John P. Elliott

Twin-twin transfusion syndrome

Twin-twin transfusion syndrome associated with acute polyhydramnios in one sac and severe oligohydramnios in the other, which characteristically is diagnosed between 18 and 28 weeks, is associated with a high mortality rate for the involved twins. Patients who are managed without intervention have essentially 100% perinatal mortality. Nineteen patients with this diagnosis were treated at Good Samaritan Medical Center over a 5-year period. Because of the known perinatal mortality and because of early experiences with the twin-twin transfusion syndrome, we began to actively intervene in such patients with various modes of therapy. As experience was gained, it was found that repeated therapeutic amniocenteses, if performed before severe maternal abdominal distention or labor, appears to be beneficial.

A Randomized Multicenter Study to Determine the Efficacy of Activity Restriction for Preterm Labor Management in Patients Testing Negative for Fetal Fibronectin

OBJECTIVE:To assess the impact of activity restriction (AR) on the incidence of preterm birth in women treated for preterm labor testing negative for fetal fibronectin (fFN).STUDY DESIGN:Women who were diagnosed with preterm labor and tocolyzed with magnesium sulfate were concurrently screened with fFN for the purpose of subsequent management. Included were consenting patients with negative fFN, gestational age 23 0/7–33 6/7 weeks, cervical dilation ≤3 cm, and minimal vaginal bleeding. Patients were randomized to AR or no AR. Primary study outcome was incidence of preterm delivery and interval from randomization to delivery.RESULTS:A total of 73 women with negative fFN were randomized (36 with AR, 37 without AR). The overall preterm birth rate was 40%, with 44.4% of patients with AR and 35.1% of patients without AR delivering preterm, p=0.478.CONCLUSION:Maternal AR did not impact pregnancy outcome. The incidence of preterm birth in symptomatic women testing fFN negative was higher than previously reported.

Twin-twin transfusion syndrome: the surgical removal of one twin as a treatment option.

The twin-twin transfusion syndrome, associated with acute polyhydramnios in the 18th to 28th week of gestation, has a high perinatal mortality rate. Patients managed without intervention have essentially a 100% mortality rate for the involved twins. Different methods of intervention have been described, including therapeutic amniocentesis, selective feticide, and placental vessel puncture. In this case report we describe selective removal of one twin at 21 weeks of gestation by hysterotomy in a patient with the twin-twin transfusion syndrome.

Oligohydramnios in each sac of a triplet gestation caused by Motrin—Fulfilling Kock's postulates

A triplet gestation was treated with Motrin for oral tocolysis. A significant reduction of amniotic fluid was observed, but this was corrected by stopping the drug. A cause-and-effect relationship was established by restarting the Motrin and observing the same development of oligohydramnios, which again returned to normal with discontinuation of the drug.

Indicated and non-indicated preterm delivery in twin gestations: impact on neonatal outcome and cost.

OBJECTIVE:To identify the etiology and impact of preterm delivery in twin gestations.STUDY DESIGN:Twin gestations delivered at 33.0 to 36.9 weeks were identified in a perinatal database, and categorized by indication for delivery. Deliveries were identified as indicated, or non-indicated (discretionary). Neonatal outcomes were measured by birth weight, length of stay, NICU admission, and ventilator utilization. Data were divided and analyzed by indicated or discretionary delivery, and gestational age at delivery.RESULTS:Analyzed were 3252 twin gestations (6504 infants), with 78% having indicated delivery. Of the 22% with discretionary delivery, nearly 40% required NICU admission. With each advancing week of gestation, there was a significant decrease in incidence of NICU admission and nursery days.CONCLUSION:The majority of preterm deliveries were indicated, though 22% were discretionary. It is vital to consider neonatal morbidity and costs related to gestational age when choosing discretionary delivery.

Reliability of ultrasonographic formulary in the prediction of fetal weight and survival of very-low-birth-weight infants

Antenatal management of very-low-birth-weight infants often requires difficult obstetric decisions. This study was designed to evaluate the predictive value for neonatal outcome of antenatally acquired estimation of gestational age and ultrasonographically estimated fetal weight or a combination of both in very-low-birth-weight infants. Sixty-seven fetuses with estimated gestational ages between 22 0/7 and 28 6/7 weeks were studied ultrasonographically to estimate fetal weight. A comparison of accuracy of estimated fetal weight with actual birth weight showed good correlation (r = 0.93). Neonatal outcome of these infants was analyzed by estimated gestational age and estimated fetal weight. Estimated gestational age and estimated fetal weight greater than 25 weeks and greater than 750 gm were associated with 50% survival, respectively. However, when both of these conditions were met survival reached 85%. This information may be useful to guide antepartum management decisions in this very-low-birth-weight group.

Fetal monitoring during emergency obstetric transport

The practicality of fetal heart rate monitoring during fixed-wing transport of obstetric emergencies was evaluated. Fifty-seven transports were performed and 40 (70%) were monitored successfully with the electronic fetal heart rate monitor. External fetal heart rate monitoring was technically accomplished in 83% of monitored transports. Of the 40 patients monitored, 33 (83%) of the fetal heart rate tracings were considered useful for adequate evaluation of the fetal heart rate and contraction frequency. No patients had late decelerations during transport. At cabin pressures from 1100 feet to 7000 feet, fetal hypoxia as measured by late decelerations was not present in any patient.

Fetal recoil during labor to evaluate fetal well-being when heart rate monitoring is not informative*

Background Fetal movement is a predictor of fetal wellbeing. Fetal movement in response to a stimulation (fetal recoil) has been tested, and all fetuses that demonstrated recoil had umbilical arterial blood pH at least 7.20. Cases We used fetal recoil to allow labor in three women with fetal heart tracings that were not informative. In all three, Apgar scores or umbilical artery pH values confirmed normal fetal acid-base status at birth. Conclusion Fetal recoil is a potentially useful method to assess fetal status when fetal heart rate monitoring is not informative.

In utero Fetal Cardiac Resuscitation: A Case Report

A patient presented at 21 weeks gestation with nonimmune hydrops of her singleton fetus. A cordocentesis confirmed fetal anemia. During the course of the procedure, fetal cardiac arrest occurred. The fetus was resuscitated with intracardiac epinephrine and fetal transfusion was performed. The resuscitation was initially successful, however the fetus died 12 h later.

Preterm birth : can we do better?

Preterm birth (PTB) remains the most serious complication in obstetrics and a substantial excess burden in US healthcare economics. The etiology of PTB is complex and likely has multiple physiological pathways. Unfortunately, current antenatal care screening methods have not been successful in predicting and, eventually, preventing PTB. Although treatments such as progesterone, cerclage and pessary are available for patients with historical risk factors and shortened cervix, these treatments are not universally efficacious. Antenatal care is in great need of new prediction and prevention strategies. The role of more global methods of screening and treatment is still undefined. Most women with clinical risk factors will not deliver early, and aggressive interventions in large segments of the population may not be warranted or cost effective. Furthermore, over half of women who experience PTB have no historical risk factors. Even second-trimester cervical length (CL) has only modest ability to predict which women will experience PTB. There is thus a clear need to identify biomarkers that provide quantitative, individualized assessment of risk early in pregnancy that is specific for each individual woman. The ideal biomarkers would be indicative of the pathway leading to PTB, require no special testing equipment, have a low false positive and negative rate, and offer early identification, allowing adequate time to intervene. We need an aggressive and comprehensive approach to see a dramatic reduction in rates of preterm delivery in the U.S. Division of Maternal-Fetal Medicine of the Department of Obstetrics & Gynecology at the Medical University of South Carolina, Charleston, SC. Department of Obstetrics and Gynecology and the Division of Education and Research for the Christiana Care Health System, Newark, DE. Maternal Fetal Medicine at Valley Perinatal Services and Banner Good Samaritan Medical Center in Phoenix, AZ. Recent media reports have praised several states (Iowa, Virginia, Arkansas, Nevada and Oklahoma) for achieving Proceedings in Obstetrics and Gynecology, 2016;6(3):1 Preterm birth 2 reductions in the rate of preterm birth (PTB). Though these reports represent progress, we must acknowledge that the current rate of 9.6% in the US, which is the highest among developed countries, is unacceptable, and that our current thinking about PTB requires revision. Preterm Birth as a Public Health Issue PTB remains the most serious complication in obstetrics and a substantial excess burden in US healthcare economics. In addition, it accounts for 85% of neonatal morbidity and mortality worldwide, is a leading cause of death in children <5 years of age, is responsible for nearly 1 million deaths per year, and a leading cause of chronic disability, straining the Medicaid budgets of most states. Persistent and wide disparities in PTB also exist, especially for Africa-American women. The rate of PTB increased in the United States until 2006, is now declining slightly. Currently, the average cost of a stay in a neonatal intensive care unit (NICU) exceeds