Faculty Bibliography

Placental implantation abnormalities, including placenta previa, placenta accreta, vasa previa, and velamentous cord insertion, can have catastrophic consequences for both mother and fetus, especially as pregnancy progresses to term. In these situations, current recommendations for management usually call for an indicated preterm delivery even in asymptomatic patients. However, the recommended gestational age(s) for delivery in asymptomatic patients are empirically determined without consideration of the recent literature regarding the usefulness of specific ultrasound findings to help individualize management. The purpose of this article is to propose literature-supported guidelines to the current opinion-based management of asymptomatic patients with placental implantation abnormalities based on relevant and specific ultrasound findings such as cervical length, distance between the internal cervical os and placenta, and placental edge thickness.

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.

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.