Rigoberto Santos-Ramos

Color flow mapping for myometrial invasion in women with a prior cesarean delivery.

OBJECTIVES Our aim was to evaluate the utility of color flow mapping in the prediction of placental myometrial invasion in women with Cesarean delivery. METHODS Ultrasound color flow mapping was performed on placental implantations in potential proximity to the hysterotomy scar. The smallest myometrial thickness was measured under the placenta to evaluate the degree of myometrial attenuation in this area and note was made of unusual vascular lakes. RESULTS Two hundred fifteen women with placentas in proximity to the prior hysterotomy scar underwent color Doppler mapping. Of 20 women with placenta previa and Cesarean delivery, 15 had Cesarean hysterectomy for bleeding complications and nine had the pathological diagnosis of placental invasion. The measurement of <1 mm for the smallest myometrial thickness or presence of large intraplacental lakes was predictive of myometrial invasion (sensitivity 100%, specificity 72%, PPPV 72%, and NPV 100%). CONCLUSIONS Color flow mapping predicted myometrial invasion when the smallest myometrial thickness was <1 mm and large intraplacental lakes were demonstrated.

Persistence of placenta Previa according to Gestational age at ultrasound detection

OBJECTIVE To evaluate gestational age at ultrasound detection of placenta previa as a predictor of previa persistence until delivery, and to estimate the effects of previa type, parity, and prior cesarean delivery on previa persistence. METHODS This was a retrospective cohort study of pregnancies with placenta previa detected during transabdominal or endovaginal ultrasound examination. Previa was categorized as complete if the placenta completely covered the internal cervical os or incomplete if the inferior placental edge partially covered or reached the margin of the os. Gestational age was grouped into 4‐week intervals from 15 to 36 weeks. The outcome was cesarean delivery for persistent previa. RESULTS Previa was detected during 940 ultrasound examinations in 714 pregnancies. Of those with placenta previa at 15–19 weeks, 20–23 weeks, 24–27 weeks, 28–31 weeks, and 32–35 weeks, previa persisted until delivery in 12%, 34%, 49%, 62%, and 73%, respectively. At each interval, complete previa was more likely to persist than incomplete previa, all P < .001. Prior cesarean delivery was an independent risk factor for persistent previa among women diagnosed with previa in the second trimester, P < .05. However, parity was not an independent risk factor for persistence at any gestational age interval after adjusting for prior cesarean delivery. CONCLUSION Gestational age at ultrasound detection of placenta previa may be used to predict likelihood of previa persistence. After midpregnancy, risk of persistence appears to be higher than previously reported. Type of placentation and prior cesarean delivery are important factors that modify the risk that previa will complicate delivery.

Hydramnios: Anomaly prevalence and sonographic detection

OBJECTIVE To characterize the prevalence and ultrasound detection of fetal anomalies in pregnancies with hydramnios, and to estimate anomaly and aneuploidy risks when no sonographic abnormality is noted. METHODS This was a retrospective cohort study of singleton pregnancies with hydramnios. Hydramnios was categorized as mild, moderate, or severe based on greatest amniotic fluid index of 25.0–29.9 cm, 30.0–34.9 cm, or 35.0 cm or more, respectively. Antenatal anomaly detection was compared with assessment in the immediate neonatal period. Aneuploidy and fetal deaths were analyzed separately. RESULTS Hydramnios was diagnosed in 672 pregnancies, and 77 (11%) of neonates had one or more anomalies. Though more severe hydramnios was associated with higher likelihood of anomaly (P < .001), sonographic anomaly detection (79%) did not differ according to degree of hydramnios (P = .4). Of anomalies which eluded sonographic diagnosis, cardiac septal defects, cleft palate, imperforate anus, and tracheoesophageal fistula were the most frequent. If sonographic evaluation was normal, the risk of a major anomaly was 1% with mild hydramnios, 2% with moderate hydramnios, and 11% with severe hydramnios (P < .001). Aneuploidy was present in 10% of fetuses with sonographic anomalies and 1% without apparent sonographic anomalies. The fetal death rate was 4% in the setting of hydramnios; 60% of these cases had anomalies. CONCLUSION The anomaly detection rate in pregnancies with hydramnios was nearly 80%, irrespective of the degree of amniotic fluid increase. Residual anomaly risk after normal sonographic evaluation was 2% or less if hydramnios was mild or moderate and 11% if severe.

The Ovarian Tumor Index Predicts Risk for Malignancy

Prediction of ovarian malignancy by ultrasonographic findings and patient age in the scenario of clinically suspected adnexal masses is a desirable goal.

Sinusoidal fetal heart rate pattern after intrauterine transfusion.

&NA; Two pregnancies complicated by severe Rh‐isoimmunization and the development of sinusoidal fetal heart rate patterns immediately after intrauterine transfusions are presented. An intermittent sinusoidal pattern resolved, in one fetus, with sonographic evidence of delayed but complete absorption of transfused red blood cells. In contrast, the second fetus exhibited a continuous sinusoidal pattern coincident with cardiac decompensation detected by echocardiography, severe anemia, and failure to absorb transfused red blood cells. Possible pathophysiologic mechanisms for the development of sinusoidal patterns after fetal transfusions are discussed. It is concluded that a sinusoidal fetal heart rate pattern may occur after fetal transfusion and that the subsequent course of this pattern provides meaningful information about fetal condition as well as the success of intrauterine transfusion. (Obstet Gynecol 64:21S, 1984)

Unilateral Twin Ectopic Pregnancy in a Patient With a History of Multiple Sexually Transmitted Infections

Background. The incidence of unilateral twin ectopic pregnancy is a rare condition. Several factors increase the risk of ectopic pregnancy, the most important of which is pelvic inflammatory disease, followed by operative trauma, congenital anomalies, tumors, and adhesions resulting in anatomically distorted fallopian tubes. We present a case of a woman with a history of four confirmed sexually transmitted infections (STIs) including Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex virus 2, and Treponema pallidum. The case illustrates the potential impact of sexually transmitted infections (STIs) on the risk of a twin ectopic pregnancy. Case. A 24-year-old primigravida, presented with an unknown last menstrual period, lower abdominal pain, watery vaginal discharge, and vaginal spotting. During this hospitalization, serum β-HCG testing was 263 mIU/mL and transvaginal ultrasonographic examination suggested a nonviable unilateral twin ectopic pregnancy. At exploratory laparotomy, a 10 cm mass involving the right fallopian tube and ovary was excised. Pathological evaluation of the specimen identified a monochorionic, diamnionic twin ectopic pregnancy within the fallopian tube. Conclusions Patients with a history of multiple (STIs) are known to be at risk for the development of chronic pelvic infection and postinflammatory scarring. The resulting distortion of the normal tubal anatomy leads to an increased risk of an uncommon presentation of ectopic pregnancy.

Subcutaneous tissue: to suture or not to suture at cesarean section.

Objective: The null hypothesis for this investigation was that there was no difference in the frequency of wound disruption between women who had their subcutaneous tissues approximated with suture and those who did not during cesarean section. Methods: During alternating months, consecutive women delivered by cesarean section either did (N = 716) or did not (N = 693) have their subcutaneous tissues closed with suture. All data were analyzed using chi square, Students t-test, Fishers exact probability test, analysis of variance, or logistic regression. Results: A 32% decrease in the frequency of wound disruption was observed when subcutaneous tissues were brought into apposition with suture at cesarean section (P = 0.03). Conclusions: Closure of Scarpas and Campers fascia with suture during cesarean section significantly decreased the frequency of wound disruption in this population.

Ultrasound prediction of fetal weight in prolonged pregnancy

In this study we applied two commonly used birth weight prediction equations to a sample of 121 women with prolonged pregnancies. Subjects had sonographic measurements of biparietal diameter and abdominal perimeter taken within 2 days of delivery at Parkland Memorial Hospital. Although the two prediction equations were obtained from a population of women in New Haven, Connecticut, who delivered over a wide range of gestational ages, when the equations were applied to the sample of prolonged pregnancies in Dallas, Texas, there was a strong correlation (0.71) between predicted and actual birth weight. Moreover, reestimation of the New Haven equations with use of the Dallas data yielded similar regression coefficients. Finally, birth weight prediction equations for black, white, and Hispanic patients in Dallas were not significantly different. These findings suggest a remarkably constant relationship between fetal head and abdominal dimensions and birth weight over different gestational ages and for different population groups.

Middle cerebral artery peak systolic velocity in monochorionic and dichorionic twin pregnancies

The purpose of this study was to compare middle cerebral artery (MCA) peak systolic velocity (PSV) values in monochorionic (MC) and dichorionic (DC) twin pregnancies.

Endocrine studies in a pregnancy complicated by ovarian theca lutein cysts and hyperreactio luteinalis

&NA; Severe virilization developed in a pregnant woman in association with the occurrence of theca lutein cysts and hyperreactio luteinalis of the ovaries. At term, maternal serum levels of androstenedione (58 ng/mL) and testosterone (20 ng/mL) were elevated massively; estrone (24 ng/mL) and estradiol‐17&bgr; (23 ng/mL) levels were increased moderately. Maternal serum levels of human chorionic gonadotropin (hCG) just before delivery, 22,276 mlU/mL, though twice the mean for normal women at term, were within the normal range. The levels of androstenedione (1.06 ng/mL) and testosterone (0.26 ng/mL) in umbilical cord serum of her normal newborn female infant were normal. The levels of androstenedione and testosterone in serum of this woman declined slowly, but progressively, during the first two months after delivery; the serum levels of androstenedione and testosterone increased substantially, however, after she was treated with hCG eight weeks postpartum. These results are suggestive that, for reasons unknown, markedly increased androgen production with theca lutein cysts and hyperreactio luteinalis in some pregnant women results ultimately because of increased ovarian sensitivity to hCG. (Obstet Gynecol 67:66S, 1986)