Nader Z. Rabie

Oligohydramnios in complicated and uncomplicated pregnancy: a systematic review and meta‐analysis

To evaluate adverse pregnancy outcomes in singleton pregnancies diagnosed with oligohydramnios through a systematic review and meta‐analysis of controlled trials.

Incarceration of the Gravid Uterus.

Objective The aim of this review was to describe the risk factors, clinical and radiographic criteria, and management of this rare complication of pregnancy. Methods A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched. Results There were 60 articles identified, with 53 articles being the basis of this review. Multiple risk factors have been suggested in the literature including retroverted uterus in the first trimester, deep sacral concavity with an overlying sacral promontory, endometriosis, previous abdominal or pelvic surgery, pelvic or uterine adhesions, ovarian cysts, leiomyomas, multifetal gestation, uterine anomalies, uterine prolapse, and uterine incarceration in a prior pregnancy. The diagnosis is difficult to make owing to the nonspecific presenting symptoms. The diagnosis is clinical and confirmed by imaging. Magnetic resonance imaging is superior to ultrasound to accurately diagnose and elucidate the distorted maternal anatomy. Treatment is dictated by gestational age at diagnosis based on risks and benefits. The recommended route of delivery is cesarean delivery when uterine polarity cannot be corrected. Conclusions Incarceration of the gravid uterus is a rare but serious complication of pregnancy. The diagnosis is clinical and confirmed with imaging, with magnetic resonance imaging being superior to delineate the distorted maternal anatomy. Reduction of the incarcerated uterus should be attempted to restore polarity and avoid unnecessary cesarean delivery. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner should be better able to evaluate the published literature regarding incarceration of the gravid uterus and associated outcomes, differentiate normal and pathologic anatomy on various imaging modalities, determine the most beneficial treatment strategy based on gestational age, and review recommendations regarding management of subsequent pregnancies.

Uncomplicated Pregnancies and Ultrasounds for Fetal Growth Restriction: A Pilot Randomized Clinical Trial.

Objective The purpose of this multicenter pilot study was to determine the feasibility of randomizing uncomplicated pregnancies (UPs) to have third trimester ultrasonographic exams (USE) versus routine prenatal care (RPNC) to improve the detection of small for gestational age (SGA; birth weight < 10% for GA). Material and Methods At three referral centers, 50 UPs were randomized after gestational diabetes was ruled out. Women needed to screen, consenting, and loss to follow-up was ascertained, as was the detection rate of SGA in the two groups. Results During the study period at the three centers, there were 7,680 births, of which 64% were uncomplicated. Of the 234 women approached for randomization, 36% declined. We recruited 149 women and had follow-up delivery data on 97%. The antenatal detection rate of SGA in the intervention group was 67% (95% confidence intervals 31–91%) and 9% (0.5–43%) in control. Conclusion The pilot study provides feasibility data for a multicenter randomized clinical trial to determine if third trimester USE, compared with RPNC, improves the detection of SGA and composite neonatal morbidity.

Prenatal diagnosis and telemedicine consultation of fetal urologic disorders.

In Arkansas, telemedicine is used commonly in obstetrics through Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS), the existing statewide telemedicine network. This network is used primarily for tele-ultrasound and maternal-fetal medicine consultation. This study is a retrospective case series, describing all the patients who had a prenatally diagnosed urologic anomaly that required prenatal urologic consultation. From 2009–2013, approximately 1300 anomalies were recorded in the Arkansas Fetal Diagnosis and Management (AFDM) database, 14% of which were urologic anomalies. Twenty-six cases required prenatal urologic consultation, 25 of which were conducted via telemedicine. Teleconsultation allowed patients to combine maternal-fetal medicine and urologic consultations in one visit, saving time and effort and ultimately, for most patients, providing reassurance that delivery could be accomplished locally with postnatal follow-up already arranged. While there are several studies reporting the use of telemedicine for various subspecialty consultations, to our knowledge, this is the first to describe the use of telemedicine for prenatal urology consultation. Future research could randomize patients prospectively to allow comparison of both the outcomes as well as the patient experience.

Teleultrasound: How Accurate Are We?

Ultrasound serves an important role in the prenatal diagnosis of fetal structural anomalies. Recently, there has been increased use of teleultrasound protocols. We aimed to evaluate the sensitivity and accuracy of teleultrasound.

Normal amniotic fluid volume across gestation: Comparison of statistical approaches in 1190 normal amniotic fluid volumes

Ultrasound estimation and evaluation of amniotic fluid volume (AFV) is an important component of pregnancy surveillance and fetal well‐being. The purpose of this study was to compare and contrast four statistical methods used to construct gestational age‐specific reference intervals for the assessment of AFV.

Arkansas fetal diagnosis and management: identifying and coordinating care for anomalous fetuses

Abstract Objective: Describe a novel system of coordinating the identification and management of fetal anomalies in a rural state, where there is a large proportion of impoverished and Medicaid eligible patients, and centralization of the majority of tertiary care resources. Methods: The Arkansas Fetal Diagnosis and Management program was initiated to coordinate the care of anomalous fetuses. Data from the beginning of the program (2009) to 2013 was collected and analyzed. The data is reported in a descriptive fashion, to report the outcomes of this program. The specific type and number of anomalies diagnosed and managed were tabulated and analyzed. Results: From 2009 to 2013, data from 1300 pregnancies was collected. From 2009 to 2013, there were 7.9%, 10.9%, 15.0%, 18.6%, and 22.3% of ultrasound referrals with fetal anomalies. The anomalies were grouped by physiologic system, and despite the total numbers increasing each year, the frequency and distribution of anomalies remained constant. Conclusions: The Arkansas Fetal Diagnosis and Management Program streamlined the coordination of care for pregnancies affected by anomalous fetuses.

Fetal Mortality in the Delta.

Objectives To compare the fetal mortality rate in the Delta counties of a state in the Mississippi Delta region of the United States with that of the non-Delta counties of the same state. Methods Hospital discharge data for maternal hospitalizations were linked to fetal death and birth certificates for 2004–2010. Data on maternal characteristics and comorbidities and pregnancy characteristics and outcomes were evaluated. The frequency of characteristics of pregnant women and pregnancy outcomes between Delta and non-Delta areas of the state was compared. Results There were a total of 248,255 singleton births, of which 35,605 occurred in the Delta counties. Delta patients were more likely to be younger than 20 years old, African American, multigravida, Medicaid recipients, smokers, and not married (P < 0.001) when compared with the non-Delta patients. The overall odds of fetal death within Delta counties are 1.40 times (95% confidence interval [CI] 1.22–1.61) higher than the non-Delta counties, and the odds of fetal death at ⩽28 weeks are 1.56 times (95% CI 1.28–1.91) higher. After controlling for maternal age, race/ethnicity, level of prenatal care, and maternal comorbidities, the odds of fetal death remained 1.21 times higher (95% CI 1.05–1.41) and 1.28 times higher at ⩽28 weeks’ gestational age (95% CI 1.03–1.60). Conclusions Fetal mortality is significantly greater in the Delta counties compared with the non-Delta counties, with a 21% increase in the odds of overall fetal death in the Delta counties compared with non-Delta counties and a 28% increase in the odds of fetal death at ⩽28 weeks.

Intra-Amniotic Hemorrhage Imitating Gastroschisis: A Case Report and Review of the Literature

Patient: Female, 33 Final Diagnosis: Intramamniotic hemorrhage Symptoms: Abdominal pain • uterine contractions • vaginal bleeding Medication: — Clinical Procedure: Cesarean delivery Specialty: Obstetrics and Gynecology Objective: Unusual clinical course Background: A spontaneous intra-amniotic hemorrhage is rarely encountered during pregnancy. The correct diagnosis and management are problematic because of the infrequency of this condition and the high likelihood of a misdiagnosis. Case Report: A primigravida with an uncomplicated pregnancy and a normal targeted ultrasound presented late in the second trimester of pregnancy with antepartum bleeding of unknown origin. A repeat ultrasound was suggestive of an abdominal wall defect (gastroschisis). The patient continued to have antepartum bleeding and developed uterine contractions and abdominal pain necessitating frequent visits to labor and delivery. An MRI ruled out gastroschisis and diagnosed intra-amniotic hematoma. The patient presented with acute abdominal pain and was clinically considered to be having an abruption, and was delivered by cesarean. Old blood was noted in the abdominal cavity and within the uterine cavity. At the time of the cesarean, an area of intra-amniotic hematoma was identified, as well as a retroplacental blood clot. Conclusions: An intra-amniotic hematoma is unusual and may be misdiagnosed. MRI may be helpful in determining the correct diagnosis and subsequent management.