Early pregnancy failure as a training tool for chorionic villus sampling.

OBJECTIVES: The goal of this study is to evaluate the success of a training program in chorionic villus sampling (CVS) of early pregnancy failure (EPF) for maternal-fetal medicine (MFM) fellows. METHODS: We conducted a retrospective review of a new training program in CVS for MFM fellows. Women with EPF up to 13 weeks estimated gestational age were offered inclusion in our program and counseled on alternatives. Transcervical CVS was performed for both fellow education and cytogenetic diagnosis. The primary outcome was a successful diagnosis, and the secondary outcome was cell growth by fellow experience. RESULTS: Thirty-nine patients diagnosed with EPF from December 2011 to March 2013 underwent CVS. Villi obtained via CVS yielded a diagnosis in 62% of cases. CVS samples with successful karyotype had more villi but were otherwise similar. CVS by experience showed a trend towards increased success and villi volume after the first five procedures. Abnormal results were obtained in 72% of cases, 15% of which led to changes in care. CONCLUSION: CVS of EPF is an option for the training of MFM fellows as it was acceptable to most patients, and the majority of CVS specimens yielded a karyotype diagnosis.

ST waveform analysis versus cardiotocography alone for intrapartum fetal monitoring: a meta-analysis of randomized trials.

OBJECTIVE: To estimate the effectiveness of intrapartum ST waveform analysis (STAN) versus cardiotocography (CTG) alone in prevention of metabolic acidosis. STUDY DESIGN: Meta-analysis of randomized trials comparing intrapartum fetal monitoring utilizing STAN with CTG versus CTG alone. Primary outcome was neonatal metabolic acidosis, defined as umbilical arterial pH <7.05 and base deficit >12 mmol/L. RESULTS: Five randomized trials including 15,303 singletons, vertex, term, or near-term pregnancies met inclusion criteria and were analyzed. Compared with CTG alone, STAN with CTG was associated with similar incidences of metabolic acidosis (0.81% versus 1.12%, relative risk [RR] 0.80; 95% confidence interval [CI] 0.44 to 1.47), perinatal death, neonatal encephalopathy, Apgar score <7 at 5 minutes, admission to neonatal intensive care unit, and cesarean delivery. Operative vaginal delivery (OVD) was lower in the STAN with CTG compared with CTG alone (13.56% versus 15.20%; RR 0.89; 95% CI 0.83 to 0.97). CONCLUSION: There is no difference in perinatal outcomes between STAN with CTG compared with CTG alone, except for lower rate of OVD.

Novasure as a mechanical endometrial preparation agent in large uteri.

OBJECTIVE: We evaluated Novasure ablation as a mechanical endometrial preparation agent before Roller Ball endometrial ablation in lieu of GnRH agonists in large uteri. METHODS: A retrospective chart review of 20 consecutive patients undergoing Novasure ablation for mechanical endometrial preparation before Roller Ball ablation (RBNovasure group) was conducted and the results compared to that of 23 consecutive patients who received GnRH agonist (Leuprolide acetate) as a medical endometrial preparation before Roller Ball ablation (RB-Lupron group). The postoperative follow-up time frame was divided into immediate (3 mo), intermediate (3 to 12 mo) and long-term (12 to 32 mo). Rates of amenorrhea, heavy bleeding, cramping, and failure (repeat ablation or hysterectomy for heavy bleeding or persistent pain) were compared between the 2 groups. RESULTS: The mean rates of amenorrhea for the patients not lost to follow-up at 3 mo, 3 to 12 mo, and 12 to 32 mo visits were 45.5%, 58.8%, and 44.4% for the RB-Lupron group, and 80%, 86.7%, and 100% for the RB-Novasure group (P = .02, P = .08, and P = .02). Failure rates were 4.8%, 6.2%, and 55.6% for the RB-Lupron group; and 0 (0/20), 12.5% (2/16) and 0 (0/8) for the RB-Novasure group (P = .51, P = .50, and P = .02). The RB-Novasure group had a significantly lower rate of heavy bleeding and cramping. 86.4%, 58.8%, and 33.3% patients reported satisfaction with their treatment in the RB-Lupron group and 100%, 87.5%, and 75% in RB-Novasure group (P = .13, P = .07, and P = .11). CONCLUSION: Novasure ablation, for mechanical endometrial preparation before Roller Ball ablation, appears to be a superior alternative to medical preparation with GnRH agonists in patients with large uteri.

Obstetric outcomes in normal weight and obese women in relation to gestational weight gain: comparison between Institute of Medicine guidelines and Cedergren criteria.

We compared obstetric outcomes based on gestational weight gain in normal-weight and obese women using traditional Institute of Medicine (IOM) guidelines and newly recommended Cedergren criteria. Using the New Jersey Pregnancy Risk Assessment Monitoring System (PRAMS) database and electronic birth records, perinatal outcomes were analyzed to estimate the independent effects of prepregnancy body mass index (BMI) and gestational weight gain by IOM versus Cedergren criteria. Of 9125 subjects in PRAMS database from 2002 to 2006, 53.7% had normal BMI, 12.3% were overweight, 18.2% were obese, and the rest were underweight. Among normal-weight mothers, when compared with the IOM guidelines, macrosomia (6.45% versus 4.27%) and cesarean delivery rates (30.42% versus 29.83%) were lower using Cedergren criteria but the rates of preterm delivery (5.06% versus 9.44%), low birth weight (0.38% versus 2.42%), and neonatal intensive care unit (NICU) admissions (7.02% versus 10.86%) were higher with the Cedergren criteria. Similarly, among obese patients, when compared with IOM guidelines, macrosomia (10.79% versus 5.47%) and cesarean delivery rates (43.95% versus 40.71%) were lower using Cedergren criteria but the rates of preterm delivery (6.83% versus 8.32%), low birth weight (0.87% versus 1.88%), and NICU admissions (8.92% versus 13.78%) were higher with the Cedergren criteria. Based on our results, ideal gestational weight gain is presumably somewhere between the IOM and Cedergren's guidelines.

Self-perceptions of body size in women at an inner-city family-planning clinic.

OBJECTIVE: The objective of the study was to determine the relationship between body mass index (BMI) and body size perception among female patients in an inner-city family-planning clinic. STUDY DESIGN: All participants (n = 81) were measured for height and weight and completed an anonymous survey. Self-perceived, current, and ideal body sizes were determined by using a standardized scale. Body image discrepancy was calculated by the difference between body image perception and measured BMI. RESULTS: Approximately two-thirds of the participants were obese or overweight. As measured BMI increased, the body image discrepancy increased, with significant differences in body perception in both obese (P < .001) and overweight (P < .001) women. Ideal body size increased with measured BMI. CONCLUSION: Overweight and obese women in an inner-city clinic are likely to underestimate their body size. Our data support the need for culturally sensitive education for this population, because many do not view themselves at risk for complications related to excessive weight.

Embolization of uterine arteriovenous malformation for treatment of menorrhagia.

BACKGROUND: Uterine arteriovenous malformations are rare but potentially life-threatening conditions that should be suspected in unexplained severe vaginal bleeding. CASE: A 28-year-old gravida 7, para 3 presented to the emergency department with heavy vaginal bleeding and passage of blood clots. In the emergency room, her hemoglobin dropped from 11.2 to 7.4 gm%. Transvaginal ultrasonographic scan showed a large vascular mass in the uterus measuring 2.6 cm in diameter with low resistance of flow within, concerning for arteriovenous malformation or an arteriovenous fistula. Digital subtraction arteriography confirmed the lesion. She underwent angiography and bilateral uterine artery embolization. CONCLUSION: The diagnosis of uterine arteriovenous malformation requires a high index of suspicion in the scenario of unexplained severe vaginal bleeding. Digital subtraction angiography is the gold standard for definitive diagnosis and allows immediate treatment by embolization.

Prior Ultrasound-Indicated Cerclage: Comparison of Cervical Length Screening or History-Indicated Cerclage in the Next Pregnancy.

OBJECTIVE: To evaluate outcomes of women with prior ultrasound-indicated cerclage, who in their subsequent pregnancy were either followed by transvaginal ultrasound cervical length screening or received a planned history-indicated cerclage. METHODS: Multicenter cohort study of singleton gestations with a prior ultrasound-indicated cerclage performed from 1994 to 2014. We evaluated three pregnancies in the study participants: first pregnancy with prior spontaneous preterm birth at less than 37 weeks of gestation; second pregnancy with ultrasound-indicated cerclage for cervical length 25 mm or less; and the third index pregnancy managed with either transvaginal ultrasound cervical length screening with ultrasound-indicated cerclage for cervical length 25 mm or less or planned history-indicated cerclage. The primary outcome was incidence of spontaneous preterm birth at less than 37 weeks of gestation. We planned a subgroup analysis for women who delivered at less than 32 weeks of gestation compared with 32 weeks of gestation or greater in their prior ultrasound-indicated cerclage pregnancy. RESULTS: Of 102 singleton gestations included, 38 (37.3%) were followed with transvaginal ultrasound cervical length screening and 64 (62.7%) underwent history-indicated cerclage. Of 38 women in the transvaginal ultrasound group, 18 (47.4%) underwent ultrasound-indicated cerclage for cervical length 25 mm or less. After adjusting for confounders, the rate of spontaneous preterm birth at less than 37 weeks of gestation was similar between transvaginal ultrasound cervical length screening and history-indicated cerclage groups (36.8% compared with 43.8%; adjusted odds ratio 0.77, 95% confidence interval 0.47-1.45). Secondary outcomes were also similar in both groups. All women (n=7) who delivered at less than 32 weeks of gestation in their prior pregnancy and subsequently had transvaginal ultrasound screening received ultrasound-indicated cerclage in the index pregnancy compared with only 35.5% of women who delivered at 32 weeks of gestation or greater in their prior pregnancy. CONCLUSION: Women with prior ultrasound-indicated cerclage have similar outcomes if they receive either transvaginal ultrasound cervical length screening with ultrasound-indicated cerclage for cervical length 25 mm or less or planned history-indicated cerclage in the subsequent pregnancy. Less than 50% of the transvaginal ultrasound cervical length screening group require a repeat ultrasound-indicated cerclage in the subsequent pregnancy. LEVEL OF EVIDENCE: II.

Risk of intrapartum cervical lacerations in women with cerclage.

OBJECTIVE: The aim of our study was to estimate whether the placement of cerclage in pregnancy to prevent preterm birth (PTB) is associated with higher incidence of intrapartum cervical lacerations. METHODS: A retrospective cohort study was conducted on singleton pregnancies with risk factors for PTB. The study group consisted of women with either a history- or ultrasound-indicated cerclage placed between 12 and 24 weeks of gestation, while the control group consisted of women with similar risk factors for PTB but who did not receive a cerclage. Primary outcome was the incidence of intrapartum cervical lacerations. A sample size calculation was performed on the basis of the results of previous studies on cervical lacerations. RESULTS: We identified 134 women who had a cerclage placed in pregnancy. They were compared with 236 controls with no cerclage. Cases and controls had similar risk factors for cervical lacerations. Cervical lacerations occurred with similar frequencies in the cerclage and no-cerclage group (2.2 vs 1.3%, p = 0.78). There was no significant difference between the two groups for the risk of cervical lacerations (RR 1.76, 95% CI: 0.36-8.60). CONCLUSIONS: Cerclage placement during pregnancy is not associated with an increased risk of intrapartum cervical lacerations.

Cervical length and risk of antepartum hemorrhage in presence of low-lying placenta.

OBJECTIVES: To evaluate whether transvaginal ultrasound cervical length (TVU CL) can predict antepartum bleeding (APB) in women with low-lying placenta. STUDY DESIGN: A retrospective study was performed including pregnancies with low-lying placenta for which third trimester TVU CL was available. Multiple pregnancies were excluded. Short cervix was defined as TVU CL ≤25 mm. Outcomes of interest were compared with respect to the TVU CL. RESULTS: Forty three cases of singleton pregnancies complicated by low-lying placenta in third trimester were identified. Short cervix was reported in 8 cases (19%). APB (75% vs. 31 %, p = 0.02), blood transfusions (25% vs. 3%, p = 0.02), lower birth weight (2246 vs. 2985 g, p = 0.02), and neonatal intensive care unit (NICU) admissions (50% vs. 17%, p = 0.04) were more frequent in the women with short cervix. Rate of unplanned cesarean delivery for APB was similar between both the groups (25% vs. 28%, p = 0.83). CONCLUSIONS: In women with low-lying placenta persisting into third trimester, short cervical length can be used as a predictor for APB.

Obstetric outcomes in pregnant women with diabetes versus hypertensive disorders versus both.

OBJECTIVE: To compare obstetrical outcomes in pregnant women with diabetes versus hypertensive disorders versus both. METHODS: One million patients in the New Jersey Database were analyzed. Of which 6.91% had hypertension, 4.79% had diabetes, and 0.91% had both. Information was derived from a perinatal linked data-set provided by the Maternal Child Health Epidemiology (MCH Epi) Program in the New Jersey Department of Health and Senior Services. Linking of electronic birth certificates, hospital discharge records for mother and newborn, and infant death certificates for all infants born in New Jersey between the years 1997 and 2005 created the data-set. RESULTS: Coexistence of hypertension and diabetes increased with advancing maternal age (OR 3.41; CI 3.12-3.72). Among ethnic groups, diabetes was more common in Asians (OR 2.92; CI 2.84-3.00), while hypertension was more common in Blacks (OR 1.49; CI 1.46-1.53). Blacks followed by Asians had a higher risk of being in the combined category. Induction of labor (OR 4.16; CI 3.96-4.38), shoulder dystocia (OR 2.56; CI 2.05-3.19), operative vaginal delivery (OR 3.92; CI 3.29-4.66), cesarean deliveries with no trial of labor (OR 2.54; CI 2.40-2.69) as well as with failed trial of labor (OR 4.09; CI 3.88-4.31) were more common in the combined group. Neonatal outcomes were poor in the combined category, with high rate of preterm deliveries, neonatal intensive care unit (NICU) admissions (OR 2.14; CI 2.01-2.28), neonatal seizures (OR 2.30; CI 1.31-4.04), low 5-min APGAR scores (OR 1.78; CI 1.57-2.01), and longer NICU stay (OR 2.30; CI 2.15-2.47). CONCLUSIONS: Coexistence of hypertension and diabetes was associated with worse obstetric and neonatal outcomes than either alone. This should be emphasized to mothers during prenatal counseling. Further research should focus on interventions to improve morbidity in the combined category.