Faculty Bibliography

The efficacy of treating cesarean scar pregnancies and cervical pregnancies with the Cook® cervical ripening balloon catheter, in a multicenter office-based setting is reported. Thirty-eight women were treated. Insertion of the catheter was performed under real-time ultrasound guidance. Patients received adjuvant systemic methotrexate, prophylactic oral antibiotics, and oral pain medication. Serum human chorionic gonadotropin and ultrasound scans were followed serially until resolution. Thirty-seven patients were successfully treated, requiring no further procedures. We found that the Cook cervical ripening balloon technique is a simple, effective, outpatient, minimally invasive treatment with few complications noted in this expanded series.

Ventriculomegaly is defined as dilation of the fetal cerebral ventricles and is a relatively common finding on prenatal ultrasound. The purpose of this document is to review the diagnosis, evaluation, and management of mild fetal ventriculomegaly. When enlargement of the lateral ventricles (≥10 mm) is identified, a thorough evaluation should be performed, including detailed sonographic evaluation of fetal anatomy, amniocentesis for karyotype and chromosomal microarray analysis (CMA), and a workup for fetal infection. In some cases, fetal magnetic resonance imaging (MRI) may identify other central nervous system abnormalities and should be considered when this technology as well as expert interpretation is available. Follow-up ultrasound examination should be performed to assess for progression of the ventricular dilation. In the setting of isolated ventriculomegaly of 10 to 12 mm, the likelihood of survival with normal neurodevelopment is greater than 90%. With moderate ventriculomegaly (13-15 mm), the likelihood of normal neurodevelopment is 75-93%. The following are Society for Maternal-Fetal Medicine recommendations: we suggest that ventriculomegaly be characterized as mild (10-12 mm), moderate (13-15 mm), or severe (>15 mm) for the purposes of patient counseling, given that the chance of an adverse outcome and potential for other abnormalities are higher when the ventricles measure 13-15 mm versus 10-12 mm (GRADE 2B); we recommend that diagnostic testing (amniocentesis) with CMA should be offered, when ventriculomegaly is detected (GRADE 1B); we recommend testing for CMV and toxoplasmosis when ventriculomegaly is detected, regardless of known exposure or symptoms (GRADE 1B); we suggest that MRI be considered in cases of mild or moderate fetal ventriculomegaly when this modality and expert radiologic interpretation are available; an MRI is likely to be of less value if the patient has had a detailed ultrasound performed by an individual with specific experience and expertise in sonographic imaging of the fetal brain (GRADE 2B); we recommend that timing and mode of delivery be based on standard obstetric indications (GRADE 1C); we recommend that with isolated mild ventriculomegaly of 10 mm to 12 mm, after a complete evaluation, women be counseled that the outcome is favorable, and the infant is likely to be normal (GRADE 1B); we recommend that with isolated moderate ventriculomegaly of 13 mm to 15 mm, after a complete evaluation, women be counseled that the outcome is likely to be favorable but that there is an increased risk of neurodevelopmental disabilities (GRADE 1B).

OBJECTIVES: To assess whether cesarean delivery changes the natural position of the uterus. METHODS: In this retrospective Institutional Review Board-approved cohort study, we conducted a search of our university gynecologic ultrasonography (US) database. Patients with transvaginal US images before and after either vaginal or cesarean delivery between 2012 and 2015 were included. Women with prior cesarean delivery were excluded. Two readers independently measured antepartum and postpartum flexion angles between the longitudinal axis of the uterine body and the cervix. We calculated intraclass correlation coefficients to measure inter-reader agreement. Antepartum and postpartum uterine flexion angles were compared between patients with vaginal and cesarean delivery. RESULTS: We included 173 patients (107 vaginal and 66 cesarean delivery). The mean interval between scans +/- SD was 18 +/- 10 months. Inter-reader agreement for flexion angles was almost perfect (intraclass correlation coefficients: antepartum, 0.939; postpartum, 0.969; both P < .001). There was no difference in mean antepartum flexion angles for cesarean delivery (154.8 degrees +/- 45.7 degrees ) versus vaginal delivery (145.8 degrees +/- 43.7 degrees ; P = .216). Mean postpartum flexion angles were higher after cesarean delivery (180.4 degrees +/- 51.2 degrees ) versus vaginal delivery (152.8 degrees +/- 47.7 degrees ; P = .001. Differences in antepartum and postpartum flexion angles between cesarean and vaginal delivery were statistically significant (25.6 degrees versus 7.0 degrees ; P = .027). CONCLUSIONS: Cesarean delivery can change the uterine flexion angle to a more retroflexed position. Therefore, all women with a history of cesarean delivery should undergo a transvaginal US examination before any gynecologic surgery or intrauterine device placement to reduce the possibility of surgical complications.

OBJECTIVE:Early-onset fetal growth restriction is associated with poor pregnancy outcomes, but frequently is due to fetal structural or chromosomal abnormalities. The objective of this study was to determine outcomes in patients with early-onset fetal growth restriction without diagnosed fetal or genetic anomalies and to identify additional risk factors for poor outcomes in these patients. METHODS:This was retrospective cohort study of singleton pregnancies in women with early-onset growth restriction defined as a sonographic estimated fetal weight <10% diagnosed between 16-28 weeks' gestation. We excluded all women with a fetal structural or chromosomal abnormality diagnosed prenatally. Data on pregnancy characteristics and outcomes were collected and analyzed for estimated fetal weight <10% and ≤5%. A nested case-control study within the cohort of patients with ongoing pregnancies was then performed to identify risk factors associated with poor pregnancy outcome using chi-squared test. RESULTS:One hundred forty-two patients were identified who met inclusion and exclusion criteria and 20 patients were found to have fetal structural or chromosomal abnormalities. In the remaining 122 patients, the incidence of intrauterine fetal demise was 5.7% and there were high rates of preterm birth <37 weeks (20%), birth weight <10% (59.3%), and gestational hypertension (14.1%). Later gestational age at diagnosis and the presence of echogenic bowel and abnormal initial umbilical artery Dopplers were associated with poor pregnancy outcome (22.56 versus 20.86 weeks, p = .046), (17.4 versus 2.2%, OR 9.68, 95%CI 1.65-56.73), and (35.3 versus 0%, OR 4.46, 95%CI 2.65-7.50) respectively. CONCLUSIONS:Patients with early-onset fetal growth restriction with no fetal structural or genetic abnormality have a high risk of poor pregnancy outcomes. Gestational age at diagnosis and certain ultrasound findings are associated with poor pregnancy outcome.

Vein of Galen Malformation (VGM) constitutes a spectrum of arterio-venous malformations resulting in excess blood flow to the cerebral veins (1,2). Arteriovenous shunting caused by this malformation increases cardiac preload. Prenatal diagnosis is commonly made during the third trimester, with signs of cardiac failure (3,4). This report describes the challenges of prenatal diagnosis of VGM which presented as intracranial hemorrhage in the second trimester, prior to the onset of cardiac volume overload.

OBJECTIVES/OBJECTIVE:The primary aim of this systematic review was to ascertain whether ultrasound signs suggestive of abnormally invasive placenta (AIP) are present in the first trimester of pregnancy. Secondary aims were to ascertain the strength of association and the predictive accuracy of such signs in detecting AIP in the first trimester. METHODS:An electronic search of MEDLINE, EMBASE, CINAHL and Cochrane databases (2000-2016) was performed. Only studies reporting on first-trimester diagnosis of AIP that was subsequently confirmed in the third trimester either during operative delivery or by pathological examination were included. Meta-analysis of proportions, random-effects meta-analysis and hierarchical summary receiver-operating characteristics curve analysis were used to analyze the data. RESULTS:Seven studies, involving 551 pregnancies at high risk of AIP, were included. At least one ultrasound sign suggestive of AIP was detected in 91.4% (95% CI, 85.8-95.7%) of cases with confirmed AIP. The most common ultrasound feature in the first trimester of pregnancy was low implantation of the gestational sac close to a previous uterine scar, which was observed in 82.4% (95% CI, 46.6-99.8%) of cases. Anechoic spaces within the placental mass (lacunae) were observed in 46.0% (95% CI, 10.9-83.7%) and a reduced myometrial thickness in 66.8% (95% CI, 45.2-85.2%) of cases affected by AIP. Pregnancies with a low implantation of the gestational sac had a significantly higher risk of AIP (odds ratio, 19.6 (95% CI, 6.7-57.3)), with a sensitivity and specificity of 44.4% (95% CI, 21.5-69.2%) and 93.4% (95% CI, 90.5-95.7%), respectively. CONCLUSIONS:Ultrasound signs of AIP can be present during the first trimester of pregnancy, even before 11 weeks' gestation. Low anterior implantation of the placenta/gestational sac close to or within the scar was the most commonly seen early ultrasound sign suggestive of AIP, although its individual predictive accuracy was not high.

Cesarean scar pregnancy and cervical pregnancy are 2 relatively rare types of abnormally implanted pregnancies. Both if unrecognized can result in significant morbidity to the patient. The most important issue regarding cesarean scar pregnancy and cervical pregnancy is to establish the diagnosis early in order for the patient to be adequately counseled and appropriate management carried out. For both of these conditions early detection and treatment can result in preservation of fertility.

BACKGROUND: The term "cesarean scar pregnancy" (CSP) refers to placental implantation within the scar of a prior cesarean delivery. The rising numbers of cesarean deliveries in the last decades have lead to an increased incidence of CSP. Complications of CSP include: morbidly adherent placenta, uterine rupture, severe hemorrhage, and preterm labor. It is suspected that CSPs implanted within a dehiscent scar ("niche") behave differently compared to those implanted on top of a well healed scar. To date there are no studies comparing pregnancy outcomes between CSPs implanted either "on the scar" or "in the niche". OBJECTIVES: To determine the pregnancy outcome of CSP implanted either "in the scar" or "in the niche". MATERIAL AND METHODS: This was a retrospective two-center study of 17 patients with CSP diagnosed between 5-9 weeks gestation (median 8 weeks). All CSPs were categorized as either implanted or "on the scar" (Group A) or "in the niche" (Group B), based on their first trimester transvaginal ultrasound examination. Clinical outcomes based on gestational age at delivery, mode of delivery, blood loss at delivery, neonate weight and placental histopathology were compared between the groups using Mann-Whitney U-test. Myometrial thickness overlying the placenta was compared between all the patients requiring hysterectomy and those who did not, using Mann-Whitney U test. Myometrial thickness was also correlated with gestational age at delivery using Spearman's correlation. RESULTS: Group A consisted of 6 patients, and 11 patients were in group B. Gestational age at delivery was lower in group B (median 34 weeks, range 20-36 weeks) than in group A (median 38 weeks , range 37-39 weeks), p=0.001. In group A, 5 patients were delivered via cesarean delivery (with normal placenta) and one underwent a cesarean-hysterectomy for placenta accreta. In group B, 10 patients had a cesarean-hysterectomy for placenta increta/percreta and one patient underwent gravid-hysterectomy for vaginal bleeding at 20 weeks. Blood loss was increased, but not significantly higher in group B (median 1200ml, 600-4000ml) than in group A (median 700ml, 600-1400ml) p=0.117. Myometrium was statistically significantly thinner in the patients group requiring hysterectomy (median 1mm, range 0-2) than in than in the group that did not (median 5mm, range 4-9mm), p=0.001. Myometrial thickness showed a positive correlation with the gestational age (r=0.820, p<0.0005). CONCLUSION: Patients with CSP implanted "on the scar" had a substantially better outcome compared to patients in which the CSP implanted "in the niche". Myometrial thickness below 2mm in the first trimester ultrasound is associated with morbidly adherent placenta at delivery.