Sri Gottimukkala

Spontaneous Heterotopic Pregnancy: Dual Case Report and Review of Literature.

Introduction. Heterotopic pregnancy is a rare complication usually seen in populations at risk for ectopic pregnancy or those undergoing fertility treatments. It is a potentially dangerous condition occurring in only 1 in 30,000 spontaneous pregnancies. With the advent of Assisted Reproduction Techniques (ART) and ovulation induction, the overall incidence of heterotopic pregnancy has risen to approximately 1 in 3,900 pregnancies. Other risk factors include a history of pelvic inflammatory disease (PID), tubal damage, pelvic surgery, uterine Mullerian abnormalities, and prior tubal surgery. Heterotopic pregnancy is a potentially fatal condition, rarely occurring in natural conception cycles. Most commonly, heterotopic pregnancy is diagnosed at the time of rupture when surgical management is required. Case. This paper represents two cases of heterotopic pregnancies as well as a literature review. Conclusion. Heterotopic pregnancy should be suspected in patients with an adnexal mass, even in the absence of risk factors. Clinicians must be alert to the fact that confirming an intrauterine pregnancy clinically or by ultrasound does not exclude the coexistence of an ectopic pregnancy. A high index of suspicion in women is needed for early and timely diagnosis, and management with laparotomy or laparoscopy can result in a favorable and successful obstetrical outcome.

Amniotic Band Syndrome, Perinatal Hospice, and Palliative Care versus Active Management

Introduction. Amniotic band syndrome and sequence are a relatively rare condition in which congenital anomalies occur as a result of the adherence and entrapment of fetal parts with coarse fibrous bands of the amniotic membrane. A large percentage of reported cases have an atypical gestational history. The frequency of this obstetric complication is not affected by fetal gender, genetic abnormality, or prenatal infection. Case. A 21-year-old, G1P0 female parturient at 18 weeks and 5 days with a single intrauterine gestation during a routine ultrasound evaluation was noted to have amniotic band sequence. The pregnancy was subsequently complicated by preterm premature rupture of membranes with oligohydramnios, resulting in a surviving neonate scheduled for rehabilitative treatment. Conclusion. Amniotic band syndrome is an uncommon congenital anomaly resulting in multiple disfiguring and disabling manifestations. Several theories are proposed with most involving early rupture of the amnion and entanglement of fetal parts by amniotic bands. This syndrome can be manifested by development of multiple malformations, with the majority of the defects being limb abnormalities of a disorganized nature, as in the case we present. In the absence of a clear etiology of consequential congenital abnormalities, obstetric management guidelines should use shared decision models to focus on the quality of life for the offspring.

Intrahepatic cholestasis of pregnancy.

To the Editor: The Clinical Expert Series article “Intrahepatic Cholestasis of Pregnancy” is an inappropriate endorsement of adoption of active management for intrahepatic cholestasis of pregnancy. The evidence on which the article bases much of it support for active management is actually manipulated, incorrectly interpreted primary data. Rioseco et al report three and four stillbirths in the control and study groups, respectively. Glantz et al list increased complications in intrahepatic cholestasis of pregnancy–affected pregnancies owing to other complications, such as twin-twin transfusion and knotting of the umbilical cord. Henderson et al, in a recent review of the literature, found no evidence to support active management of intrahepatic cholestasis–affected pregnancies, finding reported similar stillbirth rates in intrahepatic cholestasis–affected and cholestasis–unaffected pregnancies (0.04% and 0.03%, respectively). However, in this retrospective review, the authors did find suggestions that active management of this obstetric complication may be associated with perinatal harm. We suggest that caution may be warranted in the use of active management for intrahepatic cholestasis–affected pregnancies, as we recall the medical creed of “first do no harm.” Williamson and colleagues correctly indicate that reference levels for bile acids in pregnancy have not been well-established. In contrast, these authors incorrectly conclude that there is adequate evidence to calculate a risk-to-benefit ratio to support empiric use of active management for intrahepatic cholestasis–affected pregnancies. Rather than adoption of active management, each affected gravid woman should be engaged in an informed decision-making process that presents the known risks of labor induction before 39 weeks of gestation and the potential risk of preterm fetal demise associated with intrahepatic cholestasis of pregnancy.

Review of Stillbirths among Antepartum Women with Gestational and Pre-Gestational Diabetes

Background: The literature is replete with reports describing the effect of diabetes on pregnancy outcomes, particularly the risk of stillbirth. The goal of this review is to explore the relationship between maternal diabetes and fetal demise. Aim: To review the risk of stillbirths in pregnancies complicated by Type 1, Type 2, and gestational Diabetes Mellitus. Discussion: Type 1 diabetes mellitus (T1D), Type 2 diabetes mellitus (T2D), and gestational Diabetes Mellitus (GDM) identified during pregnancy have been independently associated with an increased risk of stillbirth compared to pregnancies not affected by these conditions. Published guidelines for prevention and management of GDM are lacking, but the existing evidence indicates that achieving glycemic targets during pre-conception is associated with decreased rates of stillbirth. Conclusion: Diabetes is an independent risk factor for stillbirth that is amenable to achieving glycemic targets. Evidence-based recommendations for antenatal screening glycemic management are warranted to achieve reduction in stillbirth rates for gravidas with pre-gestational and gestational DM.