Kacey Eichelberger

Placenta Previa in the Second Trimester: Sonographic and Clinical Factors Associated with Its Resolution

We identify characteristics that predict resolution of placenta previa and develop a clinical model for likelihood of resolution. We conducted a retrospective study of 366 singleton pregnancies complicated by placenta previa diagnosed with resolution of the previa as the primary outcome. Regression analyses were performed to determine variables associated with resolution and optimal timing for repeat sonographic evaluation. A likelihood of resolution model was created using a parametric survival model with Weibull hazard function. Of the 366 cases, 84% of complete placentae previae and 98% of marginal placentae previae resolved at a mean gestational age of 28.6 ± 5.3 weeks. Only gestational age and distance from the internal cervical os at the time of diagnosis were significantly associated with resolution ( P < 0.01). Likelihood of resolution was not significantly associated with any other variables. Marginal previae diagnosed in the second trimester do not appear to warrant repeat ultrasound evaluation for resolution.

Antiviral-resistant fulminant herpes hepatitis in pregnancy.

Fulminant herpes hepatitis with disseminated extrahepatic involvement in pregnancy is rare and carries a high mortality risk. Although acyclovir remains standard first-line therapy, effective management of acyclovir-resistant disseminated herpes simplex virus (HSV) in pregnancy remains elusive. We present a case of disseminated HSV resistant to both acyclovir and foscarnet, the first double-agent resistant case in pregnancy reported in the literature to date. In this case, therapeutic delivery was the ultimate treatment resulting in full recovery.

Robotic resection of adnexal masses during pregnancy.

OBJECTIVE To characterize the safety and feasibility of robotic adnexal surgery during pregnancy, and to compare surgical and obstetric outcomes for robotic versus laparoscopic treatment of adnexal masses during pregnancy. STUDY DESIGN A retrospective cohort study of all cases of robotic resection of adnexal masses in gravid patients performed at our institution between 2006 and 2009 compared with 50 consecutive historic laparoscopic controls performed between 1999 and 2007. RESULTS During the study period, 19 parturients underwent planned robotic resection of adnexal masses, all of which were uncomplicated. Compared with 50 consecutive laparoscopic controls, no differences in operative time, conversion to laparotomy, intraoperative or postoperative complications, or observed obstetric outcomes were apparent. The robotic cohort had a significantly shorter length of hospital stay (p < 0.01) and estimated blood loss (p = 0.02). CONCLUSION Robotic resection of adnexal masses during pregnancy appears both safe and feasible, with similar surgical outcomes when compared with a historic laparoscopic cohort.

Training needs in operative obstetrics for maternal-fetal medicine fellows.

Abstract Objective: To define residual operative obstetric training needs for first-year maternal-fetal medicine (MFM) fellows. Methods: We administered a web-based survey to all 100 first-year fellows. We used descriptive statistics to report frequency data for 13 procedures, and logistic regression to estimate odds ratios for comfort in doing and teaching selected procedures. Results: Response rate was 86% (n = 86). Fellows who completed residency in the Northeast/Midatlantic (n = 26) were less likely to report comfort doing or teaching low forceps deliveries (OR 0.21, 95% CI 0.05, 0.78; and 0.20, 95% CI 0.04, 0.85, respectively), while those completing fellowship in the West (n = 13), reported more comfort performing breech extraction of a second twin (OR 6.84, 95% CI 1.24, 51.50); fellows completing residency in the Southeast formed the referent group. Fellows reporting completion of the three selected procedures >5 times each during residency were significantly more likely to report comfort doing and teaching them as fellows. Type of residency program (community/academic) was not significantly associated with reported comfort. Conclusion: The wide range of operative obstetric experience fellows reported gaining in residency varies by region. Additional research is needed to understand competency and teaching ability for procedural skills, and many MFM fellows may need additional procedural experience.

Scope of Global Health Training Opportunities During Residency in Obstetrics and Gynecology

INTRODUCTION: Interest in global womens health is reported to be high among incoming obstetrics–gynecology residents. However, data regarding number and characteristics of programs offering formal training have not been collected systematically. METHODS: We administered a web-based survey to all program directors of Accreditation Council for Graduate Medical Education-accredited obstetrics–gynecology residency programs and used frequency statistics, Fishers exact, and &khgr;2 for data analysis. RESULTS: One hundred five of 243 program directors completed the survey (response rate 43.2%). A total of 78.1% report at least one resident participating in a global womens health rotation during the last 5 years. A total of 34.3% offer formal didactics and 27.6% offer a formal rotation in global womens health. Of those programs offering a formal rotation, 44.8% offer predeparture training and 62.1% have formal competency-based objectives. Of all respondents, 43.8% report having at least one faculty member in their department for whom global womens health is a dedicated part of their practice. We identified a nonsignificant trend between having a dedicated global womens health faculty member and a program offering a formal global womens health rotation (relative risk 1.91, 95% confidence interval [CI] 0.97–3.7, P=.06) and a significant association between programs with dedicated global womens health faculty and offering formal global womens health didactics (relative risk 1.84, 95% CI 1.07–3.14, P=.03). The most commonly identified barriers to global womens health training include cost or lack of funding, time constraints for faculty and residents, and educational constraints by Accreditation Council for Graduate Medical Education Residency Review Committee. CONCLUSION: Many obstetrics–gynecology residency programs have experience with a trainee participating in a global womens health rotation but do not offer either formal didactics or a formal rotation. Specific barriers are identified to developing more comprehensive global womens health programs.

Second-Trimester Maternal Serum Paraxanthine, CYP1A2 Activity, and the Risk of Severe Preeclampsia.

OBJECTIVE: To measure the association between second-trimester maternal caffeine intake and caffeine metabolism through the CYP1A2 system and the risk of subsequent severe preeclampsia. METHODS: This was a nested case–control study of women who had undergone second-trimester screening for fetal aneuploidy and had banked serum available for analysis. The outcome of interest was severe preeclampsia, and exposures were serum paraxanthine (1,7-dimethylxanthine), measured through high-performance liquid chromatography, and CYP1A2 activity, assessed by paraxanthine/caffeine ratios. RESULTS: We identified 51 cases of severe preeclampsia from our population of 3,992 women (1.3%), of whom 33 had sufficient serum for analysis. These were compared with 99 healthy women. Median paraxanthine concentrations were not significantly higher in women in the control group than women in the case group (96.4 ng/mL compared with 38.0 ng/mL, P=.12), and higher serum paraxanthine was not associated with lower odds of severe preeclampsia (odds ratio [OR] 0.72, confidence interval [CI] 0.48–1.08). However, we found a significantly higher paraxanthine/caffeine ratio in women in the control group than women in the case group (0.37 compared with 0.23, P=.02) and a decreased risk of preeclampsia per every log standard deviation increase in paraxanthine/caffeine ratio (OR 0.53, 95% CI 0.31–0.90). CONCLUSION: Faster caffeine metabolism in the second trimester, assessed by paraxanthine/caffeine ratios, is associated with a reduced risk of subsequent severe preeclampsia. LEVEL OF EVIDENCE: II

Pitfalls in prenatal diagnosis of a fixed retroflexed fetal head

of such a diagnosis made on fetal MRI5. There has also been one case report of a cystic hypothalamic hamartoma on fetal MRI6. The location of arachnoid cysts associated with a hypothalamic hamartoma appears to show some correlation with age, with reports of cysts located in the suprasellar region in the very young (5 years and under) and in the middle cranial fossa in older patients7–10. Fetal MRI is useful for the work-up of cysts diagnosed on ultrasound and contributes to presurgical planning for those who may require intervention soon after birth. Furthermore, antenatal MRI helps to distinguish suprasellar arachnoid cysts from other cystic suprasellar masses such as the more heterogeneous craniopharyngiomas. Central arachnoid cysts detected on antenatal ultrasound can be associated with hypothalamic hamartomas, which can be confidently diagnosed on second-trimester fetal MRI.

Efficient Use of Early Obstetric Sonography in the Emergency Department Setting

Transvaginal sonography is frequently used in the emergency department (ED) to triage pregnancies of unknown location. The purpose of this study was to examine the utility of sonography in clinically stable patients with β‐human chorionic gonadotropin (β‐hCG) values below the discriminatory zone.