Origin of a Post-Cesarean Delivery Niche: Diagnosis, Pathophysiologic Characteristics, and Video Documentation [Letter]
Prehypertension in Early versus Late Pregnancy
INTRODUCTION: Hypertensive disorders play a significant role in maternal morbidity and mortality. Limited data on prehypertension (preHTN) in pregnancy exists. We examine the risk of adverse outcomes in patients with preHTN in early (< 20 weeks) versus late pregnancy (> 20 weeks). MATERIALS AND METHODS: Retrospective cohort study of singleton gestations between August 2013 and June 2014. Patients were divided based on when they had the highest blood pressure in pregnancy, as defined per the Joint National Committee 7 (JNC-7). Groups were compared using Chi2, Fisher's exact, Student t-test and Mann-Whitney U test with p < 0.05 used as significance. RESULTS: There were 125 control, 95 early preHTN, 136 late preHTN and 21 chronic hypertension (CHTN). Early preHTN had an increased risk of pregnancy related hypertension (PRH) (OR 12.26, p < 0.01), and composite adverse outcomes (OR 2.32, p < 0.01). Late preHTN had an increased risk for PRH (OR 4.39, p = 0.02) compared to normotensive and decreased risk for PRH (OR 0.26, p = 0.02), and composite adverse outcomes (OR 0.379, p = 0.04) compared to CHTN. Compared to late preHTN, early preHTN had more PRH (OR 2.85, p < 0.01), and composite adverse outcomes (OR 1.68, p = 0.04). CONCLUSIONS: Early prehypertension increases the risk of adverse obstetrical outcomes. Other than an increased risk of PRH, patients with late prehypertension have outcomes similar to normotensive women.
The price of abandoning diagnostic testing for cell free fetal DNA screening [Letter]
Fifth Recurrent Cesarean Scar Pregnancy: A Case Report and Historical Perspective [Letter]
The increase in the cesarean delivery (CD) rate, from 5% in 1970 to 32% in 2015, has been associated with an increase in cesarean scar pregnancies (CSP) approximately 1 in 1,800-2,500 pregnancies complicated by previous cesarean deliveries (CD). There is currently no consensus on the optimal management of CSP or recurrent CSP. We describe the case of a 35-year-old G7P2042 with two prior CD and four prior CSP with positive fetal heart activity, all treated with intra-gestational injection of methotrexate, in conjunction with the practice of favoring termination of CSP. Transabdominal and transvaginal ultrasound was used to perform serial 2D and 3D renderings. A live CSP was diagnosed on initial scan at 6 4/7 weeks as a gestational sac was noted to be at the cesarean scar niche with a mostly posterior placenta previa wrapping anteriorly to the level of the bladder. By 9 4/7 weeks the placenta had multiple lacunae and hypervascularity therefore a morbidly adherent placenta (MAP) was diagnosed. A placenta percreta was diagnosed by 17 5/7 weeks. An MRI was performed at 32 2/7 weeks with an impression of placenta previa with increta. Outpatient betamethasone course was given 48 hours prior to scheduled cesarean hysterectomy at 34 0/7 weeks. The pathology confirmed a MAP, placenta percreta. The details of this case highlight that although CSP is a rare pregnancy complication of CD, its frequency is mirroring the increasing CD rates. Cases of recurrent CSP are even more infrequent, and a fifth repeat has not been previously described and adds more to the mounting data that CSP is a precursor to MAP. Additionally, this case displays how the counseling of CSP has shifted over time; indicating that patients with CSP can be offered continuation of pregnancy with understanding the maternal risks, including uterine rupture and cesarean hysterectomy for MAP.
A New Minimally Invasive Treatment for Cesarean Scar Pregnancy and Cervical Pregnancy [Note]
Fetal fraction and adverse perinatal outcomes [Meeting Abstract]
Is there an association between placental location and cell-free DNA fetal fraction? [Meeting Abstract]
Prehypertension in Early Pregnancy: What is the Significance?
Objective Hypertensive disorders play a significant role in maternal morbidity and mortality. There is limited data on prehypertension (pre-HTN) during the first half of pregnancy. We sought to examine the risk of adverse pregnancy outcomes in patients with prehypertension in early pregnancy (<20 weeks' gestational age). Study Design A retrospective cohort study of 377 patients between 2013 and 2014. Patients were divided based on the highest blood pressure in early pregnancy, as defined per the JNC-7 criteria. There were 261 control patients (69.2%), 95 (25.2%) pre-HTN patients, and 21 (5.6%) chronic hypertension (CHTN) patients. The groups were compared using X2, Fisher's Exact, Student t-test, and Mann-Whitney U test with p < 0.05 used as significance. Results Patients with pre-HTN delivered earlier (38.8 +/- 1.9 weeks vs 39.3 +/- 1.7 weeks), had more pregnancy related hypertension (odds ratio [OR], 4.62; confidence interval [CI], 2.30-9.25; p < 0.01) and composite maternal adverse outcomes (OR, 2. 10; 95% CI, 1.30-3.41; p < 0.01), NICU admission (OR, 2.21; 95% CI, 1.14-4.26; p = 0.02), neonatal sepsis (OR, 6.12; 95% CI, 2.23-16.82; p < 0.01), and composite neonatal adverse outcomes (OR, 2.05; 95% CI, 1.20-3.49; p < 0.01). Conclusion Although women with pre-HTN are currently classified as normal in obstetrics, they are more similar to women with CHTN. Pre-HTN in the first half of pregnancy increases the likelihood of adverse outcomes.
Cardiac Arrest and Resuscitation Unique to Pregnancy
Maternal cardiopulmonary arrest (MCPA) is a catastrophic event that can cause significant morbidity and mortality. A prepared, multidisciplinary team is necessary to perform basic and advanced cardiac life support specific to the anatomic and physiologic changes of pregnancy. MCPA is a challenging clinical scenario for any provider. Overall, it is an infrequent occurrence that involves 2 patients. However, key clinical intervention performed concurrently can save the life of both mother and baby.
A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy
BACKGROUND: Cesarean scar pregnancy and cervical pregnancy are unrelated forms of pathological pregnancies carrying significant diagnostic and treatment challenges, with a wide range of treatment effectiveness and complication rates ranging from 10 to 62%. At times, lifesaving hysterectomy and uterine artery embolization are required to treat complications. Based on our previous success with using a single balloon catheter for treatment of cesarean scar pregnancy after local injection of methotrexate we evaluated the use of a double balloon catheter to terminate the pregnancy while preventing bleeding without any additive treatment. This is a retrospective study. OBJECTIVES: To describe the placement of a cervical ripening double balloon catheter as a novel minimally invasive treatment in patients with cesarean scar and cervical pregnancies to terminate the pregnancy and at the same time prevent bleeding by compressing the blood supply of the gestational sac. MATERIAL AND METHODS: Patients with diagnosed, live cervical pregnancy and cesarean scar pregnancy between 6 and 8 weeks' gestation were considered for the office based treatment. Paracervical block with 1% lidocaine was administered in 3 patients for pain control. Insertion of the catheter and inflation of the upper balloon were done under transabdominal ultrasound guidance. The lower (pressure) balloon was inflated opposite the gestational sac under transvaginal ultrasound guidance. After an hour, the area of the sac was scanned. When fetal cardiac activity was absent and no bleeding was noted, patients were discharged. After 2-3 days a follow-up appointment was scheduled for possible catheter removal. Serial ultrasound (US) and serum hCG were followed weekly or as needed. RESULTS: Three live cervical pregnancies and 7 live cesarean scar pregnancies were successfully treated. Median gestational age at treatment was 6 6/7 weeks (range 6 1/7 - 7 4/7 weeks). Patients' acceptance for the double balloon treatment was high in spite of the initial low abdominal pressure felt at the inflation of the balloons. All but one patient noted vaginal spotting at the follow-up appointment. Only one patient experienced bleeding of dark blood. The balloons were in place for a median of 3 days (range 1- 5 days). Median time from treatment to total drop of hCG was 49 days (range 28 - 97 days). CONCLUSION: The double balloon is a successful, minimally invasive and well tolerated single treatment for cervical pregnancy and cesarean scar pregnancy.. This simple treatment method has four main advantages: It effectively stops embryonic cardiac activity, prevents bleeding complications, does not require any additional invasive therapies and is familiar to obstetricians/gynecologists who use the same cervical ripening catheters for labor induction. Its wider application, however, has to be validated on a larger patient population.