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Prophylactic percutaneous left ventricular assist device in pregnancy [Case Report]

Westcott, Jill M; Yaghoubian, Yasaman; Williams, Mathew R; Roman, Ashley S; Hughes, Francine; Rosner, Mara
Pregnancy-associated cardiomyopathy can present earlier in gestation than traditionally defined peripartum cardiomyopathy. Management and optimal delivery timing for these patients are not well defined. We present the case of a 30-year-old primigravid at 26 weeks who presented with new onset ventricular tachycardia, biventricular cardiac failure, and severe mitral regurgitation. She was medically stabilized for two weeks prior to delivery with modest improvement in her condition. Due to concern for life-threatening cardiac failure and pulmonary edema at the time of delivery, a percutaneous left ventricular assist device was inserted immediately prior to cesarean delivery. She remained on mechanical circulatory support for 36 h. We discuss considerations regarding use of a percutaneous left ventricular assist device as a novel therapy to support the hemodynamic changes following delivery in parturients with decompensated heart failure.
PMCID:6734636
PMID: 31523273
ISSN: 1753-495x
CID: 4085712

Fetal abdominal circumference in the second trimester and prediction of small for gestational age at birth

Doulaveris, Georgios; Gallagher, Patience; Romney, Elizabeth; Richley, Michael; Gebb, Juliana; Rosner, Mara; Dar, Pe'er
BACKGROUND:Infants that are small for gestational age (SGA) at birth are at increased risk for morbidity and mortality. Unfortunately, the antenatal prediction of SGA is suboptimal. OBJECTIVES:We sought to: 1. examine the association between second trimester fetal abdominal circumference < 10% (2T-AClag) with SGA and other gestational and neonatal adverse outcomes; 2. assess 2T-AClag as a predictor of SGA. STUDY DESIGN:Retrospective study of 212 singleton gestations with 2T-AClag on routine ultrasound between 18-24 weeks. The study group was compared to 424 gestations without 2T-AClag for maternal characteristics as well as pregnancy and neonatal adverse outcomes. A multivariate logistic regression was used to determine the predictive value of 2T-AClag for SGA, adjusting for maternal and pregnancy characteristics. The screening model accuracy was assessed through receiver operating characteristic (ROC) curves. Fetal growth restriction (FGR) was defined as an estimated fetal weight (EFW) less than the 10th percentile. RESULTS:Gestations with 2T-AClag had higher rates of SGA (35.7 versus 11.6%, p < 0.0001), FGR (17 versus 1.7%, p < 0.0001), pregnancy induced hypertension (31.1 versus 17%, p < 0.0001), preeclampsia (14.6 versus 7.8%, 0 = 0.01), abnormal umbilical artery Doppler (30 versus 5.1%, p < 0.0001), indicated preterm birth (5.7 versus 1.9%, p = 0.01), primary cesarean birth (29.6 versus 20.1%, p = 0.01) and NICU admission (12.9 versus 6.4%, p = 0.009). After adjusting for maternal and gestational risk factors, 2T-AClag remained an independent risk factor for SGA (OR 4.53, 95%CI 2.91-7.05, p < 0.0001) and FGR (OR 11.57, 95%CI 5.02-26.65, p < 0.0001). The inclusion of 2T-AClag in a regression model with traditional risk factors, significantly improved the model's predictability for SGA and FGR (area under ROC curve increased from 0.618 to 0.723 and 0.653-0.819, respectively, p < 0.0001). CONCLUSIONS:Second trimester abdominal circumference (AC) lag is associated with an increased risk of SGA, FGR and other adverse outcomes. The inclusion of 2T-AClag in a screening model for prediction of SGA and FGR may improve the identification of this at-risk group and assist in customizing surveillance plans.
PMID: 30482067
ISSN: 1476-4954
CID: 4048832

Universal Cervical Length Screening and Antenatal Corticosteroid Timing

Sahasrabudhe, Nicole; Igel, Catherine; Echevarria, Ghislaine C; Dar, Pe'er; Wolfe, Diana; Bernstein, Peter S; Angert, Robert; Dayal, Ashlesha; Gallagher, Patience; Rosner, Mara
OBJECTIVE: To evaluate the relationship between universal transvaginal screening for short cervical length in the second trimester and the timing of antenatal corticosteroids. METHODS: We performed a retrospective cohort study of patients with nonanomalous singleton gestations and spontaneous preterm birth between 24 and 34 weeks of gestation after the initiation of a universal transvaginal cervical length screening program between October 2012 and August 2015. Our primary outcome was antenatal corticosteroid administration to a delivery interval of fewer than 7 days. Secondary outcomes were delivery 24 hours to 7 days after the initial steroid injection, steroid administration to delivery interval, neonatal survival, neonatal intensive care unit length of stay, and respiratory distress syndrome. Multivariable logistic regression was used to estimate the association between antenatal corticosteroid timing and the diagnosis of a short cervix adjusted for potential confounders. RESULTS: Among 266 eligible patients, 69 with a short cervical length and 197 without a short cervical length were identified. There were no statistically significant differences in baseline characteristics between the groups. During the study period, 64 of 69 (92.8%) of patients with a short cervix and 176 of 197 (89.3%) without a short cervix received at least one steroid injection before delivery (P=.411). Steroids were given within 7 days of delivery in 33 of 69 (47.8) patients with a short cervix compared with 126 of 197 (64%) patients in the no short cervix group (P=.015; adjusted odds ratio 0.51, 95% confidence interval 0.29-0.9). Median interval between steroid administration and delivery was 8 days in patients diagnosed with a short cervix compared with 3 days for those without a short cervical length (P<.001). CONCLUSION: Patients identified as having a short cervical length by universal transvaginal ultrasound screening were at greater risk of delivering more than 7 days after the initiation of corticosteroids for fetal lung maturation compared with women without a short cervical length.
PMID: 28486361
ISSN: 1873-233x
CID: 2634982

High Maternal BMI Associated With Cervical Shortening in Women With Short Cervix on Second Trimester Anatomy Scan [Meeting Abstract]

Igel, Catherine; Dar, Peer; Rosner, Mara; Bernstein, Peter; Dayal, Ashlesha K; Wolfe, Diana
ISI:000398934900335
ISSN: 0029-7844
CID: 2634972

The impact of universal cervical length screening on the optimal timing of antenatal corticosteroid administration [Meeting Abstract]

Igel, Catherine; Neto, Nicole; Wolfe, Diana; Dar, Pe'er; Dayal, Ashlesha; Angert, Robert; Rosner, Mara
ISI:000367092800849
ISSN: 1097-6868
CID: 2634962

Actual rates of recommended diagnostic testing after first trimester screening vs. same-day screening by cell free DNA [Meeting Abstract]

Buresch, Arin; Rosner, Mara; Suskin, Barrie; Einstein, Francine; Bircaj, Emnonila; Lister, Rolanda; Klugman, Susan; Dar, Pe'er
ISI:000367092800604
ISSN: 1097-6868
CID: 2634952

Long-term neurologic outcomes after common fetal interventions

Gebb, Juliana; Dar, Pe'er; Rosner, Mara; Evans, Mark I
OBJECTIVE: Fetal interventions have clearly decreased mortality, but the neurological outcomes of survivors are of critical concern. Here we consolidated available data on long-term neurological outcomes after common fetal interventions to guide counseling, management, and future research. STUDY DESIGN: Published studies assessing long-term neurological outcomes after common fetal interventions from 1990 through 2014 were collected. We included all studies with a cohort of more than 5 patients and with follow-up of 1 year or longer. We divided procedures into those performed for singletons and for multiples. Singleton procedures included amnioinfusion for preterm premature rupture of membranes, intrauterine transfusion for red cell alloimmunization-associated anemia, intrauterine transfusion for parvovirus-associated anemia, vesicoamniotic shunts, thoracoamniotic shunts, ventriculoamniotic shunts, fetal endoscopic tracheal occlusion for congenital diaphragmatic hernia, and open fetal cases by myelomeningocele and others. Multiple procedures included those done for monochorionic twins including serial amnioreduction, selective fetoscopic laser photocoagulation, and selective termination. RESULTS: Of 1341 studies identified, 28 met the inclusion criteria. We combined available literature for all procedures. Studies varied in their length of follow-up and method of assessing neurological status. Neurological outcome after intervention varied by procedure but was normal in 40-93%, mildly impaired in 3-33%, and severely impaired in 1-40%. Follow-up to school age was rare with the exception of procedures for monochorionic twins. CONCLUSION: Fetal treatments have been successful in achieving survival in previously hopeless cases, but success should also be determined by the outcomes of survivors. Except for monochorionic twins, there is a dearth of reported long-term outcomes. Standardized reporting of long-term neurological sequelae is imperative so that meaningful analysis and study comparisons can be made.
PMID: 25448510
ISSN: 1097-6868
CID: 2634992

First-trimester 3D power Doppler of the uteroplacental circulation space and fetal growth restriction

Rosner, Mara; Dar, Pe'er; Reimers, Laura L; McAndrew, Thomas; Gebb, Juliana
OBJECTIVE: The objective of the study was to compare the 3-dimensional power Doppler (3DPD) of the uteroplacental circulation space in the first trimester between women who subsequently deliver growth-restricted vs normally grown neonates. STUDY DESIGN: This was a prospective observational study of singleton pregnancies at 11-14 weeks' gestation. The 3DPD indices, vascularization index, flow index, and vascularization flow index were determined on a uteroplacental circulation space sphere biopsy with the virtual organ computer-aided analysis program. Growth restriction was defined as a birthweight less than the 10th percentile for gestational age and was evaluated using both population-based and customized birth curves. RESULTS: Five hundred seventy-seven women were enrolled. Five hundred twenty-six were eligible for analysis using population centiles, and 497 were available for evaluation using customized centiles. There was no difference in the first-trimester 3DPD indices between patients with growth-restricted and normally grown neonates using either curve. CONCLUSION: Three-dimensional power Doppler indices of the uteroplacental circulation space in the first trimester are similar between neonates who develop growth restriction and those who will grow normally.
PMID: 24834864
ISSN: 1097-6868
CID: 2635002

Clinical Outcomes of Anterior Compared With Posterior Placenta Accreta [Meeting Abstract]

Koai, Esther; Hadpawat, Anita; Gebb, Juliana; Goffman, Dena; Dar, Peer; Rosner, Mara
ISI:000339079900127
ISSN: 1873-233x
CID: 2634932

Clinical Outcomes and Efficacy of Antenatal Diagnosis of Placenta Accreta Using Ultrasonography and Magnetic Resonance Imaging [Meeting Abstract]

Koai, Esther; Hadpawat, Anita; Gebb, Juliana; Goffman, Dena; Dar, Peer; Rosner, Mara
ISI:000339079900128
ISSN: 1873-233x
CID: 2634942