Faculty Bibliography

OBJECTIVE:We hypothesized that the origins of abruption may extend to the stages of placental implantation; however, there are no reliable markers to predict its development. Based on this hypothesis, we sought to evaluate whether first-trimester and second-trimester serum analytes predict placental abruption. METHODS:We performed a secondary analysis of data of 35,307 women (250 abruption cases) enrolled in the First and Second Trimester Evaluation of Risk cohort (1999-2003), a multicenter, prospective cohort study. Percentiles (based on multiples of the median) of first-trimester (pregnancy-associated plasma protein A and total and free β-hCG) and second-trimester (maternal serum alpha-fetoprotein, unconjugated estriol, and inhibin-A) serum analytes were examined in relation to abruption. Associations are based on risk ratio (RR) and 95% confidence interval (CI). RESULTS:Women with an abnormally low pregnancy-associated plasma protein A (fifth percentile or less) were at increased risk of abruption compared with those without abruption (9.6% compared with 5.3%; RR 1.9, 95% CI, 1.2-2.8). Maternal serum alpha-fetoprotein 95th percentile or greater was more common among abruption (9.6%) than nonabruption (5.1%) pregnancies (RR 1.9, 95% CI 1.3-3.0). Inhibin-A fifth percentile or less (8.0% compared with 5.1%; RR 1.8, 95% CI 1.1-2.9), and 95th percentile or greater (9.6% compared with 5.0%; RR 2.0, 95% CI 1.3-3.1) were associated with abruption. Women with all three abnormal pregnancy-associated plasma protein A, maternal serum alpha-fetoprotein, and inhibin-A analytes were at 8.8-fold (95% CI 2.3-34.3) risk of abruption. No associations were seen with other analytes. CONCLUSION:These data provide support for our hypothesis that the origins of placental abruption may extend to the early stages of pregnancy.

STUDY OBJECTIVE:To compare operative time in women stratified by body mass index (BMI) undergoing robotic-assisted sacrocolpopexy (RASC). Secondary objectives included characterizing perioperative characteristics and reoperation rates. DESIGN:Retrospective cohort study (Canadian Task Force classification II-2). SETTING:University-affiliated teaching hospital. PATIENTS:One hundred seventy-nine consecutive patients who underwent RASC by a single surgeon from 2009 through 2013. INTERVENTIONS:RASC. MEASUREMENTS AND MAIN RESULTS:). Overweight patients were significantly older, more parous, more frequently postmenopausal, and more frequently underwent concomitant salpingo-oophorectomy. Median operative times were 202, 206, and 216 minutes in the normal-weight, overweight, and obese groups, respectively (p = .53). CONCLUSION:Obese women undergoing RASC have similar operative time and procedural characteristics as normal-weight and overweight patients. Longer term outcomes are needed to ensure comparable surgical and anatomic success.

OBJECTIVE: The prenatal detection rate of isolated fetal limb abnormalities ranges from 4 to 29.5%. Our aim was to determine the accuracy of a detailed ultrasound protocol in detecting isolated fetal limb abnormalities Methods: This is a retrospective study of infants born at our institution with isolated limb defects from 2009 to 2014. Antepartum and postpartum records were reviewed for genetic testing results. We routinely image both upper and lower extremities, including all long bones, hands, feet, fingers and toes. Posturing, muscular tone and movement are also noted. RESULTS: During the study period, there were 52 neonates born with isolated fetal limb abnormalities who had received a fetal anatomic survey in our ultrasound unit and 15 930 sonograms performed with normal findings; 36 out of the 52 had been prenatally diagnosed (detection rate 69%). The specificity of the protocol was 100% as there were no false positive cases, the positive predictive value was 100% and negative predictive value 99.8%. Forty-three of 52 neonates had normal genetic testing either prenatally or postnatally; 9 neonates did not undergo genetic testing. The average additional time required for this detailed protocol was <5 min for second trimester sonogram. CONCLUSION: A minimal investment in time for detailed evaluation of fetal limbs more than doubles the previously reported prenatal detection rate.

PURPOSE OF REVIEW:Placental implantation abnormalities (PIAs) comprise a large group of disorders associated with significant maternal, fetal, and neonatal morbidity. RECENT FINDINGS:Risk factors include prior uterine surgery/myometrial scarring and the presence of placenta previa with or without prior cesarean delivery. Newly identified risk factors include previous prelabor cesarean delivery and previous postpartum hemorrhage. PIAs contribute substantially to preterm birth with prematurity rates ranging from 38 to 82%. Diagnosis is typically made by ultrasound in the second or third trimester; transvaginal ultrasound and color Doppler are useful in evaluating for placental invasion, placental edge thickness, presence of fetal vessels, and cervical length. Suggestive MRI features include increased vascularity, dark T2 bands, uterine bulging, thin or indistinct myometrium, and loss of dark T2 interface. An important first-trimester finding is the implantation of the gestational sac into prior hysterotomy scar (cesarean scar pregnancy). Recommendations for delivery are universally preterm and based on expert opinion. Proposed management strategies are outlined depending on cervical length, distance between internal cervical os and placenta, and placental edge thickness. SUMMARY:There has been a recent shift in focus to individualizing management in order to improve delivery timing and in some cases even decrease risks associated with prematurity. There is a need for larger prospective studies or randomized trials to show that individualizing care can improve outcomes.

Background:Cesarean scar ectopic pregnancies (CSPs) are becoming more prevalent and can have an extremely poor prognosis, with high morbidity and mortality. Management guidelines for patients desiring conservative treatment should be established to improve outcomes. Case:A 33-year-old woman with a conservatively managed CSP now in the second trimester presented from an outside institution. After thorough counseling regarding potential maternal morbidity and extreme prematurity in the newborn based on clinical findings of progressive cervical shortening and vaginal spotting with a significant drop in hemoglobin, she abandoned conservative therapy and underwent a hysterectomy with the previable fetus in situ. Conclusion:As pregnancy progresses, danger to the mother and fetus can become severe and imminent. Progressive cervical shortening may be associated with much more significant bleeding than evidenced by spotting, indicating the importance of using cervical shortening in abandonment of conservative management to reduce impending morbidity and mortality.

OBJECTIVE:The objective of this study is to compare resource utilization (efficiency) and obstetrical/cost outcomes of single dose misoprostol versus dinoprostone for induction of labor (IOL) at term. METHODS:Retrospective cohort of induced deliveries 37-41 weeks gestation presenting with a Bishop score ≤4 using single-dose-50 mcg vaginal misoprostol or 10 mg-dinoprostone vaginal-inserts. Dinoprostone patients were compared (5:1) with misoprostol patients. The primary outcome variable was length of L&D stay (proxy for resource utilization). Baseline characteristics, clinical outcomes, and costs were compared. RESULTS:Three-hundred thirty-one patients were included, 276 received dinoprostone and 55 received misoprostol. The misoprostol group had statistically significant decreased time to active labor [median 8 h (1.6,24) versus 12(0.8,52)], time-to-delivery [median 11 h (4,31) versus 17(2.8,56)] and L&D stay [median 16 h (13,28) versus 24(18,30)]. Differences remained significant after adjustment for race, method of delivery, birth weight, gravidity/parity, gestational age, and BMI (adjusted p values <0.001,  <0.01, and < 0.05, respectively). There were no statistical differences in Apgar scores, tachysystole rate, cesarean section rate, and composite maternal/neonatal morbidity. A policy of using misoprostol would result in annual cost savings of approximately $242 500 at our institution as compared with dinoprostone. CONCLUSION/CONCLUSIONS:Single-dose misoprostol is more efficient in IOL at term with respect to L&D utilization and cost and its use is not associated with increased adverse obstetrical outcomes.