Faculty Bibliography

BACKGROUND:Patent foramen ovale (PFO) is a common finding that occurs in approximately 25% of the population and, in the absence of clinical sequelae, is considered benign. However, PFO can potentially become clinically significant and result in systemic embolization, strokes, or hypoxemia. During pregnancy, hemodynamic cardiovascular changes may unmask previously undetected congenital heart anomalies or exacerbate existing ones, affecting both mother and fetus. CASE SUMMARY/METHODS:A healthy 33-year-old woman developed symptomatic hypoxemia on minimal exertion during pregnancy secondary to newly diagnosed right-to-left intracardiac shunting through a PFO. We posit that the physiological changes of pregnancy enhanced this abnormal streaming through the PFO without evidence of pulmonary hypertension. The patient had a successful percutaneous occlusion of the PFO with a 25-mm Amplatzer cribriform septal occluder device at 18 weeks' gestation, with appropriate fetal protection. CONCLUSIONS:Pregnancy may produce or accentuate acute hypoxemia due to right-to-left shunting through a PFO. The PFO may be safely treated with percutaneous device closure to resolve hypoxemia-related symptoms and avert risks of hypoxia to the developing fetus.

BACKGROUND/UNASSIGNED:Although infective endocarditis during pregnancy is rare, it carries significant morbidity and mortality for both mother and foetus. While professional societies provide recommendations for the treatment of infective endocarditis, there are no specific guidelines for the management of pregnancy-associated infective endocarditis. In this report, we present two cases of infective endocarditis presenting during the second trimester of pregnancy that required surgical intervention, focusing on the unique considerations when caring for pregnant individuals. CASE SUMMARIES/UNASSIGNED:Two patients in the second trimester of pregnancy presented with fevers and malaise. Both were found to have positive blood cultures and mitral valve vegetations, leading to diagnoses of mitral valve endocarditis. Their hospital courses were complicated by embolic strokes, and one patient required transcatheter embolization of a mycotic aneurysm. Both patients underwent surgical valve replacements with bioprosthetic valves. Ultimately, both patients delivered at term without complication. DISCUSSION/UNASSIGNED:In addition to the standard management of infective endocarditis, pregnancy-associated infective endocarditis requires multidisciplinary collaboration regarding the relative timing of cardiac surgery and delivery, the use of intraoperative foetal monitoring, and the choice of valve replacement and anticoagulation. Each of these decisions requires balancing the risk of morbidity and mortality to the patient, the risk of neonatal prematurity and associated complications and disability, and the risk of foetal death during cardiopulmonary bypass. We discuss our teams' decision-making processes with a focus on the relevant considerations for each of these challenging decisions.

OBJECTIVE:The aim of this study was to evaluate the incidence of congenital anomalies in dichorionic-diamniotic twins conceived with in-vitro fertilization (IVF) versus unassisted conception pregnancies in a large geographically diverse population. DESIGN/METHODS:This is a secondary analysis of data from a retrospective cohort study of twin pregnancies seen at 17 centers between 12/2011-2/2020. SUBJECTS/METHODS:This study included dichorionic-diamniotic twins conceived unassisted, or by in-vitro fertilization. EXPOSURE/METHODS:The exposure group is dichorionic-diamniotic twins conceived with IVF. MAIN OUTCOME MEASURE/METHODS:The primary outcome was presence of a congenital anomaly. Neonates with an abnormal newborn exam were evaluated for having a major or minor congenital anomaly and the major anomalies were further classified by organ system (cardiac, renal/genitourinary, gastrointestinal, and musculoskeletal). RESULTS:Of the 968 dichorionic-diamniotic twin pregnancies included, 521 (53.8%) were conceived with IVF and 447 (46.2%) were conceived unassisted. Congenital anomalies were found in 70 pregnancies (7.23%). Of those, 37 were found in pregnancies conceived by IVF (52.9%) versus 33 unassisted conception pregnancies (47.1) (p=0.87). There were no significant differences between IVF and unassisted conception pregnancies for major anomalies (p=0.65) or minor anomalies (p=0.94). CONCLUSION/CONCLUSIONS:In this large cohort of twin pregnancies, there is no significant difference in the incidence of anomalies for dichorionic-diamniotic twin pregnancies conceived by IVF versus unassisted conception pregnancies.

BACKGROUND:Perinatal ovarian cysts may spontaneously resolve or cause ovarian torsion. Cyst size and appearance often guide surgical decision making. The natural history of these cysts and impact of perinatal interventions on ovarian outcomes remain unclear. We investigated the association of various clinical parameters with operative intervention and ovarian loss. METHODS:Infants with ovarian cysts meeting our definition of perinatal (diagnosed between 15 weeks gestational age and 1 year) from November 2006-January 2022 were identified. Cysts were characterized by size, morphology, laterality, and evolution. Outcome measures included resolution, ovarian loss, and operative intervention. Mann-Whitney U and Fisher exact tests were used. Optimal maximal size cutoffs were obtained using ROC curves. RESULTS:Sixty-two female patients with perinatal ovarian cysts were identified. Spontaneous resolution occurred in 35, prenatally and postnatally, with follow-up length averaging 186 days. Of 18 undergoing cystectomies, 9 revealed non-viable ovaries. Overall ovarian loss rate was 29%. Loss occurred more frequently with large, complex, and right-sided cysts (P < 0.05) but some complex cysts also resolved spontaneously. Operative intervention occurred more frequently with larger cysts (P=<0.001) and was associated with ovarian salvage when performed earlier (P = 0.008) on larger cysts (P = 0.02). Maximal cyst diameter > 4.05 cm predicted ovarian loss with 78% sensitivity, 64% specificity (AUC = 0.67,95%CI = 0.54-0.81, P = 0.04). Maximal cyst diameter > 4.55 cm predicted surgery with 83% sensitivity, 82% specificity (AUC = 0.86,95%CI = 0.77-0.96, P < 0.001). CONCLUSIONS:29% of perinatal ovarian cysts resulted in ovarian loss. 56% resolved spontaneously (prenatal and postnatal resolution) including some complex cysts. Cysts that were postnatally complex and maximally > 4 cm had higher rates of ovarian loss and operative intervention. Earlier postnatal operative intervention was associated with ovarian preservation. Standardized imaging (such as the IOTA terminology) and management protocols are needed to better understand behavior and improve treatment of these cysts.

OBJECTIVE:Social determinants of health (SDOH) may impact the incidence of Respiratory Syncytial Virus (RSV) infection and the uptake of vaccinations in pregnancy. The objective of this study is to identify contributors to disparities in RSV vaccination in pregnancy. DESIGN/METHODS:This is a retrospective cohort study of patients delivering at term within three hospitals during February and March 2024, comparing pregnant patients identified as receiving vs not receiving RSV vaccinations. This period and gestational age were chosen to include patients who would have qualified for RSV vaccination administration. Vaccination status was extracted from standardized admission templates where these variables were recorded as discrete fields. Patients without RSV vaccination information were excluded. Sociodemographic factors, COVID vaccination status, and delivery campus were evaluated. Outcomes were analyzed using chi-squared, t-test, and McNemar test. RESULT/RESULTS:2181 patients met inclusion criteria and RSV vaccination information was available for 1548 patients (71%) with a 14% vaccination rate. Compared to those not vaccinated (n=1332), RSV vaccinated patients (n=216) were more likely to be older (30.7 vs 34.8, p<0.001), have private insurance (42% vs 85%, p<0.001), speak English (82% vs 95%, p<0.001), and deliver at our regional perinatal center (26% vs 77%, p<0.001). 50% of RSV vaccinated patients had a history of COVID vaccination compared to 33% of those not vaccinated against RSV (p<0.001). CONCLUSIONS:SDOH were associated with differences in RSV vaccination status. In addition, patients without RSV vaccination were less likely to have had COVID vaccination. These findings highlight the need to address SDOH to increase vaccination rates for vulnerable populations.

BACKGROUND:The relationship between fetal fraction and birth weight in twin gestations is poorly understood. OBJECTIVE:To investigate the relationship between first trimester cfDNA fetal fraction and birth weight < 10th percentile in twin gestations. STUDY DESIGN/METHODS:This is a planned secondary analysis of the Twin cfDNA Study, a 17-center retrospective cohort of twin pregnancies screened for aneuploidy using cfDNA in the first trimester from 12/2011 - 2/2022, excluding those with positive screen results for chromosomal aneuploidy. CfDNA testing was performed by a single lab using massively parallel sequencing (MPSS). Baseline characteristics and birth weight of pregnancies with normal fetal fraction were compared to those with low (<5%) and high (>95%) fetal fraction using univariable analyses and multivariable regression. RESULTS:A total of 1041 twin pregnancies were included. Chronic hypertension, elevated BMI, and self-identified Black race were associated with fetal fraction <5th percentile. There was no difference in median fetal fraction between those with birth weight <10th percentile in at least one twin (median [IQR] fetal fraction 12.2% [9.8, 14.8] versus those with normal birth weight (10th percentile) in both twins (median [IQR] fetal fraction 12.3% [9.7, 15.2] for normal birth weight, p = 0.49). There was no association between high or low fetal fraction and birth weight <10th percentile for one (p=0.45) or both (p=0.81) twins, and there was no association between high or low fetal fraction and birth weight <5th percentile for one (p=0.44) or both (p=0.74) twins. The results were unchanged after adjustment for potential confounders. CONCLUSION/CONCLUSIONS:In this large cohort, there was no association between the extremes of cfDNA fetal fraction and birthweight < 10th percentile, suggesting that first trimester fetal fraction may not predict impaired fetal growth in twin gestations.

OBJECTIVE:To investigate the relationship between platelet indices (count, size and production/immaturity) and hypertensive disorders of pregnancy. STUDY DESIGN/METHODS:This was a secondary analysis of a prospective cohort of pregnant individuals followed from first trimester through delivery at an academic tertiary care institution. Routine platelet indices obtained prospectively during prenatal care and delivery were compared between those who developed a hypertensive disorder of pregnancy and those who did not. We assessed platelet count (by trimester), mean platelet volume, and immature platelet fraction measured as percent (%) and absolute count. Data were analyzed using Fisher's Exact test, chi-square test, and multivariable logistic regression. P < 0.05 was considered statistically significant. RESULTS: = 0.01) compared to those without a hypertensive disorder of pregnancy, after adjusting for age, race/ethnicity, obesity, nulliparity, and chronic hypertension. The prevalence and likelihood of a hypertensive disorder of pregnancy increased with increasing mean platelet volume, as well as with both the percent and absolute immature platelet fraction. There was no difference between groups in platelet count in the first trimester, second trimester, or at delivery. CONCLUSIONS:An increase in platelet size and immaturity was observed in those with a hypertensive disorder of pregnancy. These data support further investigation of platelets in the mechanisms of the development of hypertensive disorders of pregnancy and the use of platelet indices to better identify high risk groups in pregnancy.

Vasa previa is an abnormality of the umbilical cord and fetal membranes that affects ∼1 in 1300 pregnancies. The diagnosis is made by visualization of velamentous fetal vessels coursing within the membranes over the cervix unprotected by Wharton jelly or placenta. When it is not diagnosed prenatally, it is associated with a high risk of fetal death. Prenatal diagnosis of vasa previa using ultrasound, followed by close surveillance, and appropriately timed late preterm delivery by cesarean is associated with intact survival in >95% of cases. In this review, we review epidemiology, risk factors, diagnosis, and management of patients with vasa previa.