Nadav Schwartz

Adnexal masses in pregnancy.

With the increased use and quality of ultrasound in pregnancy, adenxal masses are being encountered with greater frequency. Fortunately, most of such masses are benign and resolve on their own. However, complications such as ovarian torsion can occur. In addition, a malignancy can be present in a small minority of cases. In this article, we review the available literature on this subject to help guide the clinician in the diagnosis and management of adnexal masses in pregnancy.

Progesterone suppresses the fetal inflammatory response ex vivo.

OBJECTIVE Progesterone supplementation has been shown to be efficacious in preventing preterm birth. We sought to investigate the effects of progesterone on fetal inflammatory responses. STUDY DESIGN Fetal mononuclear cells were isolated from umbilical cord blood and exposed to vehicle or progesterone (P4) for 1 hour prior to lipopolysaccharide (LPS) stimulation. Supernatants were assayed for tumor necrosis factor-alpha. Similar experiments were performed using cyclic adenosine monophosphate (cAMP) and progesterone modulators. The effect of P4 treatment on intracellular cAMP levels was also determined. RESULTS LPS treatment led to a significant increase in cytokine production by fetal mononuclear cells. Despite the lack of detectable nuclear progesterone receptors, P4 suppressed this inflammatory response. R5020 (progesterone agonist), forskolin (cAMP inducer), and dibutyryl cAMP (cAMP agonist) all achieved immunosuppression. The cAMP antagonist, Rp-cAMP, blocked the inhibitory effect of progesterone. P4 significantly increased intracellular cAMP levels. CONCLUSION Progesterone rapidly suppresses the fetal inflammatory response, possibly via nongenomic activation of the cAMP cascade.

Novel 3-Dimensional Placental Measurements in Early Pregnancy as Predictors of Adverse Pregnancy Outcomes

Objective. We sought to determine whether novel approaches to volumetric assessment of the early placenta can yield significant predictors of adverse outcome. Methods. We measured placental volume (PV) at 11 to 14 weeks using virtual organ computer‐aided analysis and normalized the PV to the crown‐rump length (CRL) to yield the placental quotient (PQ = PV/CRL). We also calculated the mean placental diameter (MPD) from 4 measurements taken at 45° intervals to serve as a surrogate for the fetal‐maternal surface area. On the fetal side, the distance from the cord insertion (CI) to the placental margin was measured every 45°. Mean cord distance (MCD) is proposed as a novel descriptor of the chorionic plate and CI. Sonographic variables were analyzed as predictors of a composite adverse pregnancy outcome (COMP = small for gestational age [SGA], preeclampsia, spontaneous preterm birth, or neonatal intensive care unit admission). Results. A total of 135 patients were included, and 40 (29.6%) had an adverse outcome. The mean PQ (P = .02) and MCD (P = .02) were significantly lower in patients with COMP, although MPD was not significantly different (P = .26). A PQ of less than 1.00 (relative risk [RR], 2.3 [95% confidence interval, 1.4–2.7]) and an MCD of less than 4.00 cm (RR, 1.8 [1.1–2.9]) conferred an increased risk for COMP. Prediction models adjusting for parity and race yielded favorable characteristics [PV: area under the curve [AUC], 0.796; P = .04; PQ: AUC, 0.802; P = .03; MCD: AUC, 0.800; P = .04; and MPD: AUC, 0.782; P = .07). Secondary models targeting SGA as the sole outcome also showed excellent prediction (PV: AUC, 0.820; PQ: AUC, 0.810; MCD: AUC, 0.827; and MPD: AUC, 0.795). Conclusions. In addition to volume, 3‐dimensional sonography allows for novel techniques to measure other aspects of gross placental morphologic characteristics and CI, which can yield promising biologically plausible early predictors of fetal growth and adverse perinatal outcome.

Universal tuberculosis screening in pregnancy.

We reviewed our practice of universal tuberculosis (TB) screening in an at-risk pregnant population with regards to utility and patient compliance. The Gouverneur Healthcare Services prenatal database was analyzed for compliance with TB screening. Age, ethnicity, country of origin, and education level were also analyzed. Of 4049 patients, 95.0% were compliant with their purified protein derivative (PPD) testing. Universal screening identified 1935 (50.4%) PPD+ patients, with chest X-rays (CXR) available for 95.1%. Only one patient had a CXR consistent with active TB, although sputum testing was negative for acid-fast bacilli. Asian women were more likely to be PPD-compliant (adjusted odds ratio [aOR]: 4.94, 95% confidence interval [CI]: 2.34 to 10.45). Similarly, PPD+ Asian women were more likely to be compliant with CXR (aOR: 12.67, 95% CI: 3.44 to 46.7). U.S.-born women were significantly less likely to be compliant with PPD (aOR: 0.44, 95% CI: 0.30 to 0.64) or with CXR (aOR: 0.22, 95% CI: 0.08 to 0.61). Universal prenatal TB screening is associated with excellent compliance rates and is an effective way to identify a high prevalence of latent TB, but not active disease.

Detection of Twin Reversed Arterial Perfusion Sequence at the Time of First-Trimester Screening The Added Value of 3-Dimensional Volume and Color Doppler Sonography

Twin reversed arterial perfusion (TRAP) sequence, also known as acardiac malformation, is a rare complication unique to monozygotic multiple gestations. It occurs in approximately 1 per 35,000 pregnancies and in 0.3% of all monozygotic twin gestations. The malformation is characterized by the lack of a well-defined cardiac structure in one twin (acardiac), which acts as a parasite that is hemodynamically dependent on the normal (pump) twin. The malformation in the acardiac twin is always incompatible with survival regardless of its extent, whereas the prognosis of the pump twin may vary considerably. Common complications that affect the prognosis of the pump twin include complications of prematurity secondary to preterm delivery and polyhydramnios as well as congestive heart failure due to the expended cardiac demand. Without prompt detection, follow-up, and treatment, mortality rates for pump twins have been noted to be as high as 50% to 70%. Early sonographic diagnosis, appropriate follow-up, and intervention via cord occlusion when indicated are the mainstays of prenatal care in cases of TRAP sequence and have been associated with substantial improvements in survival. We report a case that emphasizes the added value of 3-dimensional (3D) and color Doppler techniques for both diagnosis of TRAP sequence and detection of poor prognostic features in the first or early second trimester.

Placental Morphologic Features and Chorionic Surface Vasculature at Term Are Highly Correlated With 3-Dimensional Sonographic Measurements at 11 to 14 Weeks

The purpose of this study was to examine the potential for 3‐dimensional sonographic measurement of the early placenta in predicting ultimate placental morphologic features at delivery.

Predictors of severe perineal lacerations in Chinese women

Abstract Objective: Chinese women have been shown to have a higher incidence of severe perineal laceration compared to other ethnic groups. We sought to test the hypothesis that this risk is related to body mass index (BMI) or to a relative fetal-maternal size disproportion as measured by the ratio of the newborn birthweight to maternal BMI (BW:BMI). Methods: A retrospective cohort study was performed using a pre-existing obstetric database. Third- and fourth-degree perineal lacerations served as the primary outcome of interest. Logistic regression was used to compare Chinese women to other ethnic groups and adjust for confounders. Results: Three thousand and eighty-five singleton vaginal deliveries were identified, with BMI data available for 2281. Chinese women had a greater risk for severe perineal laceration compared to Caucasian (OR: 3.22; 95% CI: 0.73–14.32) and Hispanic women (OR: 2.88; 95% CI: 1.92–4.30). Multivariate analysis found that newborn birth weight plays a role (OR: 1.0012; 95% CI: 1.0007–1.0016), but BMI alone did not explain the discrepancy (P=0.89). However, the BW:BMI ratio appears to be a stronger predictor of laceration rate than either variable alone (OR: 1.011; 95% CI: 1.003–1.020). Conclusion: The higher risk of severe perineal laceration in Chinese women compared to other ethnicities can be attributed, in part, to a relative fetal-maternal size disproportion.

Practice patterns in the management of isolated oligohydramnios: a survey of perinatologists

Objective. Optimal management of isolated oligohydramnios (IO) remains debatable. We surveyed Society for Maternal–Fetal Medicine (SMFM) members regarding their opinions and practice patterns. Study Design. Questionnaires were mailed to perinatologists across the US. IO was defined as sonographic low fluid (per the practitioners definition) in the absence of intrauterine growth restriction, fetal anomaly or significant maternal comorbidity. Results. The overall response rate was 35% (n = 632). Ninety-two percent of respondents consider IO to be a risk factor for various adverse outcomes. With a favourable cervix, 34% and 82% would consider inducing labour without documented lung maturity prior to 37 and 39 weeks, respectively. When asked whether induction of labour in cases of IO reduces perinatal morbidity, 45% were unsure and 21.4% thought it would not. Only 33% believe induction could decrease adverse outcomes. Newer members of SMFM (<10 years) and those of private practice were more likely to believe that induction is efficacious in decreasing morbidity. Conclusion. There is significant divergence regarding the management of IO. Despite being unsure of its benefit, most practitioners lean towards intervention. The available literature is insufficient to make firm recommendations supporting intervention for IO.

Transabdominal ultrasonography as a screening test for second-trimester placenta previa.

OBJECTIVE: To determine the test characteristics of transabdominal ultrasonography as a screening test for second-trimester placenta previa. METHODS: This secondary analysis of a prospective cohort study evaluated the distance from the placental edge to the internal os (placenta–cervix distance) through both transabdominal and transvaginal ultrasonography during the anatomic survey. Patients were recruited in the Maternal-Fetal Medicine Ultrasound Unit at the Hospital of the University of Pennsylvania, an urban tertiary care center. Transabdominal placenta–cervix distance cutoffs with high sensitivity for detection of previa and low-lying placenta were identified, and test characteristics were calculated. Follow-up ultrasound data, pregnancy, and delivery outcomes for those with second-trimester previa or low-lying placenta were obtained. RESULTS: One thousand two hundred fourteen women were included in the analysis. A transabdominal placenta–cervix distance cutoff of 4.2 cm was 93.3% sensitive and 76.7% specific for detection of previa with a 99.8% negative predictive value at a screen-positive rate of 25.0%. A cutoff of 2.8 cm was 86.7% sensitive and 90.5% specific with a 99.6% negative predictive value at a screen-positive rate of 11.4%. Only 9.8% (four of 41) of previas and low-lying placentas persisted through delivery. CONCLUSION: Transabdominal ultrasonography is an effective screening test for second-trimester placenta previa. At centers not performing universal transvaginal ultrasonography at the time of the anatomic survey, evidence-based transabdominal placenta–cervix distance cutoffs can optimize the identification of patients who require further surveillance for previa. LEVEL OF EVIDENCE: II

Intrapartum fetal monitoring today.

Abstract The literature on intrapartum fetal monitoring is reviewed emphasizing the pathophysiology, and current practice guidelines are discussed. FHR monitoring, ancillary tests, and investigational modalities are considered.