Cara Dolin

Gestational weight gain and obesity: is 20 pounds too much?

OBJECTIVE To compare maternal and neonatal outcomes in obese women according to weight change and obesity class. STUDY DESIGN Cohort study from the Consortium on Safe Labor of 20,950 obese women with a singleton, term live birth from 2002-2008. Risk for adverse outcomes was calculated by multiple logistic regression analysis for weight change categories (weight loss [<0 kg], low [0-4.9 kg], normal [5.0-9.0 kg], high weight gain [>9.0 kg]) in each obesity class (I 30.0-34.9 kg/m(2), II 35.0-39.9 kg/m(2), and III ≥40 kg/m(2)) and by predicted probabilities with weight change as a continuous variable. RESULTS Weight loss was associated with decreased cesareans for class I women (nulliparas odds ratio [OR], 0.21; 95% confidence interval [CI], 0.11-0.42; multiparas OR, 0.61; 95% CI, 0.45-0.83) and increased small for gestational age infants (class I OR, 1.8; 95% CI, 1.3-2.5; class II OR, 2.2; 95% CI, 1.5-3.2; class III OR, 1.7; 95% CI, 1.1-2.6). High weight gain was associated with increased large for gestational age infants (class I OR, 2.4; 95% CI, 1.9-2.9; class II OR, 1.7; 95% CI, 1.3-2.1; class III OR, 1.6; 95% CI, 1.3-2.1). As weight change increased, the predicted probability for cesareans and large for gestational age infants increased. The predicted probability of low birthweight never exceeded 4% for all obesity classes, but small for gestational age infants increased with decreased weight change. The lowest average predicted probability of adverse outcomes (cesarean, postpartum hemorrhage, small for gestational age, large for gestational age, neonatal care unit admission) occurred when women (class I, II, III) lost weight. CONCLUSION Optimal maternal and neonatal outcomes appear to occur when weight gain is less than current Institute of Medicine recommendations for obese women. Further study of long-term outcomes is needed with respect to gestational weight changes.

Natural History of Vasa Previa Across Gestation Using a Screening Protocol

The purpose of this study was to estimate the prevalence and persistence rate of vasa previa in at‐risk pregnancies using a standardized screening protocol.

Prehypertension in early versus late pregnancy

Abstract Introduction: Hypertensive disorders play a significant role in maternal morbidity and mortality. Limited data on prehypertension (preHTN) in pregnancy exist. 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 χ2, Fisher’s exact, Student’s t-test, and Mann–Whitney U test with p < .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 < .01) and composite adverse outcomes (OR 2.32, p < .01). Late preHTN had an increased risk for PRH (OR 4.39, p = .02) compared with normotensive and decreased risk for PRH (OR 0.26, p = .02), and composite adverse outcomes (OR 0.379, p = .04) compared with CHTN. Compared with late preHTN, early preHTN had more PRH (OR 2.85, p < .01), and composite adverse outcomes (OR 1.68, p = .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.

Pregnancy in Women with Obesity

Pregnancy in women with obesity is an important public health problem with short- and long-term implications for maternal and child health. Obesity complicates almost all aspects of pregnancy. Given the growing prevalence of obesity in women, obstetric providers need to understand the risks associated with obesity in pregnancy and the unique aspects of management for women with obesity. Empathic and patient-centered care, along with knowledge, can optimize outcomes for women and children.

Human term amniotic fluid: a novel source of stem cells for regenerative medicine

elsewhere. Thereafter, injury-related deaths rose significantly, with more than one third of injuries being intentional, a similar proportion to that in a study of 129 maternal deaths in Australia. This study did not capture out-of-hospital births, which are less than 1% of births in Ontario, or maternal deaths occurring antepartum. Although direct and indirect causes of death were not differentiated herein, the striking difference in maternal mortality rates following a stillbirth vs a livebirth deserves further study. Future studies should further classify maternal deaths by injury subtypes, including overdoses, and additionally evaluate antepartum deaths. -

Fifth recurrent Cesarean scar pregnancy: observations of a case and historical perspective

The increase in the rate of Cesarean delivery (CD), from 5% in 1970 to 32% in 2015, has been associated with an increase in Cesarean scar pregnancies (CSP); approximately 1 in 1800–2500 pregnancies is complicated by a previous CD. There is currently no consensus on the optimal management of CSP or recurrent CSP. We describe a case of a 35-year-old woman with two prior CDs and four prior CSPs with positive fetal heart activity, all treated with intragestational injection of methotrexate in accordance with the practice of favoring termination of CSP. After diagnosis of a fifth recurrent CSP and preference to continue the pregnancy, the patient delivered a viable neonate via Cesarean hysterectomy performed for morbidly adherent placenta (MAP). This case displays how the counseling of CSP has changed over time, indicating that patients with CSP can be offered continuation of pregnancy after counseling on the perinatal risks. A 35-year-old woman, gravida 7 para 2, with a history of two CDs and four live CSPs that were terminated via intraembryonic injection of methotrexate under transvaginal ultrasound guidance (Figure 1) was diagnosed with a fifth recurrent CSP at 6 + 4 weeks’ gestation. The previous CSPs have been reported on previously1. In the index pregnancy, the gestational sac was implanted in the Cesarean scar niche with mostly posterior placenta previa but wrapping around anteriorly at the level of the bladder (Figure 2a). By 9 + 4 weeks the placenta had multiple

Management of Pregnancy in Women Who Have Undergone Bariatric Surgery

Importance As the problem of obesity continues to grow, more patients are choosing to undergo bariatric surgery to lose weight and treat comorbidities, such as diabetes. Of the more than 200,000 procedures performed each year, 80% are in women, many of reproductive age. Taking care of a pregnant woman who has undergone bariatric surgery requires understanding of the risks, the need for additional surveillance, and the limitations of our knowledge about how bariatric surgery affects pregnancy. Objective The aims of this study were to review the current literature on bariatric surgery and pregnancy and summarize the important evidence to help the obstetrician care for a pregnant woman after bariatric surgery. Evidence Acquisition Evidence for this review was acquired using PubMed. Conclusions Pregnancy after bariatric surgery is safe and may be associated with improved pregnancy outcomes; however, more research is needed to better understand how to manage pregnant women with a history of bariatric surgery. Relevance Obstetricians will increasingly be caring for women who have undergone bariatric surgery and subsequently become pregnant. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After participating this activity, the learner should be better able to understand the indications for bariatric surgery and how different types of bariatric procedures change gastrointestinal physiology and nutrient metabolism; appropriately counsel patients about the risks and benefits of pregnancy after bariatric surgery; and understand the importance of monitoring nutritional status and supplementation in pregnancies after bariatric surgery.

Obstetrical outcomes in patients with early onset gestational diabetes

Abstract Objective: The objective of this study was to characterize patients with early onset gestational diabetes and compare outcomes to patients diagnosed with standard gestational diabetes and pregestational diabetes. Methods: This is a retrospective cohort study of patients diagnosed with gestational or pregestational diabetes. All patients received a glucose challenge test at their first prenatal visit to diagnose early onset gestational diabetes and were recommended to have postpartum glucose tolerance tests to detect undiagnosed type 2 diabetes. Outcomes were compared between patients with early onset gestational diabetes and both standard gestational diabetes and pregestational diabetes with p < 0.05 was used for significance. Results: Four hundred and twenty-four patients met the inclusion criteria. Nine percent of the patients with early onset gestational diabetes were found to have undiagnosed type 2 diabetes based on postpartum testing and 91% to have resolution in the postpartum period. No patient with early onset gestational diabetes and resolution in the postpartum period had abnormal screening for renal or ophthalmologic disease, but 5% had abnormal fetal echocardiograms. These patients were more likely to require pharmacotherapy for glycemic control than patients with standard gestational diabetes and less likely than patients with pregestational diabetes (55% versus 39% versus 81%). Conclusion: Most patients diagnosed with early onset gestational diabetes do not have undiagnosed type 2 diabetes but do have unique characteristics and obstetrical outcomes.

Limb arteriovenous malformation identified after radiofrequency ablation for selective termination in twin-to-twin transfusion syndrome.

A 34-year-old woman, gravida 9 para 7 (seven previous term births, one miscarriage), underwent an uncomplicated radiofrequency ablation (RFA) procedure at 17 weeks’ gestation for selective termination of the donor twin in a case of Stage III twin–twin transfusion syndrome (TTTS). At 21 weeks’ gestation, a 2.0 × 1.5-cm mass was noted on the volar surface of the left forearm, with motion noted in the left hand and fingers (Figure 1). There were Doppler findings of increased flow to the left arm. At 28 weeks, the mass measured 6.8 × 7.1 × 3.7 cm, with the left hand appearing clenched with no signs of movement. The left ulna and radius appeared to be lagging in growth. At 37 + 4 weeks, the patient delivered a vigorous male neonate, weighing 2570 g, via Cesarean section. A vascular mass engulfed the left arm from the forearm to the axilla (Figure 2). The left arm and hand were severely malformed with no movement. Radiographs and magnetic resonance images demonstrated an arteriovenous malformation (AVM) along the ventral surface of the left forearm extending from the elbow to the hand. The neonate underwent embolization of the AVM followed by surgical amputation above the elbow. The postoperative course was uncomplicated and he was discharged home in good condition on postoperative day 4. Pathological evaluation at our institution concluded that the specimen was an AVM; however, an outside institution concluded involuting hemangioma. Selective termination, which involves reduction of a specific twin because of a fetal anomaly, is an option in twin and higher-order pregnancies. RFA is a relatively new technique for selective termination in monochorionic twin pregnancies with TTTS. There are few data published documenting the shortand long-term neonatal outcomes of fetuses exposed to in-utero RFA procedures. Paramasivam et al. reported a case of major unilateral lower limb abnormality detected 4 weeks after RFA for fetal reduction in a triplet pregnancy, performed at 15 weeks’ gestation1. Bebbington et al. reported no neonatal Figure 1 Three-dimensional ultrasound image of the fetus at 21 weeks’ gestation, showing a 2.0 × 1.5-cm mass on the volar surface of the left forearm.

Placenta Increta After Cervical Conization: Clinical Letter

A 42-year-old woman, gravida 1, para 0, with a medical history of Sjogren syndrome, hypothyroidism, infertility, and cervical dysplasia treated by a loop electrosurgical excision procedure (LEEP) and cold-knife cone biopsy (CKC) was referred to our maternal-fetal medicine practice at 9 weeks. This pregnancy was the result of in vitro fertilization. The patient denied any instrumentation of the uterus other than embryo transfer and the LEEP and CKC procedure. However, per patient report, a generous amount of cervical tissue was removed during the CKC procedure. Ultrasonography (US) at 9 weeks confirmed a normal intrauterine pregnancy. Routine US assessment of the nuchal translucency at 12 weeks 4 days incidentally showed placenta previa with a 2.0 3 1.5-cm supracervical hematoma. Follow-up US was performed at 14 weeks 4 days and the findings were concerning for placenta previa with features of a morbidly adherent placenta (Figure 1A). There was loss of placental homogeneity adjacent to the involved myometrium, loss of the hypoechoic area behind the placenta (Nitabuch layer), increased vascularity at the junction of the placenta and myometrium, and vascular lakes with turbulent flow. The patient was followed with serial US examinations throughout the pregnancy, which continued to show features of a morbidly adherent placenta. She was extensively counseled about the risk of abnormal placentation and the possibility of hysterectomy. The patient was also counseled by Gynecologic Oncology and she strongly desired uterinesparing surgery if possible. The final US examination before delivery was at 34 weeks 2 days. Again, placenta previa was noted with multiple lacunae and increased vascularity at the anterior lower uterine segment and over the cervical stroma (Figure 1B). Magnetic resonance imaging was performed at 29 weeks 1 day, which showed placenta previa with two areas of focal placenta accreta, both directly anterior and posterior to the cervix (Figure 1C). Secondary to the suspicion of a morbidly adherent placenta, the patient was offered delivery at 34 weeks but declined. She was ultimately scheduled for cesarean delivery at 36 weeks 3 days after receiving antenatal corticosteroids. After uncomplicated delivery of the neonate, delivery of the placenta was attempted, but a small area of the placenta remained morbidly adherent at the level of the cervix. The placenta was removed via manual extraction and the hysterotomy repaired. The uterus remained atonic despite attempted conservative management with multiple uterotonics and placement of a B-lynch suture. The decision was made to proceed with total hysterectomy. Total estimated blood loss during the procedure was 3 L. The patient recovered well and was discharged home on postoperative day 4. Placental pathologic results were consistent with placenta increta. A morbidly adherent placenta occurs in approximately 3 per 1000 deliveries, with only 11.8% of those cases being placenta increta, in which the myometrium is invaded by chorionic villi. Major risk factors for a morbidly adherent placenta are placenta previa and prior cesarean delivery. The risks of a morbidly adherent placenta in women without prior cesarean delivery are 3% for those with placenta previa and 0.2% for those without placenta previa. Other uterine surgery such as myomectomy, uterine curettage, or endometrial ablation is also a risk factor. A morbidly adherent placenta has been reported in women with no surgical history but with other uterine conditions such as adenomyosis, fibroids, or uterine anomalies. Additional reported risk factors include uterine irradiation, Asherman syndrome, hypertensive disorders, and tobacco use. To our knowledge, there are no published cases of a morbidly adherent placenta occurring after a LEEP or CKC. A CKC procedure consists of excision of the portion of the cervix surrounding the endocervical canal, including the transformation zone. We hypothesize, that during this patient’s CKC procedure, the excision extended into the uterine cavity, potentially scarring the endometrium near the internal os of the cervix. This prior disruption of the normal endometrial cavity served as a nidus for abnormal placentation. Multiple studies have shown an association between treatment of cervical dysplasia by a LEEP or CKC and increased risks to future pregnancies, including increased risk of preterm birth and perinatal morbidity. Counseling patients about the risk of preterm birth is a standard part of preoperative counseling before a LEEP or CKC, but perhaps counseling about the potential for abnormal placentation should also be discussed with patients, especially when a larger excision is performed. We report a case of placenta increta after a cervical LEEP and CKC procedure. In patients with a history of a LEEP or