James Airoldi

Transvaginal ultrasonography of the cervix to predict preterm birth in women with uterine anomalies

Objective: Women with uterine anomalies have higher rates of preterm birth, but the reason for this has not been elucidated. Transvaginal ultrasound examination has been shown to be an accurate test for the prediction of preterm birth but has not been studied specifically in this population. Methods: Pregnant women with uterine anomalies were followed prospectively with transvaginal ultrasound examination of the cervix, performed between 14 and 23 6/7 weeks of gestation. A short cervical length was defined as less than 25 mm of cervical length. The primary outcome was spontaneous preterm birth, defined as birth at less than 35 weeks. Results: Of the 64 pregnancies available for analysis, there were 28 with a bicornuate uterus, 13 with a septate uterus, 11 with a uterine didelphys, and 12 with a unicornuate uterus. The overall incidence of spontaneous preterm birth at less than 35 weeks was 11%. Of the 10 (16%) women with a short cervical length, 5 (50%) had spontaneous preterm birth. Of the 54 women without a short cervical length, only 2 (4%) had a spontaneous preterm birth. The sensitivity, specificity, and positive and negative predictive values of a short cervical length for spontaneous preterm birth were 71%, 91%, 50%, and 96%, respectively (relative risk 13.5, 95% confidence interval 3.49–54.74). Of the 7 women with both short cervical length and preterm birth, all uterine subtypes were represented except septate uterus. Conclusion: A short cervical length on transvaginal ultrasonography in women with uterine anomalies has a 13-fold risk for preterm birth. Unicornuate uterus had the highest rate of cervical shortening and preterm delivery. Level of Evidence: II-2

Misoprostol for second trimester pregnancy termination in women with prior caesarean: a systematic review

Background  Second trimester pregnancy induction with misoprostol in women with prior caesarean delivery is not well studied.

Clinical Significance of Proteinuria in Pregnancy

Urinary protein excretion is considered abnormal in pregnant women when it exceeds 300 mg/24 hours at anytime during gestation, a level that usually correlates with 1+ on urine dipstick. Proteinuria documented before pregnancy or before 20 weeks’ gestation suggests preexisting renal disease. The National High Blood Pressure Education Program Working Group recommended that that the diagnosis of proteinuria be based on the 24-hour urine collection. Preeclampsia is the leading diagnosis that must be excluded in all women with proteinuria first identified after 20 weeks of gestation. Given the vasospastic nature of this condition, when it is present, the degree of proteinuria may fluctuate widely from hour-to-hour. Hypertension or proteinuria may be absent in 10–15% of patients with HELLP syndrome and in 38% of patients with eclampsia. The acute onset of proteinuria and worsening hypertension in women with chronic hypertension is suggestive of superimposed preeclampsia, which increases adverse outcomes. However, because proteinuria is not independently predictive of adverse outcome, an exclusive proteinuric criterion as an indication for preterm delivery in preeclampsia should be discouraged. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state that measurement of urinary protein levels by simple techniques are not sensitive or specific, recall that both hypertension and proteinuria may be absent in patients with preeclampsia, and explain that proteinuria is not predictive of adverse outcomes and that delivery should not be based on protein excretion alone.

Hepatitis C and pregnancy

Hepatitis C is the most common chronic bloodborne infection in the United States. The diagnosis of vertical transmission is reliably established by a positive serum hepatitis C virus (HCV) RNA on 2 occasions 3 to 4 months apart after the infant is at least 2 months old and/or by the detection of anti-HCV antibodies after the infant is 18 months old. Vertical transmission in HCV RNA-negative pregnant women is approximately 1% to 3% versus approximately 4% to 6% in HCV RNA-positive women. From the standpoint of vertical transmission, no critical HCV RNA titer has been established. Coinfection with HIV has been shown to increase the risk of vertical transmission of HCV, but highly active antiretroviral therapy may decrease the risk significantly. In HIV-negative women, route of delivery does not influence vertical transmission. In HCV/HIV-coinfected women, decisions regarding mode of delivery should be based on HIV status. There is no association between vertical transmission of HCV and gestational age at delivery or the presence of chorioamnionitis. The use of a scalp electrode has been associated with vertical transmission and this practice is discouraged. Data are conflicting regarding duration of ruptured membranes and the risk of vertical transmission of hepatitis C. When the duration of membrane rupture exceeds 6 hours, the risk may be increased. There is no evidence demonstrating an increased risk of HCV transmission in HIV-negative women who breast feed. In HCV/HIV-coinfected women, breast feeding is discouraged in women who have consistent access to safe infant formula. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that vertical transmission of hepatitis C (HCV) does occur, state that coinfection with HIV increases the transmission rate, and summarize that there is no association between gestational age or presence of chorioamnionitis and no evidence that a cesarean delivery prevents transmission.

Indomethacin administration at the time of ultrasound-indicated cerclage: is there an association with a reduction in spontaneous preterm birth?

OBJECTIVE The purpose of this study was to estimate the effect of indomethacin on the prevention of preterm birth (PTB) in women with an ultrasound-indicated cerclage. STUDY DESIGN We performed a retrospective cohort study from 1995-2006. Asymptomatic women with a cerclage for a short cervical length (CL), which was defined as <25 mm, between 14-23 weeks 6 days of gestation were included. Women who received indomethacin therapy at the time of ultrasound-indicated cerclage for a short CL were compared with those women who did not. Our primary outcome was spontaneous PTB at <35 weeks of gestation. RESULTS Fifty-one women received indomethacin, and 50 women did not. There were no differences between groups regarding previous PTB, gestational age, or CL at time of cerclage. The rate of spontaneous PTB at <35 weeks of gestation was similar between those who received indomethacin (20/51 [39%]) and those who did not (17/50 [34%]; relative risk, 1.15 [95% CI 0.69-1.93]). In our post hoc power analysis, 190 patients would have been needed to detect a 50% reduction in the rate of PTB. CONCLUSION Administration of indomethacin around the time of ultrasound-indicated cerclage was not associated with a decrease in spontaneous PTB.

OP01.27: First-trimester nuchal translucency and ductus venosus measurement: are they independent markers?

directly to the laboratory. The average number of needle insertions was 1.01 per singleton and 1.5 per twin pregnancy. In case of obturation of the needle, the vacutainer system allows up to 5 reinsertions of the tube without loss of the negative pressure. The costs of the 2 tubes, adapter an holder ((0.07 × 2) + 0.08 + 0.02 = 0.24 Eur) are equal to the costs of one syringe 20 ml and 2 transport bottles (0.08 + (0.1 × 2) = 0.28 Eur). Conclusions: The vacutainer serves as an automatic aspiration tool. We found this method easy, safe and reliable.

OP07.20: Ductus venosus dilatation and its temporal relationship to other Doppler parameters in growth restricted fetuses

converting the results in z-scores. ROC and ORs analyses were performed Results: Perinatal death occurred in 13 cases (25%). ROC analysis showed: Mod-MPI = 1.6 z-scores (95th percentile) had 84.6% sensitivity (Sen), 68.4% specificity (Spe), 47.2% positive predictive value (PPV), 93% negative predictive value (NPV), 2.68 positive likelihood ratio (LR+), 0.22 LR−; DV-PI = 6.74 z-scores had 46.2% Sen, 97.4% Spe, 85.7% PPV, 84.4% NPV, 18.00 LR+, 0.55 LR−; and IFI = −9.48 z-scores had 58.3% Sen, 80.6% Spe, 50% PPV, 85.3% NPV, 3.0 LR+,0.52 LR−. When 2 out of 3 parameters were altered, the risk of perinatal mortality increased significantly (OR: 6.2; 95% confidence intervals (CI) 1.59–24.18, p = 0.0001). Conversely none or only one altered parameter reduced significantly the risk (OR; 0.16; 95%CI 0.04–0.62 p = 0.0001). Conclusion: Mod-MPI = 1.6 z-scores has the highest sensitivity and negative predictive value. The combination of DV-PI, Mod-MPI and IFI (at least two altered) may be helpful in the identification of IUGR fetuses at risk of mortality.

OP10.14: Placental cyst or extra-amniotic pregnancy?

JM is a 22 year old G2P1 who initially had a 13 week ultrasound which showed a thick membrane adjacent to the superior edge of the placenta, most likely representing a marginal hematoma. A 21 week ultrasound showed normal fetal anatomy, normal amniotic fluid and a normal left anterior placenta. A follow up 28 week ultrasound showed the following: turbid amniotic fluid filled with echoreflections, thick and heterogeneous placenta, numerous cystic structures emanating from the placenta, with no vascular flow, easily deformable by fetal body parts. The differential diagnosis at this point was: placental cyst (s), late amniotic rupture (extraamniotic pregnancy), previously undiagnosed early amnion rupture with amniotic bands. A follow up 33 week ultrasound showed good growth (45 percentile) and normal amniotic fluid. A fetal echo showed mild tricuspid regurgitation and mild narrowing of the ductus arteriosis. A maternal hyperoxygenation pulmonary vascular test showed normal pulmonary vascular reactivity in response to oxygen, thus decreasing the likelihood for pulmonary hypoplasia. At 36 weeks, the fetus was less than the 10th percentile for size with preservation of the head/abdomen ratio. The fetus was tested with umbilical artery Doppler, NST and AFI. She was induced at 39 weeks and delivered a healthy neonate weighing 5 lbs, 9 ounces. There were no gross anomalies and no evidence of amniotic bands. The placenta grossly showed a 2 × 2 × 3 centimeter placental cyst on the fetal side. Placental pathology reported a marginal hematoma, multiple subchorionic cysts, intervillous thrombosis and old hemorrhage in the membranes. Pathology noted that while not specific, marginal hematoma and evidence of old hemorrhage are characteristic of extramembranous pregnancy.

P05.22: Ductus venosus dimensions during gestation

We present the prenatal diagnosis in a fetus of an absent ductus venosus resulting hepatic vascular malformation and congestive heart failure. The infant was delivered at 33 weeks by cesarean section. The neonate presented with congestive heart failure and respiratory distress and with thrombocytopenia, disseminated intravascular coagulation, and hemolytic anemia as seen in the Kasabach-Merrit syndrome. The infant underwent coil embolization of the right hepatic artery and later resection of the right hepatic lobe and the gallbladder. Anatomic and hemodynamic features of the mass resembled a hemangioendothelioma, but histological analysis showed absence of endothelial cells, indicating a venous to venous malformation.

OC14.04: Outcomes after the functional evaluation of fetal pulmonary vascular reactivity by the maternal hyperoxygenation test in diaphragmatic hernia

Objective: In utero diagnosed congenital diaphragmatic hernia (CDH) is associated to high antenatal and neonatal loss rates. Accurate prediction of outcome is crucial in counselling parents about management options. We evaluated lung-to-head ratio (LHR) and liver position in prediction of outcome of isolated left CDH in the previable period. Methods: Retrospective review of consecutive patients diagnosed with isolated LCDH prior to 28 weeks, evaluated at 6 tertiary units from 1995 onwards. Only patients with LHR measurements, obtained by experienced sonographers and with determined liver position by ultrasound or MRI, both ≤ 28 wks, were included. In all participating centers, LHR measurement was performed as previously described (Metkus et al. JPS 1996; 31 : 148–52) by experienced operators. Outcome measure was survival at discharge from NICU. Results: 134 cases were available for review; LHR was obtained at a mean of 24.4 ± 2.8 wks. Eleven patients (8%) opted for termination after being evaluated, all having LHR < 1.4. There were no postnatal diagnoses of chromosomal anomalies. Overall survival rate was 43% (58/134), after substraction of antenatal losses (11 TOP) it was 47% (58/123). LHR correlated to survival irrespective of liver position. In case of liver herniation survival was 35%. Combination of both variables predicted neonatal outcome better: liver up & LHR < 1 predicted a survival of 9%. When LHR < 0.8 & liver up, there were no survivors, but with liver down (37% of cases) survival was 40%. When LHR < 0.6 there were no survivors irrespective of liver position. Conclusions: Combination of liver up & LHR < 1 at ≤ 28 wks predicts a < 10% chance of survival, dropping to 0% if LHR < 0.8 and liver up, or 0% if LHR < 0.6, irrespective of the liver. 8% of patients opted for termination, all with LHR < 1.4, but only in half this coincided with LHR < 1.0 and liver up.