Evaluation of classic and novel ultrasound signs of placenta accreta spectrum.

OBJECTIVES: Improvement in the antenatal diagnosis of placenta accreta spectrum (PAS) would allow preparation for delivery in a referral center, leading to decreased maternal morbidity and mortality. Our objectives were to assess the performance of classic ultrasound signs and to determine the value of novel ultrasound signs in the detection of PAS. METHODS: This was a retrospective cohort study of women with second-trimester placenta previa who underwent third-trimester transvaginal ultrasound and all women with PAS in seven medical centers. A retrospective image review for signs of PAS was conducted by three maternal-fetal medicine physicians. Classic signs of PAS were defined as placental lacunae, bladder-wall interruption, myometrial thinning and subplacental hypervascularity. Novel signs were defined as small placental lacunae, irregular placenta-myometrium interface (PMI), vascular PMI, non-tapered placental edge and placental bulge towards the bladder. PAS was diagnosed based on difficulty in removing the placenta or pathological examination of the placenta. Multivariate regression analysis was performed and receiver-operating-characteristics (ROC) curves were generated to assess the performance of combined novel signs, combined classic signs and a model combining classic and novel signs. RESULTS: A total of 385 cases with placenta previa were included, of which 55 had PAS (28 had placenta accreta, 11 had placenta increta and 16 had placenta percreta). The areas under the ROC curves for classic markers, novel markers and a model combining classic and novel markers for the detection of PAS were 0.81 (95% CI, 0.75-0.88), 0.84 (95% CI, 0.77-0.90) and 0.88 (95% CI, 0.82-0.94), respectively. A model combining classic and novel signs performed better than did the classic or novel markers individually (P = 0.03). An increasing number of signs was associated with a greater likelihood of PAS. With the presence of 0, 1, 2 and ≥ 3 classic ultrasound signs, PAS was present in 5%, 24%, 57% and 94% of cases, respectively. CONCLUSIONS: We have confirmed the value of classic ultrasound signs of PAS. The use of novel ultrasound signs in combination with classic signs improved the detection of PAS. These findings have clinical implications for the detection of PAS and may help guide the obstetric management of patients diagnosed with these placental disorders. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Vaginal progesterone reduces the rate of preterm birth in women with a sonographic short cervix: a multicenter, randomized, double-blind, placebo-controlled trial.

OBJECTIVES: Women with a sonographic short cervix in the mid-trimester are at increased risk for preterm delivery. This study was undertaken to determine the efficacy and safety of using micronized vaginal progesterone gel to reduce the risk of preterm birth and associated neonatal complications in women with a sonographic short cervix. METHODS: This was a multicenter, randomized, double-blind, placebo-controlled trial that enrolled asymptomatic women with a singleton pregnancy and a sonographic short cervix (10-20 mm) at 19 + 0 to 23 + 6 weeks of gestation. Women were allocated randomly to receive vaginal progesterone gel or placebo daily starting from 20 to 23 + 6 weeks until 36 + 6 weeks, rupture of membranes or delivery, whichever occurred first. Randomization sequence was stratified by center and history of a previous preterm birth. The primary endpoint was preterm birth before 33 weeks of gestation. Analysis was by intention to treat. RESULTS: Of 465 women randomized, seven were lost to follow-up and 458 (vaginal progesterone gel, n=235; placebo, n=223) were included in the analysis. Women allocated to receive vaginal progesterone had a lower rate of preterm birth before 33 weeks than did those allocated to placebo (8.9% (n=21) vs 16.1% (n=36); relative risk (RR), 0.55; 95% CI, 0.33-0.92; P=0.02). The effect remained significant after adjustment for covariables (adjusted RR, 0.52; 95% CI, 0.31-0.91; P=0.02). Vaginal progesterone was also associated with a significant reduction in the rate of preterm birth before 28 weeks (5.1% vs 10.3%; RR, 0.50; 95% CI, 0.25-0.97; P=0.04) and 35 weeks (14.5% vs 23.3%; RR, 0.62; 95% CI, 0.42-0.92; P=0.02), respiratory distress syndrome (3.0% vs 7.6%; RR, 0.39; 95% CI, 0.17-0.92; P=0.03), any neonatal morbidity or mortality event (7.7% vs 13.5%; RR, 0.57; 95% CI, 0.33-0.99; P=0.04) and birth weight < 1500 g (6.4% (15/234) vs 13.6% (30/220); RR, 0.47; 95% CI, 0.26-0.85; P=0.01). There were no differences in the incidence of treatment-related adverse events between the groups. CONCLUSIONS: The administration of vaginal progesterone gel to women with a sonographic short cervix in the mid-trimester is associated with a 45% reduction in the rate of preterm birth before 33 weeks of gestation and with improved neonatal outcome.

The influence of obstetric intervention on trends in twin stillbirths: United States, 1989-99.

OBJECTIVE: Although twin stillbirth rates have declined substantially over the past two decades, the contribution of changes in obstetric interventions to reducing twin stillbirths has not been quantified. METHODS: We carried out a retrospective cohort study of twin live births and stillbirths in the United States between 1989 and 1999 (n=1,102,212). Changes in the rate of stillbirth (> or =22 weeks) before and after adjustment for changes in labor induction, Cesarean delivery and sociodemographic factors were estimated through ecological logistic regression analysis. This analysis was based on aggregating data by each state within the United States. RESULTS: Between 1989 and 1999, rates of labor induction and Cesarean delivery among twin live births increased by 138% (from 5.8% to 13.8%) and 15% (from 48.3% to 55.6%), respectively. These changes were accompanied by a 43% decline in the stillbirth rate between 1989 and 1999 (from 24.4 to 13.9 per 1000 fetuses at risk). After excluding births weighing < 500 g, rates of labor induction among twins at 22-27 weeks', 28-33 weeks' and > or =34 weeks' gestation increased by 95%, 131% and 127%, respectively, between 1989 and 1999. Cesarean delivery rates also increased by 55%, 29% and 2% in these same gestational age categories. The 48% (relative risk (RR) 0.52, 95% confidence interval (CI) 0.49-0.55) decline in stillbirth rate between 1989-91 and 1997-99 was reduced to a 25% (RR 0.75, 95% CI 0.72-0.79) decline after adjustment for changes in labor induction and Cesarean delivery. The decline in the rate of twin stillbirths was larger at later gestational ages (at > or =32 and > or =34 weeks) where the largest absolute increases in labor induction rates were observed. CONCLUSIONS: The use of Cesarean delivery and especially labor induction for twin pregnancies has increased substantially in the United States over the last decade and these changes have been associated with a large decline in the rate of stillbirth among twins.

The effects of labor on infant mortality among small-for-gestational-age infants in the USA.

OBJECTIVE: To determine whether the presence of labor affects infant mortality among small-for-gestational-age (SGA) infants. METHODS: Data were derived from the United States national linked birth/infant death data sets for 1995-97. Singleton SGA live births in cephalic presentation delivered at 24-42 weeks' gestation were included. Mortality rates for SGA infants exposed and unexposed to labor were compared, and relative risks (RR) were derived using multivariable logistic regression models, after adjusting for potential confounding factors. RESULTS: Of 986 405 SGA infants, 87.4% were exposed to labor. Infants exposed to labor at 24-31 weeks had greater risks of dying during the early neonatal period (RR 1.79-1.86). Decreased risks of late and postneonatal death were observed at all gestational ages in the presence of labor. CONCLUSIONS: Exposure to labor is associated with an increased risk of early neonatal death among SGA infants, especially at gestational ages below 32 weeks. Future randomized trials are warranted to determine the optimal obstetric management of these high-risk infants.

Outcome of prenatally diagnosed mild unilateral cerebral ventriculomegaly.

The objective of this study was to determine the frequency of prenatally diagnosed unilateral cerebral ventriculomegaly and also to assess neonatal outcome in infants with this prenatal diagnosis. A computerized ultrasonography database identified fetuses with isolated and nonisolated unilateral cerebral ventriculomegaly from October 1994 to June 1999. The Denver II Developmental Screening Test was used to assess developmental skills. Unilateral cerebral ventriculomegaly was diagnosed in 15 of 21,172 (1 per 1,411) pregnancies. The width of the enlarged lateral ventricle ranged from 1.0 to 1.9 cm. In 10 (67%) of 15 cases unilateral cerebral ventriculomegaly was an isolated finding. Eight of the 14 infants who were born at 36 weeks' gestation or later had postnatal cranial imaging, and ventricular asymmetry was confirmed in 5 (63%). One infant with an arachnoid cyst and cerebral palsy died at 2 years of age. The remaining 11 infants in whom developmental milestones were assessed had age-appropriate skills. Unilateral fetal ventriculomegaly is usually an isolated finding and when isolated has little measurable effect on developmental outcome.

Sleep and sleep disorders in pregnancy.

Sleep problems are common in pregnant women. This review examines sleep in normal pregnancy; discusses the physiologic bases for alterations in sleep, including hormonal and mechanical factors; and correlates these factors with changes in sleep of pregnant women, as determined subjectively by surveys and objectively by polysomnographic studies. The changes in respiratory physiology during pregnancy, the possible predisposition of the pregnant woman to sleep-disordered breathing because of these changes, and results of published studies of sleep-disordered breathing in pregnancy are discussed. Finally, the effect of pregnancy on other sleep disorders and the management of these sleep disorders during pregnancy are outlined, including changes in management necessitated by this state. The paucity of available data and the need for further studies of incidence and outcomes of sleep disorders in the pregnant woman are emphasized.

Recurrent uterine rupture after abdominal pregnancy.

Uterine rupture can occur at any time throughout gestation. We present a woman with a previous Cesarean section followed by an abdominal pregnancy. In her next pregnancy, complete uterine rupture resulted in an emergency laparotomy. This case is unique in that it gives insight into the variable presentations of uterine rupture and the risks associated with prior Cesarean sections.

Medical and economic effects of twin gestations.

OBJECTIVE: To determine the incidence and trends of twinning in the United States and to review the medical and economic effects of twin versus singleton gestations. METHODS: Pertinent and recent studies on twin gestations were obtained through a MEDLINE database search of the English language between December 1987 and December 1999. Data from the 1995-1996 National Center for Health Statistics were also used to compare gestational age at delivery, fetal growth restriction, and perinatal mortality for twin and singleton gestations. Studies that have evaluated perinatal risks in relation to advanced reproductive technology also were reviewed and summarized. The economic implications of twinning from a societal perspective and infant quality of life issues of twins compared with singleton gestations are reviewed. RESULTS: Due to delayed childbearing and increased use of reproductive technologies, the incidence of twin gestations in the United States has been increasing. Twin pregnancies have a higher risk of complications, including pregnancy-induced hypertension, anemia, antepartum and postpartum hemorrhage, and maternal mortality. In addition, twin infants are more likely to deliver preterm, have low birth weight and greater perinatal mortality rates. These outcomes influence health care costs and quality of life for both parents and children. CONCLUSIONS: Women carrying twin fetuses are at increased risk for perinatal and obstetric complications. The increased perinatal risks that accompany twin fetuses may be partly due to the increasing use of advanced reproductive technologies. The economic burdens, as well as the potential for decreased quality of life among twins, needs careful evaluation.

Use of cervical ultrasonography in prediction of spontaneous preterm birth in twin gestations.

OBJECTIVE: This study was undertaken to compare various ultrasonographic cervical parameters with respect to ability to predict spontaneous preterm birth in twin gestations. STUDY DESIGN: This prospective study involved 131 women carrying twins who were longitudinally evaluated on 524 occasions between 15 and 28 weeks' gestation with transvaginal cervical ultrasonography and transfundal pressure. The following cervical parameters were obtained: funnel width and length, cervical length, percentage of funneling, and cervical index. Receiver operating characteristic curve analysis was used to determine the ultrasonographic cervical parameter evaluated at 15 to 20 weeks' gestation, 21 to 24 weeks' gestation, and 25 to 28 weeks' gestation that were best for prediction of spontaneous preterm birth at <28 weeks' gestation, <30 weeks' gestation, <32 weeks' gestation, and <34 weeks' gestation. RESULTS: The median gestational age at delivery was 36 weeks' gestation (range, 21-41 weeks' gestation). Receiver operating characteristic curve analysis indicted that a cervical length of < or =2.0 cm, regardless of gestational age category at cervical measurement, was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. Between 15 and 20 weeks' gestation a cervical length cutoff value of < or =2.0 cm had specificities of 97%, 98%, 99%, and 100% and negative predictive values of 99%, 98%, 95%, and 89% for delivery at <28, <30, <32, and <34 weeks' gestation, respectively. The positive predictive values for delivery at <32 and <34 weeks' gestation were 80% and 100%, respectively. Between 21 and 24 weeks' gestation a cervical length of < or =2.0 cm had specificities of 84%, 84%, 85%, and 86% and negative predictive values of 99%, 99%, 94%, and 87% for delivery at <28, <30, <32, and <34 weeks' gestation, respectively. Between 25 and 28 weeks' gestation cervical length had excellent negative predictive values of 99%, 98%, 95%, and 93% for delivery at <28, <30, <32, and <34 weeks' gestation, respectively. CONCLUSIONS: In twin gestations a cervical length of < or =2.0 cm measured between 15 and 28 weeks' gestation was at least as good as other ultrasonographic cervical parameters at predicting spontaneous preterm birth. The high specificities indicate that cervical length was better at predicting the absence than the presence of various degrees of spontaneous prematurity.

Continuous infusion of naloxone: effects on behavior and oxygen consumption.

Twenty-eight hours of endorphin receptor blockade by subcutaneous naloxone infusion produced behavioral and respiratory symptoms resembling opiate abstinence syndrome. Rats were implanted subcutaneously with two Alzet osmotic minipumps delivering 0.7 mg/kg per hour naloxone or with two control minipumps containing distilled water only. They were observed for 10 minutes under blind conditions at 16 and 28 hours post-implantation. The naloxone-infused rats showed significantly more wet dog shakes, abdominal writhes and overall abstinence-like symptoms than did the control rats. These symptoms decreased after 28 hours despite continued naloxone infusion. Acute administration of naloxone failed to produce abstinence-like symptoms, even when combined with the trauma of carrying two implanted water-filled minipumps for 28 hours. In another experiment, naloxone-infused rats showed a highly significant 53.4% elevation of O2 consumption over water-infused control rats in a pure O2 atmosphere at 28 hours after implantation. This difference disappeared at 48 hours post-implantation. In contrast to the effect of naloxone infusion, acute administration of three different doses of naloxone failed to significantly increase O2 consumption.