Faculty Bibliography

BACKGROUND:'Incarcerated gravid uterus' is a morbid complication that occurs in 1 in 3000 pregnancies. It is characterized by failure of a retropositioned uterus to become an abdominal organ between 12 to 14 weeks of gestation. If maternal symptoms develop or gestational age surpasses 14 to 16 weeks, replacement of a retropositioned uterus is recommended to reduce adverse outcomes. Previously described techniques for management include passive reduction, digital replacement, or more invasive methods such as laparoscopy, laparotomy, or sigmoidoscopy. These methods are either minimally effective, painful, or risky. OBJECTIVE:The objective of this report is to describe our clinical experience with a new minimally invasive technique that uses the transvaginal ultrasound probe for uterine replacement in cases of incarceration, to conduct a narrative literature review on 'incarcerated gravid uterus,' and to propose an algorithm for management of this condition. STUDY DESIGN/METHODS:This is a case series of 8 patients with an incarcerated gravid uterus who were managed with the transvaginal ultrasound probe technique at one academic medical institution between March 2020 and July 2023, as well as a narrative review of the literature on 'incarcerated gravid uterus.' PubMed, Google Scholar, and Ovid MEDLINE databases were searched for the terms "incarcerated gravid uterus," "uterine incarceration," "uterine sacculation," and "retroverted uterus" up to April 2024. RESULTS:The transvaginal ultrasound probe technique resulted in successful uterine replacement, with resolution of symptoms, in all 8 patients. All pregnancies resulted in live births with good neonatal outcomes-7 out of 8 patients delivered at term, and 1 delivered in the late preterm period. CONCLUSION/CONCLUSIONS:Our proposed technique for treatment of an incarcerated gravid uterus with the transvaginal ultrasound probe is simple, minimally invasive and effective. Based on our experience and the narrative literature review, an algorithm for the management of an incarcerated gravid uterus is proposed.

OBJECTIVE:To evaluate whether insemination via intracytoplasmic sperm injection (ICSI) provides any benefit over in vitro fertilization (IVF) insemination for nonmale factor infertility with respect to preimplantation genetic testing (PGT) results and pregnancy outcome. DESIGN/METHODS:Retrospective cohort study of the Society for Assisted Reproductive Technology database. SETTINGS/METHODS:US-based fertility clinics reporting to the Society for Assisted Reprodcutive Technology. PATIENTS/METHODS:Patients undergoing IVF or ICSI inseminations in nonmale factor PGT for aneuploidy cycles. INTERVENTION/METHODS:In vitro fertilization vs. ICSI inseminations. MAIN OUTCOME MEASURES/METHODS:Primary outcomes were the percentage of embryos suitable for transfer and live birth rates (LBRs). Secondary outcomes included subgroup analysis for embryos suitable for transfer on cycles from patients ≥35-year-old vs. <35-year-old, ≤6 oocytes retrieved vs. >6 oocytes retrieved, and unexplained infertility. Additionally, gestational age at delivery and birth weight between IVF and ICSI inseminations were evaluated. RESULTS:A total of 30,446 nonmale factor PGT diagnoses for aneuploidy cycles were evaluated, of which 4,867 were IVF inseminations and 25,579 were ICSI inseminations. Following exclusion criteria and adjustment for any necessary confounding variables, no significant differences existed in embryos suitable for transfer between IVF and ICSI treatment cycles, 41.6% (40.6%, 42.6%) vs. 42.5% (42.0%, 42.9%), respectively, or in LBRs, 50.1% (37.8, 62.4%) vs. 50.8% (38.5%, 62.9%), respectively. CONCLUSION/CONCLUSIONS:There were no significant differences in the rates of embryos suitable for transfer and LBRs between IVF and ICSI inseminations in nonmale factor cycles undergoing PGT for aneuploidy.

BACKGROUND:Diabetes mellitus is a common medical complication of pregnancy, and its treatment is complex. Recent years have seen an increase in the application of mobile health tools and advanced technologies, such as remote patient monitoring, with the aim of improving care for diabetes mellitus in pregnancy. Previous studies of these technologies for the treatment of diabetes in pregnancy have been small and have not clearly shown clinical benefit with implementation. OBJECTIVE:Remote patient monitoring allows clinicians to monitor patients' health data (such as glucose values) in near real-time, between office visits, to make timely adjustments to care. Our objective was to determine if using remote patient monitoring for the management of diabetes in pregnancy leads to an improvement in maternal and neonatal outcomes. STUDY DESIGN/METHODS:This was a retrospective cohort study of pregnant patients with diabetes mellitus managed by the maternal-fetal medicine practice at one academic institution between October 2019 and April 2021. This practice transitioned from paper-based blood glucose logs to remote patient monitoring in February 2020. Remote patient monitoring options included (1) device integration with Bluetooth glucometers that automatically uploaded measured glucose values to the patient's Epic MyChart application or (2) manual entry in which patients manually logged their glucose readings into their MyChart application. Values in the MyChart application directly transferred to the patient's electronic health record for review and management by clinicians. In total, 533 patients were studied. We compared 173 patients managed with paper logs to 360 patients managed with remote patient monitoring (176 device integration and 184 manual entry). Our primary outcomes were composite maternal morbidity (which included third- and fourth-degree lacerations, chorioamnionitis, postpartum hemorrhage requiring transfusion, postpartum hysterectomy, wound infection or separation, venous thromboembolism, and maternal admission to the intensive care unit) and composite neonatal morbidity (which included umbilical cord pH <7.00, 5 minute Apgar score <7, respiratory morbidity, hyperbilirubinemia, meconium aspiration, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pneumonia, seizures, hypoxic ischemic encephalopathy, shoulder dystocia, trauma, brain or body cooling, and neonatal intensive care unit admission). Secondary outcomes were measures of glycemic control and the individual components of the primary composite outcomes. We also performed a secondary analysis in which the patients who used the two different remote patient monitoring options (device integration vs manual entry) were compared. Chi-square, Fisher's exact, 2-sample t, and Mann-Whitney tests were used to compare the groups. A result was considered statistically significant at P<.05. RESULTS:Maternal baseline characteristics were not significantly different between the remote patient monitoring and paper groups aside from a slightly higher baseline rate of chronic hypertension in the remote patient monitoring group (6.1% vs 1.2%; P=.011). The primary outcomes of composite maternal and composite neonatal morbidity were not significantly different between the groups. However, remote patient monitoring patients submitted more glucose values (177 vs 146; P=.008), were more likely to achieve glycemic control in target range (79.2% vs 52.0%; P<.0001), and achieved the target range sooner (median, 3.3 vs 4.1 weeks; P=.025) than patients managed with paper logs. This was achieved without increasing in-person visits. Remote patient monitoring patients had lower rates of preeclampsia (5.8% vs 15.0%; P=.0006) and their infants had lower rates of neonatal hypoglycemia in the first 24 hours of life (29.8% vs 51.7%; P<.0001). CONCLUSION/CONCLUSIONS:Remote patient monitoring for the management of diabetes mellitus in pregnancy is superior to a traditional paper-based approach in achieving glycemic control and is associated with improved maternal and neonatal outcomes.

BACKGROUND:Cesarean rates have been used as obstetrical quality indicators. However, these approaches do not take into consideration the accompanying maternal and neonatal morbidity. A challenge in the field of obstetrics has been to establish a valid outcomes quality measure that encompasses pre-existing high-risk maternal factors, as well as associated maternal and neonatal morbidity that is universally acceptable to all stakeholders including patients, health care providers, payers, and governmental agencies. OBJECTIVES/OBJECTIVE:The objectives of this study were to: (i) establish a new single metric for obstetric quality improvement among nulliparous with term, singleton, vertex (NTSV) patients, which integrates cesarean rates adjusted for pre-existing high risk maternal factors with the associated maternal and neonatal morbidity; this single metric has been termed obstetric safety and quality index (OSQI); and (ii) determine if obstetrician quality ranking by this new metric is different as compared to the rating based on individual crude and/or risk-adjusted cesarean rates. STUDY DESIGN/METHODS:This is a cross-sectional study that identified all NTSV patients delivered by 12 randomly chosen obstetricians in a single institution. A review of all records was performed including maternal high-risk factors, maternal and neonatal outcomes. Maternal and neonatal charts were reviewed to determine crude and adjusted cesarean rates by obstetrician, and to quantify maternal and neonatal complications. We estimated the obstetrician-specific crude cesarean rates, as well as rates adjusted for obstetrician-specific maternal and neonatal complications from logistic regression models. From this model, we derived the OSQI index for each obstetrician. The final ranking based on the OSQI was compared to the initial ranking by crude cesarean rates. Maternal and neonatal morbidities were analyzed as ≥1 and as well as ≥2 maternal and/or neonatal complications. RESULTS:These 12 obstetricians delivered a total of 535 women; thus, 1070 (535 maternal and 535 neonatal) charts were reviewed to determine crude and adjusted cesarean rates by obstetrician, and to quantify maternal and neonatal complications. The ranking of crude cesarean delivery rates was not correlated (rho=0.05, 95% confidence interval -0.54, 0.60) to the final ranking based on the OSQI index. Eight of 12 obstetricians shifted their rank quartiles following adjustments for high-risk maternal conditions and maternal and neonatal outcomes. There was a strong correlation between the ranking based on ≥1 vs. ranking based on ≥2 CMM/CNM (rho=0.63, 95% confidence interval 0.08, 0.88). CONCLUSIONS:Ranking based on crude cesarean rates varies significantly after considering high-risk maternal conditions and the associated maternal and neonatal outcomes. Therefore, the OSQI is a single metric which may potentially help to identify ways to improve upon clinician practice standards within an institution. Use of this novel quality measure may help to change initiatives geared towards patient safety balancing cesarean rates with maternal and neonatal mortality. This metric could potentially be also used to compare obstetric quality not only among individual obstetricians but also among hospitals which practice obstetrics.