewed to determine which patients met the American Society for Colposcopy and Cervical Pathology exit criteria but continued screening. Findings detected during the extended surveillance period beyond the age of 65 years were analyzed. RESULTS: Two hundred ninety-six patients met the criteria of additional screening despite meeting guidelines for cessation. Length of the continued additional surveillance period ranged from 1 to 15 years with a mean of 3.98 years and median of 3 years. Thirty-nine individuals had abnormalities during additional surveillance: 25 high-risk human papillomavirus (HR-HPV) positive only with negative cytology, 8 atypical squamous cells of undetermined significance, 3 low-grade squamous intraepithelial lesions, 2 atypical glandular cells of undetermined significance, and 1 high-grade squamous intraepithelial lesion. No cases of cervical cancer were detected. Total rate of abnormalities including HR-HPV positive only was 332.20 per 10,000 person-years, and cytologic abnormalities alone at 119.25 per 10,000 person-years. CONCLUSIONS: Most findings were HR-HPV positive with negative cytology, which studies suggest may confer low risk of progression in older individuals. In addition, no patient was found to develop cervical malignancy. Despite controversy regarding this recommendation, our data suggest screening cessation may be appropriate with adequate negative screening history.

Mid-trimester absent nasal bone and transient unilateral hydronephrosis associated with 16p13.3 microduplication.

Characteristic phenotypic features of 16p13.3 microduplication include impaired mental development, arthrogryposis-like musculoskeletal anomalies (club-feet, congenital hip dislocation, and camptodactyly of fingers and toes), facial dysmorphology, and at times congenital cardiac disease. Most of the described affected individuals have microduplications involving the CREBBP gene. Findings indicate this gene to be dosage-sensitive and likely involved in the phenotypes of 16p13.3 microduplication syndrome. We describe the incidental finding of 16p13.3 microduplication in a fetus with mid-trimester sonographic examination showing absent nasal bone and transient unilateral hydronephrosis.