Jerasimos Ballas

Management of Diabetes in Pregnancy

The link between diabetes and poor pregnancy outcomes is well established. As in the non-pregnant population, pregnant women with diabetes can experience profound effects on multiple maternal organ systems. In the fetus, morbidities arising from exposure to diabetes in utero include not only increased congenital anomalies, fetal overgrowth, and stillbirth, but metabolic abnormalities that appear to carry on into early life, adolescence, and beyond. This article emphasizes the newest guidelines for diabetes screening in pregnancy while reviewing their potential impact on maternal and neonatal complications that arise in the setting of hyperglycemia in pregnancy.

Preoperative intravascular balloon catheters and surgical outcomes in pregnancies complicated by placenta accreta: a management paradox

OBJECTIVE The objective of the study was to compare outcomes between patients who did and did not receive preoperative uterine artery balloon catheters in the setting placenta accreta. STUDY DESIGN This was a retrospective case-control study of patients with placenta accreta from 1990 to 2011. RESULTS Records from 117 patients with pathology-proven accreta were reviewed. Fifty-nine patients (50.4%) had uterine artery balloons (UABs) placed preoperatively. The mean estimated blood loss (EBL) was lower (2165 mL vs 2837 mL; P = .02) for the group that had UABs compared with the group that did not. There were more cases with an EBL greater than 2500 mL and massive transfusions of packed red blood cells (>6 units) in the group that did not have UABs. Percreta was diagnosed more often on final pathology in the group with UABs. Surgical times did not differ between the 2 groups. Two patients (3.3%) had complications related to the UABs. CONCLUSION Preoperative placement of UABs is relatively safe and is associated with a reduced EBL and fewer massive transfusions compared with a group without UABs.

Identifying Sonographic Markers for Placenta Accreta in the First Trimester

Our study attempted to identify whether sonographic markers for placenta accreta may be present as early as the first trimester. We reviewed 10 cases with pathologically proven accreta and retrospectively analyzed their first‐trimester images. The gestational ages ranged from 8 weeks 4 days to 14 weeks 2 days. Sonographic findings included anechoic placental areas (9 of 10), low implantation of the gestational sac (9 of 10), an irregular placental‐myometrial interface (9 of 10), and placenta previa (7 of 10). Nine patients had at least 1 prior cesarean delivery; 3 had additional uterine surgical procedures. One patient underwent hysteroscopic myomectomy. Our case series suggests that signs of placenta accreta may be present in the first trimester.

Diagnosis of Fetal Limb Abnormalities Before 15 Weeks Cause for Concern

The purposes of this study were (1) to identify cases of limb abnormalities identified before 15 weeks and correlate with outcomes and (2) to assess first‐trimester nuchal translucency examinations to determine how frequently the upper and lower limbs were identified.

Preterm birth and its associations with residence and ambient vehicular traffic exposure

BACKGROUND Preterm birth (PTB) is a multifactorial disorder, and air pollution has been suggested to increase the risk of occurrence. However, large population studies controlling for multiple exposure measures in high-density settings with established commuter patterns are lacking. OBJECTIVE We performed a geospatial analysis with the use of a publicly available database to identify whether residence during pregnancy, specifically with regard to exposure to traffic density and mobility in urban and suburban neighborhoods, may be a contributing risk factor for premature delivery. STUDY DESIGN In our cohort study, we analyzed 9004 pregnancies with as many as 4900 distinct clinical and demographic variables from Harris County, Texas. On the basis of primary residency and occupational zip code information, geospatial analysis was conducted. Data on vehicle miles traveled (VMT) and percentages of inhabitants traveling to work were collected at the zip code level and additionally grouped by the three recognized regional commuter loop high-density thoroughfares resulting from two interstate/highway belts (inner, middle, and outer loops). PTB was categorized as late (34 1/7 to 36 6/7 weeks) and early PTB (22 1/7 to 33 6/7 weeks), and unadjusted odds ratios (OR) and adjusted ORs were ascribed. RESULTS PTB prevalence in our study population was 10.1% (6.8% late and 3.3% early preterm), which is in accordance with our study and other previous studies. Prevalence of early PTB varied significantly between the regional commuter loop thoroughfares [OR for inner vs outer loop: 0.58 (95% confidence interval, 0.39-0.87), OR for middle vs outer loop, 0.74 (0.57-0.96)]. The ORs for PTB and early PTB were shown to be lower in gravidae from neighborhoods with the highest VMT/acre [OR for PTB, 0.82 (0.68-0.98), OR for early PTB, 0.78 (0.62-0.98)]. Conversely, risk of PTB and early PTB among subjects living in neighborhoods with a high percentage of inhabitants traveling to work over a greater distance demonstrated a contrary tendency [OR for PTB, 1.18 (1.03-1.35), OR for early PTB, 1.48 (1.17-1.86)]. In logistic regression models, the described association between PTB and residence withstood and could not be explained by differences in maternal age, gravidity or ethnicity, tobacco use, or history of PTB. CONCLUSION While PTB is of multifactorial origin, the present study shows that community-based risk factors (namely urban/suburban location, differences in traffic density exposure, and need for traveling to work along high-vehicle density thoroughfares) may influence risk for PTB. Further research focusing on previously unrecognized community-based risk factors may lead to innovative future prevention measures.

Placental Sonolucencies in the First Trimester: Incidence and Clinical Significance.

Objectives The aims of this study were to determine the incidence of placental sonolucencies on first-trimester screening sonograms in a general obstetric population and assess whether these findings are associated with adverse obstetric outcomes. Methods A retrospective cohort analysis of 201 pregnant patients screened at a high-risk prenatal diagnostic center was conducted with first-trimester cine clips reviewed by 2 radiologists. Placental sonolucencies were defined as intraplacental anechoic or heterogeneous areas 0.7 cm or greater. Obstetric and neonatal outcomes were collected by chart review. Results Placental sonolucencies 0.7 cm or greater were seen in 45 (22.4%) of first-trimester ultrasound examinations. The ultrasonographic presence of a placenta previa, marginal sinus, and subchorionic hemorrhage was not more common in those with placental sonolucencies 0.7 cm or greater (P > 0.05). Sonolucencies were not associated with prior cesarean deliveries (P > 0.05). Both the groups with and without sonolucencies 0.7 cm or greater had similar rates of antepartum hemorrhage, preeclampsia, preterm delivery, cesarean delivery, postpartum hemorrhage, and delivery of small-for-gestational-age infants. One placenta accreta and no fetal demises occurred in the study population. Conclusions Placental sonolucencies detected on first-trimester screening sonograms in the general obstetric population are not predictive of poor obstetric outcomes.

OC20.06: Ultrasound findings of placenta accreta in the first trimester

Objectives: To assess the association between ultrasonographic parameters of the Cesarean scar in non-pregnant uterus and the number of previously performed Cesarean sections. Methods: The study group included 310 non-pregnant women with a history of low transverse Cesarean section with single-layer uterine closure. The transvaginal ultrasound was performed to assess the following parameters of the Cesarean section scar: the thickness of the knit tissue scar segment (G) and in case of visualization of a triangular shaped anechoic scar defect the basis (P) and height (W) of this triangle. G/P index and G/W index values were also calculated. Results: Transvaginal sonography enabled the visualization of the Cesarean section scar in 308/310 of the examined women (99.4%). In 55/310 cases (17.7%) the completely knit hysterotomy scar tissue was identified. In the remaining group of 255/310 women (82.2%) an anechoic triangle, defined as scar defect, was observed. The mean thickness of the knit tissue scar segment (G) after single, two and three Cesarean sections was: 9.9 mm, 8.0 mm and 4.1 mm, respectively. Statistically important decrease in the G values with the number of previous performed Cesarean sections was observed. The mean G/P index values after single, two and three Cesarean sections were as follows: 1.68, 1.53 and 0.8. The mean G/W index values were: 2.8, 1.9, 0. 9, respectively. No significant difference in the G/P index values was found between patients after one and two Cesarean sections. Statistically important decrease in G/P index values in the group of patients after three Cesarean sections comparing to the patients after one (0.80 vs. 1.68, P < 0.05) and two Cesarean sections (0.8 vs. 1.53, P < 0.05) was observed. Statistically important decrease in the G/W index values was found between the groups of women after one, two and three Cesarean sections. Conclusions: The thickness of the knit tissue scar segment (G) and the G/W index values decrease with the number of previous performed Cesarean sections.

A Standardized Approach to Cesarean Surgical Technique and Its Effect on Operative Time and Surgical Morbidity

Objective To evaluate the impact of a standardized surgical technique for primary cesarean deliveries (CDs) on operative time and surgical morbidity. Materials and Methods Two‐year retrospective chart review of primary CD performed around the implementation of a standardized CD surgical technique. The primary outcome was total operative time (TOT). Secondary outcomes included incision‐to‐delivery time (ITDT), surgical site infection, blood loss, and maternal and fetal injuries. Results When comparing pre‐ versus postimplementation surgical times, there was no significant difference in TOT (76.5 vs. 75.9 minutes, respectively; p = 0.42) or ITDT (9.8 vs. 8.8 minutes, respectively; p = 0.06) when the entire cohort was analyzed. Subgroup analysis of CD performed early versus late in an academic year among the pre‐ and postimplementation groups showed no significant difference in TOT (79.3 early vs. 73.8 minutes late; p = 0.10) or ITDT (10.8 early vs. 8.8 minutes late; p = 0.06) within the preimplementation group. In the postimplementation group, however, there was significant decrease in TOT (80.5 early vs. 71.3 minutes late; p = 0.02) and ITDT (10.6 early vs. 6.8 minutes late; p < 0.01). Secondary outcomes were similar for both groups. Conclusion A standardized surgical technique combined with surgical experience can decrease TOT and ITDT in primary CD without increasing maternal morbidity.

OP25.05: Sonographic markers for placenta accreta in the first trimester: are they reliable?

Objectives: Localization of the placenta is traditionally performed transabdominally (TA) at the time of the routine 18–20 week scan. In circumstances where the placenta is described as being low, a second scan is arranged at 34 weeks gestation. Whilst the value of transvaginal (TV) assessment for cases with a posterior placenta at 34 weeks is well recognized, there is little data comparing TA and TV approaches earlier in pregnancy. This study compares TA and TV approaches to placental localization. Methods: The distance between the leading edge of the placenta and the internal cervical os were measured in a series of pregnancies presenting for routine obstetric ultrasound scans at 12–36 weeks gestation. Bland Altman plots and paired t-tests were used to look at the differences in TA and TV measurement and the screening efficacy of an initial TA assessment in defining a group for TV evaluation is also reported. Results: 282 consented to participate in the study. A Bland Altman plot shows that TA measurements overestimated the distance compared with the TV measurements; the average difference in measurement was 11.6 mm (95% CI: 4.4–18 mm). Assuming the TV scan measurements are the ‘gold standard’, TA assessment accurately predicted that the leading edge of the placenta was within 25 mm of the internal cervical os in 22/82 (27%) of cases assessed at 16–23 weeks and 1/2 (50%) of cases > 24 weeks. The specificity of the TA approach was 96% and 97% for these two categories respectively. Conclusions: TA sonography has a low sensitivity for detecting a low-lying placenta. Placental localization is best performed by transvaginal scan.