Eric Knudtson

Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length

OBJECTIVE The objective of the study was to assess cerclage to prevent recurrent preterm birth in women with short cervix. STUDY DESIGN Women with prior spontaneous preterm birth less than 34 weeks were screened for short cervix and randomly assigned to cerclage if cervical length was less than 25 mm. RESULTS Of 1014 women screened, 302 were randomized; 42% of women not assigned and 32% of those assigned to cerclage delivered less than 35 weeks (P = .09). In planned analyses, birth less than 24 weeks (P = .03) and perinatal mortality (P = .046) were less frequent in the cerclage group. There was a significant interaction between cervical length and cerclage. Birth less than 35 weeks (P = .006) was reduced in the less than 15 mm stratum with a null effect in the 15-24 mm stratum. CONCLUSION In women with a prior spontaneous preterm birth less than 34 weeks and cervical length less than 25 mm, cerclage reduced previable birth and perinatal mortality but did not prevent birth less than 35 weeks, unless cervical length was less than 15 mm.

Management of pregnancies complicated by anti-E alloimmunization.

OBJECTIVE: To review cases of anti-c isoimmunization and determine the most appropriate management strategies. METHODS: We performed a review of 102 pregnancies managed at The Ohio State University from 1967 to 2001 for anti-c isoimmunization. Of these, 55 had complete data and are included in this report. Information collected included serum titers, ΔOD450 values, Liley zones, fetal and neonatal hemoglobin levels and antigen typing, neonatal direct antiglobulin test, and neonatal outcomes. The appropriateness of traditional management was then evaluated. RESULTS: Of the 55 pregnancies, 46 had fetuses with positive direct antiglobulin test, and nine pregnancies had unaffected fetuses. Of the affected neonates, 12 (26%) had serious hemolytic disease of the newborn. Of these 12, 8 required fetal transfusion, and the remaining 4 newborns had hemoglobin levels of less than 10 g/dL at the time of delivery. A titer of 1:32 or greater or the presence of hydrops fetalis identified all such fetuses. There were 58 amniocenteses performed for ΔOD450. When plotted on modified Liley graphs, ΔOD450 values corresponded to disease severity. There were no perinatal deaths attributable to anti-c hemolytic disease of the newborn. CONCLUSION: Anti-c isoimmunization might cause significant fetal and newborn hemolytic disease. A titer of 1:32 or greater or evidence of hydrops fetalis identified all the serious hemolytic disease at our institution. The significance of antibody titers and ΔOD450 values was similar to Rh-D sensitized pregnancies, and management by the same modalities is appropriate. LEVEL OF EVIDENCE: II-3

Pregnancy outcomes following recovery from acquired thrombotic thrombocytopenic purpura

UNLABELLED Pregnancy may precipitate acute episodes of thrombotic thrombocytopenic purpura (TTP), but pregnancy outcomes in women who have recovered from acquired TTP are not well documented. We analyzed pregnancy outcomes following recovery from TTP associated with acquired, severe ADAMTS13 deficiency (ADAMTS13 activity <10%) in women enrolled in the Oklahoma TTP-HUS Registry from 1995 to 2012. We also systematically searched for published reports on outcomes of pregnancies following recovery from TTP associated with acquired, severe ADAMTS13 deficiency. Ten women in the Oklahoma Registry had 16 subsequent pregnancies from 1999 to 2013. Two women had recurrent TTP, which occurred 9 and 29 days postpartum. Five of 16 pregnancies (31%, 95% confidence interval, 11%-59%) in 3 women were complicated by preeclampsia, a frequency greater than US population estimates (2.1%-3.2%). Thirteen (81%) pregnancies resulted in normal children. The literature search identified 382 articles. Only 6 articles reported pregnancies in women who had recovered from TTP associated with acquired, severe ADAMTS13 deficiency, describing 10 pregnancies in 8 women. TTP recurred in 6 pregnancies. CONCLUSIONS With prospective complete follow-up, recurrent TTP complicating subsequent pregnancies in Oklahoma patients is uncommon, but the occurrence of preeclampsia may be increased. Most pregnancies following recovery from TTP in Oklahoma patients result in normal children.

Resolution of hydrops secondary to cytomegalovirus after maternal and fetal treatment with human cytomegalovirus hyperimmune globulin

BACKGROUND: Congenital cytomegalovirus (CMV) is a common infection with limited treatment options. Vertical transmission can lead to fetal death or long-term neurologic injury. We present a case wherein fetal hydrops resolved after maternal and fetal intravenous administration of CMV hyperimmune globulin. CASE: A 20-year-old gravida 3, para 0 was referred for Level II ultrasonography secondary to hydrops fetalis. Amniocentesis demonstrated in utero CMV infection. Resolution of hydrops occurred after the administration of CMV hyperimmune globulin to the patient and then to her fetus. CONCLUSION: Resolution of hydrops secondary to congenital CMV was temporally related to the administration of maternal and fetal hyperimmune globulin.

Immediate compared with delayed cord clamping in the preterm neonate: a randomized controlled trial.

OBJECTIVE: The comparative risks and benefits of early compared with delayed cord clamping in the preterm neonate remain unclear. Our objective was to evaluate the short-term effects of delayed clamping of the umbilical cord in preterm neonates. METHODS: We conducted a randomized controlled trial comparing immediate with delayed cord clamping among preterm neonates born between 24 and 34 weeks of gestation. The primary study outcome was the need for blood transfusion. To detect a 33% reduction in this outcome (from 65 to 43.5%) with a two-tailed &agr; of 0.5 and &bgr; of 0.8 required 178 patients equally divided into two groups. RESULTS: A total of 200 women were randomized, 99 to the delayed and 101 to the immediate clamp group. The groups were similar with respect to baseline characteristics. The mean gestational age at delivery was 30.8±3.1 weeks in the delayed compared with 30.7±2.8 weeks in the immediate clamp group (P=.64). There was no statistically significant difference between groups with regard to the need for blood transfusion: 25 of 99 (25.3%) in the delayed cord clamp group received one or more blood transfusion compared with 24 of 101 (23.7%) in the immediate clamp group (P=.8). The rates of various neonatal outcomes including respiratory distress syndrome, periventricular leukomalacia, necrotizing enterocolitis, anemia of prematurity, and neonatal morality did not differ significantly between the groups. However, the mean initial hemoglobin (17.4±2.5 compared with 16.3±2.3 g/dL, P=.001) and hematocrit (51.3±7.3 compared with 47.4±7.3, P=.001) was significantly higher in the delayed group. In the delayed clamp group, 11.1% (11/99) of neonates had intraventricular hemorrhage compared with 19.8% (20/101) in the immediate clamp group (P=.09). CONCLUSION: Delayed cord clamping for 30 seconds did not decrease the need for blood transfusion among preterm neonates. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00579839. LEVEL OF EVIDENCE: I

A randomized controlled trial of intramuscular versus vaginal progesterone for the prevention of recurrent preterm birth

To compare the efficacy of intramuscular hydroxyprogesterone caproate with that of vaginal progesterone for prevention of recurrent preterm birth.

Multiple myeloma presenting as hypercalcemic pancreatitis during pregnancy.

BACKGROUND: Multiple myeloma is typically a disease found in older women and is a rare diagnosis in pregnancy. CASE: A 22-year-old woman, gravida 1 para 0, at 32 3/7 weeks of gestation presented with nausea, vomiting, and rib and back pain. She was hypertensive, anemic, thrombocytopenic, and in acute renal insufficiency, with hypercalcemia and laboratory parameters indicative of pancreatitis. She was admitted to the obstetric intensive care unit with working diagnoses of preeclampsia, pancreatitis, nephrolithiasis, and renal insufficiency. She ultimately was delivered because of declining clinical status, and multiple myeloma eventually was diagnosed as the underlying cause of her myriad of problems. CONCLUSION: Multiple myeloma is unusual during pregnancy. However, in patients with significant and unexplained hypercalcemia, malignancy should remain high on the differential diagnosis.

Unsuccessful trial of labor in women with and without previous cesarean delivery

Objective. To compare maternal and neonatal outcomes after unsuccessful labor in women with and those without prior cesarean delivery. Methods. This was a retrospective cohort study of all women in labor delivered by cesarean section (CS) from November 2004 through December 2006. The study population was dichotomized by previous CS and compared for various maternal and neonatal outcomes. Student t-test, χ2 and Fisher exact tests were used for analysis. Results. There was a significantly higher rate of symptomatic uterine rupture [3/100 (3%) vs. 0/449 (0%), p = 0.006], asymptomatic uterine scar dehiscence [6/100 (6%) vs. 0/449 (0%), p = 0.0001], and bladder injury [2/100 (2%) vs. 0/100 (0%), p = 0.001], among women with prior cesarean delivery compared to those without. The rate of respiratory distress syndrome [(6/100) (6%) vs. 10/449 (2.2%), p = 0.05] and meconium aspiration [4/100 (4%) vs. 2/449 (0.4%), p = 0.01] was also significantly higher among neonates of women with prior cesarean delivery. However, the rate of endomyometritis [3/100 (3%) vs. 50/449 (11.1%), p = 0.009] and febrile morbidity [17/100 (17%) vs. 144/449 (32.1%), p  = 0.003] was significantly lower among women with prior cesarean delivery compared to those without prior cesarean birth. Conclusions. Compared to laboring women without previous cesarean delivery, women with previous cesarean delivery have increased maternal and neonatal morbidity. Febrile morbidity was, however, lower among women with previous cesarean delivery. These differential findings should further inform our perinatal counseling of women contemplating trial of labor after a previous cesarean delivery.

Fetal epicardial fat thickness in diabetic and non-diabetic pregnancies: A retrospective cross-sectional study

To evaluate fetal epicardial fat thickness (EFT) in diabetic and control pregnancies.

Local anesthesia and pain perception during amniocentesis: a randomized double blind placebo-controlled trial.

To determine the effect of local anesthesia on the maternal pain perception from amniocentesis.