Faculty Bibliography

Preeclampsia, intrauterine growth restriction (IUGR), and placental abruption are obstetrical conditions that constitute the syndrome of ischemic placental disease or IPD, the leading cause of indicated preterm birth and an important cause of neonatal morbidity and mortality. While the phenotypic manifestations vary significantly for preeclampsia, IUGR, and abruption, these conditions may share a common underlying etiology as evidenced by: (1) shared clinical risk factors, (2) increased recurrence risk across pregnancies as well as increased co-occurrence of IPD conditions within a pregnancy, and (3) findings that suggest the underlying pathophysiologic processes may be similar. IPD is of major clinical importance and accounts for a large proportion of indicated preterm delivery ranging from the periviable to late preterm period. Successful prevention of IPD and resultant preterm delivery could substantially improve neonatal and maternal outcomes. This article will review the following topics: (1) The complicated research literature on aspirin and the prevention of preeclampsia and IUGR. (2) Research evidence on other medical interventions to prevent IPD. (3) New clinical interventions currently under investigations, including statins. (4) Current clinical recommendations for prevention of ischemic placental disease.

While ischemic heart disease in reproductive-age women is rare, cardiac disease is a leading cause of maternal mortality. In turn, coronary artery disease is one of the most common causes of maternal cardiac death. The incidence of coronary artery disease in pregnancy may be rising due to the increasing prevalence of comorbid risk factors. Diagnosis and clinical management of ischemic cardiac disease is largely similar in the pregnant and non-pregnant patient, and the majority of medications and diagnostic and interventional procedures are compatible with pregnancy with a few important exceptions. Care for ischemic cardiac disease in pregnancy may be suboptimal because: (1) diagnosis is delayed because many symptoms of ischemic cardiac disease are common in pregnancy, (2) a diagnostic workup is insufficiently thorough, and/or (3) consultants may be hesitant to perform diagnostic and interventional procedures in obstetric patients. Obstetric providers should be aware of the possibility of ischemic cardiac disease in pregnancy, particularly in patients with comorbid risk factors. If ischemic cardiac disease is suspected, a thorough workup should be performed.

OBJECTIVE:Universal transvaginal cervical length screening can be associated with a significant logistical burden. We hypothesized that there is a threshold cervical length measured by transabdominal ultrasound above which risk for short transvaginal cervical length is extremely low. STUDY DESIGN/METHODS:This prospective cohort study evaluated a consecutive series of women offered universal transvaginal cervical length screening during anatomy ultrasound. Transabdominal measurement of the cervix-obtained before and after voiding for each patient-was performed before transvaginal ultrasound. The study was powered to detect a transabdominal cervical length cutoff with 95% sensitivity (95% confidence interval, 90-99%) for transvaginal cervical length of ≤25 mm. RESULTS:One thousand two hundred seventeen women were included in the analysis. Prevoid transabdominal cervical length ≤36 mm detects 96% of transvaginal cervical lengths ≤25 mm with 39% specificity. A prevoid transabdominal cervical length ≤35 mm detects 100% of transvaginal cervical lengths ≤20 mm with 41% specificity. Transabdominal images of the cervix could not be obtained in 6.2% of women prevoid and 17.9% of women postvoid. CONCLUSION/CONCLUSIONS:Transabdominal cervical length screening successfully identifies women at very low risk for short transvaginal cervical length. Transabdominal screening may significantly reduce the burden of universal cervical length screening by allowing approximately 40% of women to avoid transvaginal ultrasound. To ensure high sensitivity of transabdominal screening, approximately 60% of patients will still require a transvaginal study.

OBJECTIVE:To determine whether transabdominal cervical length screening could identify women at high risk for having a short cervix on transvaginal ultrasound. DESIGN/METHODS:Retrospective cohort study. SETTING/METHODS:Tertiary referral center. POPULATION/METHODS:A total of 703 patients with a singleton pregnancy at 18 to 23(+6) weeks of gestation who underwent transabdominal and transvaginal cervical length assessment during anatomy ultrasound at a single institution between January 2007 and October 2011. METHODS:Electronic medical records were reviewed to identify women who met the study criteria. MAIN OUTCOME MEASURES/METHODS:The primary outcome was the number of women with a short transabdominal cervical length (defined as ≤ 30 mm) who needed to undergo transvaginal ultrasound to detect one woman with a short transvaginal cervical length of ≤ 20 mm. RESULTS:In all, 703 patients were included in the primary analysis; 3.42 women with transabdominal cervical length ≤ 30 mm needed to undergo transvaginal ultrasound to detect one woman with transvaginal ultrasound cervical length ≤ 20 mm. Of women with short transvaginal cervical length ≤ 20 mm, 89.8% had a transabdominal measurement ≤ 30 mm and 96.7% had a transabdominal measurement ≤ 33 mm. CONCLUSIONS:Screening of transabdominal cervical length may represent a useful strategy for detecting women with short cervix on transvaginal ultrasound.

OBJECTIVE:To characterize contemporary practice patterns for postcesarean thromboembolism prophylaxis and determine whether opportunities to substantially decrease maternal mortality and morbidity in this clinical setting are being missed. METHODS:A commercial hospitalization database that includes procedure and diagnosis codes, health care provider and hospital information, and patient demographic data were used to analyze use of venous thromboembolism prophylaxis after cesarean delivery in the United States between 2003 and 2010. The analysis evaluated whether patients received pharmacologic prophylaxis, mechanical prophylaxis, combined prophylaxis, or no prophylaxis. Hospital-level factors and patient characteristics were included in multivariable regression models evaluating prophylaxis administration. RESULTS:We identified 1,263,205 women who underwent cesarean delivery. Within the cohort, 75.7% (n=955,787) received no thromboembolism prophylaxis, 22.1% (n=278,669) received mechanical prophylaxis alone, 1.3% (n=16,639) received pharmacologic prophylaxis, and 1.0% (n=12,110) received combination prophylaxis. The rate of prophylaxis increased from 8.4% in 2003 to 41.6% in 2010. Prophylaxis rates varied significantly by geographic region. Medical risk factors for thromboembolism were associated with only modest increases in prophylaxis. CONCLUSION/CONCLUSIONS:Although our findings demonstrated increased adoption of postcesarean venous thromboembolism prophylaxis, fewer than half of patients received recommended care as of 2010, and significant variation was present. Thromboembolism prophylaxis is underused and represents a major opportunity to reduce maternal morbidity and mortality. Risk assessment tools and thromboprophylaxis guidelines are needed to assure high-quality, uniform care. LEVEL OF EVIDENCE/METHODS:: III.

Moderate preterm, late preterm, and early term deliveries represent a major and growing public health concern. These deliveries are associated with significant financial burden and pose serious risks to mothers and newborns. Women who deliver at moderate and late gestational ages in one pregnancy are at increased risk of delivering at these gestational ages, or earlier, in a subsequent pregnancy. Births in moderate preterm and late preterm gestational ages are associated with significant infant morbidity and mortality. Efforts to reduce deliveries in moderate preterm and late preterm gestations and interventions designed to ameliorate the problems in infants delivered at the gestational ages may be targets worthy of future investigation.

BACKGROUND:Ectopic pregnancy after hysterectomy is an unusual diagnosis that may lead to significant morbidity, especially when diagnosis is not timely. CASE/METHODS:A 41-year-old woman presenting with abdominal pain and vaginal bleeding 5 years after a vaginal hysterectomy was found to have a tubal ectopic pregnancy, which required emergent surgical intervention. CONCLUSION/CONCLUSIONS:Ectopic pregnancy after hysterectomy represents a challenging diagnosis because it is counter-intuitive and very uncommon. The diagnosis of posthys-terectomy ectopic pregnancy, though exceptionally rare, should be considered for women presenting with abdominal pain after hysterectomy.

OBJECTIVE:To determine if infants delivered after immature or indeterminate TDx-FLM II testing and a mature reflex test are at increased risk for neonatal respiratory complications. METHODS:The primary analysis compared neonatal respiratory morbidity (RDS or TTN) in 34-39-week fetuses delivered after either (i) mature TDx-FLM II testing, or (ii) indeterminate or immature TDx-FLM II and a positive reflex test (PG or L/S ratio). RESULTS:Fifty patients delivered after mature TDx-FLM II, and 30 after immature or indeterminate TDx-FLM II with an L/S ≥ 2.0. Respiratory morbidity was significantly higher in the group delivered after mature reflex testing compared with mature TDx-FLM II (23% vs. 2%, p < 0.01). When PG was present, there were no cases of RDS or TTN. CONCLUSIONS:Utilizing L/S ratios as a reflex test to confirm lung maturity was associated with a high risk for respiratory morbidity, particularly when PG was not present.

We sought to determine the morbidity, frequency, and demographics of pregnant patients with pyelonephritis not yet receiving prenatal care compared with patients with prenatal care. We performed a retrospective cohort analysis of 254 consecutive admissions for pyelonephritis from January 2004 to June 2007 at a single tertiary hospital comparing patients with prenatal care versus patients with no prenatal care. The sample size was adequate to detect a 1-day difference in length of admission between the two groups with an α of 0.05 and 80% power. Categorical variables were compared by Fisher exact test, and continuous variables were compared by the Wilcoxon rank sum or Kruskal-Wallis test. Of the 254 cases, 35 (13.8%) occurred in women who had not established prenatal care. There was no difference in the primary outcome of hospital length of stay. Overall, 29 cases (11.4%) occurred prior to 12 weeks and of these, significantly more patients presented having not established prenatal care (18 versus 11, p < 0.0001). The majority of cases of pyelonephritis that occur prior to 12 weeks are among women with no prenatal care. Although the U.S. Preventative Services Task Force guidelines advise screening urine culture at 12 to 16 weeks, these findings support initiating screening at an earlier gestational age.