Faculty Bibliography

OBJECTIVE: To determine if a structured teaching module improves resident competency in transvaginal sonographic cervical length measurements. METHODS: This was a prospective cohort study involving obstetrics and gynecology residents at a single institution. Residents collected 10 transvaginal cervical images from patients with threatened preterm labor presenting to Labor and Delivery. After initial image acquisition, residents participated in a lecture-based teaching module involving a pre- and post-intervention assessment. Following the didactic session, they collected 10 additional images. All the images were scored independently by two Maternal-Fetal Medicine attending physicians based on the quality and accuracy of the measured cervical length. Pre-and post- intervention test results were compared, as well as pre- and post- intervention image scores. Parametric and nonparametric tests were used as appropriate with p < 0.05 considered significant. RESULTS: Ninety-three percent of the residents (14/15) improved their scores from pre-test to post-test or maintained an already perfect score (p < 0.01). Improvement was most significant with the junior residents. Seventy-nine percent of the residents (11/14) improved their cervical image scores after the educational session. Mean score for total residents was 73.7 + 12.6 pre-intervention and 90.2 + 9.9 post-intervention (p < 0.01) out of a total of 120. CONCLUSIONS: There is an improvement in the competence of resident measured cervical lengths via transvaginal ultrasound when a structured educational module is implemented for resident education.

Triplet gestations are associated with high perinatal morbidity. Dichorionic-diamniotic triplet pregnancies with growth discordance, polyhydramnios and structural anomalies carry a significantly increased risk of fetal morbidity and mortality from the baseline risks of high-order multiple pregnancies. Intrauterine fetal death of one fetus of a monochorionic pregnancy may cause neurological injury to the surviving fetus. We present a case where an innovative technique was created combining use of the fetoscopic laser and miniature laparoscopic instruments to selectively reduce and disentangle the umbilical cord of the acranial growth-restricted fetus from the structurally normal fetus's umbilical cord in a dichorionic-diamniotic triplet pregnancy.

Untreated fetal pleural effusion can cause significant perinatal morbidity and mortality. Treatment of pleural effusions with pleuro-amniotic shunting has been shown to improve outcomes. Pleuro-amniotic shunting is associated with complications including ruptured membranes, preterm labor and shunt dislodgement into either the amniotic cavity or the fetal thorax. Shunt dislodgement into the thoracic cavity can cause prenatal complications from the shunt itself or may necessitate neonatal surgery for removal. We present a case where a novel ultrasound-guided technique was used to replace the dislodged pleural shunt in utero, thereby effectively draining the effusion while simultaneously obviating the need for neonatal surgery and decreasing possible perinatal complications.

OBJECTIVE: To determine the practice patterns of antenatal corticosteroid (AS) administration in women with threatened preterm labor. METHODS: This was a retrospective cohort of patients who received betamethasone between 2009 and 2010, identified through a pharmacy database. Patients with high order multiples; incomplete records and indicated preterm delivery were excluded. Demographic and obstetrical factors were compared between women with an AS to delivery latency of 7 days. Parametric and non-parametric tests were used as appropriate. p < 0.05 denotes statistical significance; relative risks with 95% confidence intervals were calculated. RESULTS: Three-hundred forty-five patients were included. Sixty-eight patients (20%) received AS within 7 days of delivery. Women who received AS /=2 cm (RR: 3.86, CI: 2.7-5.6) and positive fFN (RR: 2.59, CI: 1.1-6.3). Preterm premature ruptured membranes were also associated with optimal timing of AS (RR: 4.86, CI: 3.4-6.8). CONCLUSIONS: Eighty percent of patients receive suboptimal timing of AS administration. Factors associated with suboptimal timing are: cervical length >2 cm, cervical dilation <2 cm and negative fFN. Cervical assessment should be a key factor in the decision for AS administration. More research is needed for accurate timing of AS in women with threatened preterm labor.

OBJECTIVE: We sought to determine the timing of administration of antenatal corticosteroids (AS) for indicated preterm births and to identify which indications are associated with the most optimal timing of administration. STUDY DESIGN: This was a retrospective cohort of patients who received AS in anticipation of indicated preterm birth from 2009 through 2012 at Winthrop University Hospital, Mineola, NY. Medical records of patients who received AS, as identified through the hospital pharmacy database, were reviewed. Patients were included if they had a singleton or twin gestation and they received AS for maternal or fetal indications. Women were excluded if they received AS for spontaneous preterm labor or preterm rupture of membranes. Maternal demographic and obstetrical characteristics were compared between those who received AS7 days from delivery using parametric and nonparametric tests with relative risks and 95% confidence intervals. P<.05 was considered significant. RESULTS: In all, 193 patients were included in this study. Median latency from AS administration to delivery was 9 days (range, 0-83); 93 patients (48%) received AS within 7 days of delivery. There were no significant differences between the 2 groups with regards to baseline maternal characteristics. Those delivering within 7 days of AS administration were more likely to have maternal vs fetal indications (84% vs 16%). CONCLUSION: Only 48% of patients with an indication for preterm birth received AS within 7 days of its administration. AS appear to be more optimally timed in the presence of maternal rather than fetal indications.

OBJECTIVES: To determine whether intertwin discordant abdominal circumference, femur length, head circumference, and estimated fetal weight sonographic measurements in early second-trimester monochorionic diamniotic twins predict adverse obstetric and neonatal outcomes. METHODS: We conducted a multicenter retrospective cohort study involving 9 regional perinatal centers in the United States. We examined the records of all monochorionic diamniotic twin pregnancies with two live fetuses at the 16- to 18-week sonographic examination who had serial follow-up sonography until delivery. The intertwin discordance in abdominal circumference, femur length, head circumference, and estimated fetal weight was calculated as the difference between the two fetuses, expressed as a percentage of the larger using the 16- to 18-week sonographic measurements. An adverse composite obstetric outcome was defined as the occurrence of 1 or more of the following in either fetus: intrauterine growth restriction, twin-twin transfusion syndrome, intrauterine fetal death, abnormal growth discordance (>/=20% difference), and very preterm birth at or before 28 weeks. An adverse composite neonatal outcome was defined as the occurrence of 1 or more of the following: respiratory distress syndrome, any stage of intraventricular hemorrhage, 5-minute Apgar score less than 7, necrotizing enterocolitis, culture-proven early-onset sepsis, and neonatal death. Receiver operating characteristic and logistic regression-with-generalized estimating equation analyses were constructed. RESULTS: Among the 177 monochorionic diamniotic twin pregnancies analyzed, intertwin abdominal circumference and estimated fetal weight discordances were only predictive of adverse composite obstetric outcomes (areas under the curve, 79% and 80%, respectively). Receiver operating characteristic curves showed that intertwin discordances in abdominal circumference, femur length, head circumference, and estimated fetal weight were not acceptable predictors of twin-twin transfusion syndrome or adverse neonatal outcomes. CONCLUSIONS: In our cohort, only second-trimester abdominal circumference and estimated fetal weight discordances in monochorionic diamniotic twin pregnancies were predictive of adverse composite obstetric outcomes. Twin-twin transfusion syndrome and adverse neonatal outcomes were not predicted by any of the intertwin discordances measured.

BACKGROUND: The incidence of cesarean scar pregnancy (CSP) is rising due to the increasing numbers of cesarean deliveries in the United States. However, little is known with respect to epidemiology, best screening methodologies, and treatment options. CASES: Three patients in their first trimester of pregnancy presented with a history of cesarean delivery and were diagnosed by pelvic ultrasound as having CSP. Methods of treatment included definitive surgery with hysterectomy or conservative management with methotrexate and lidocaine injection into the gestational sac. CONCLUSION: In patients with prior cesarean delivery, careful attention to all possible ultrasound signs of CSP during routine first trimester ultrasound is important for an early diagnosis, which can allow for various treatment options.