Victoria Minior

Non‐surgical management of live ectopic pregnancy with ultrasound‐guided local injection: a case series

To describe a series of consecutive cases of live ectopic pregnancies managed with ultrasound‐guided local injection of methotrexate (MTX) or potassium chloride (KCl).

The Closure of Iatrogenic Membrane Defects after Amniocentesis and Endoscopic Intrauterine Procedures

Objective: To describe a new technique for wound closure after endoscopic intrauterine procedures which prevents amniotic fluid leakage after the procedure. Study Design: This is an observational study which reviews a new technique under an IRB-approved protocol. The rationale for this study was the increasing frequency of intrauterine endoscopic procedures. The most common complication of these procedures is persistent leakage of amniotic fluid from puncture sites, which can result in preterm labor and preterm delivery. Thus, these procedures carry a high morbidity rate that may overcome the benefit of the intervention. We have employed a new technique, which has successfully prevented amniotic fluid leakage following the procedure. The instruments used for the endoscopic procedures were no larger than 3.5 mm for all cases. A sealant of platelets was rapidly injected followed by injection of fibrin glue and powdered collagen slurry at each puncture site. Sonography for modified AFI, clinical examination for nitrazine and ferning, and pad count were performed after each procedure at three intervals: immediately after the procedure, 24 h and 48 h. Results: Eight patients undergoing an endoscopic intrauterine procedure (either cord ligation for twin-twin transfusion syndrome or sealing of ruptured membranes after amniocentesis) were included. All patients were treated between 18 and 24 weeks of gestation. Sonography, clinical examination and pad count revealed no evidence of amniotic fluid leakage either intra-abdominally or vaginally in any of the patients. There was 1 patient who ruptured membranes 12 h after the procedure due to severe vomiting. Another patient elected to terminate the pregnancy 48 h after the procedure without evidence of leakage. The remaining patients continued for 8 weeks or more without fluid leakage. Conclusion: The technique described, immediate sealing of puncture wounds following endoscopic intrauterine procedures, is effective in preventing amniotic fluid loss after the procedure.

Vaginal fetal fibronectin as a predictor of spontaneous preterm delivery in the patient with cervical cerclage

OBJECTIVE The purpose of this study was to assess the validity of vaginal fetal fibronectin as a screening test for spontaneous preterm birth in patients with cervical cerclage. STUDY DESIGN A historic cohort of 117 patients who underwent cervical cerclage placement between 1996 and 2002 were identified. All patients were followed up in a maternal-fetal medicine faculty practice in a university setting. Serial fetal fibronectin samples of vaginal secretions were collected every 2 to 3 weeks, starting at 22 weeks of gestation and continuing until 32 weeks or delivery, whichever came first. RESULTS There were 81 singleton, 23 twin, 12 triplet, and 1 quadruplet pregnancies. There were 61 ultrasound-indicated, 47 prophylactic, and 9 emergency cerclages that were placed. Most cerclages were of the modified Shirodkar type (95%) with a median gestational age at cerclage placement of 16.6 weeks. Overall, 33.3% of gestations were delivered spontaneously before 37 weeks of gestation; 17.1% of gestations were delivered spontaneously before 34 weeks. For deliveries within 2 weeks and 3 weeks of a single fetal fibronectin assessment, the test had a sensitivity of 50% and 48.3%, a specificity of 90% and 91.1%, a positive predictive value of 16.3% and 28.6%, and a negative predictive value of 97.9% and 96%, respectively. Subgroup analysis by number of fetuses (singleton, twin, and higher order multiple gestations) revealed similar values. For delivery before 34 weeks of gestation, fetal fibronectin had a sensitivity of 50%, a specificity of 78.4%, a positive predictive value of 33.3%, and a negative predictive value of 88%. CONCLUSION This study is the first to evaluate the use of vaginal fetal fibronectin assessments to screen for preterm birth in patients who had undergone cervical cerclage procedures. We conclude that this test has similar validity to predict spontaneous preterm delivery in these high-risk pregnancies, as in previously published cohorts.

Combined sonographic and endoscopic umbilical cord occlusion in twin and triplet gestations.

Abstract Objective: To review our experience with a minimally invasive technique for umbilical cord occlusion as a method of selective feticide in monochorionic sets. Study design: Umbilical cord occlusion was completed using 3 mm bipolar cautery under ultrasound guidance (3D/4D, n=6; 2D, n=6) with pre and post ligation endoscopic evaluation. Results: 12 cases of monochorionic sets where selective feticide was performed were identified during the period 2000 to present. There were four triplet and eight twin gestations in the study cohort. Median interval from intervention to delivery was 16 weeks (range, 5–19). All co-twins survived the procedure and 15 of 16 were delivered after 33 weeks. Conclusions: Umbilical cord occlusion in monochorionic sets can be accomplished in a minimally invasive manner with combined endoscopic and ultrasound guidance in both twin and triplet pregnancies.