Yinka Oyelese

Acute and chronic respiratory diseases in pregnancy: Associations with spontaneous premature rupture of membranes

Objective. To examine whether acute and chronic respiratory diseases are associated with an increased risk of spontaneous premature rupture of the membranes (PROM). Methods. We used the 1993–2004 National Hospital Discharge Survey data of singleton deliveries in the USA (N = 41 250 539). The International Classification of Diseases Ninth Revision was utilized to identify acute (acute upper respiratory diseases, viral/bacterial pneumonia, and acute bronchitis/bronchiolitis) and chronic (chronic bronchitis and asthma) respiratory conditions and spontaneous PROM. All analyses were adjusted for potential confounders. Results. The incidence of PROM was 5%, and rates of acute and chronic respiratory conditions were 2.1 and 9.5 per 1000 pregnancies, respectively. Chronic bronchitis was associated with a reduced risk of PROM (RR 0.39, 95% CI 0.31, 0.48). Asthma was significantly associated with PROM at preterm (RR 1.15, 95% CI 1.14, 1.17) and term (RR 1.27, 95% CI 1.23, 1.30). Stratification by race showed that acute upper respiratory disease was associated with preterm PROM in whites (RR 1.90, 95% CI 1.71, 2.11) and blacks (RR 6.76, 95% CI 5.67, 8.07). Viral/bacterial pneumonia was associated with preterm PROM in blacks and term PROM in both races. Asthma was associated with term PROM in blacks but not whites. Conclusions. Acute respiratory diseases and asthma during pregnancy are associated with spontaneous PROM, with substantially stronger association among blacks than whites. We speculate that timely diagnosis and treatment, coupled with closely mentoring of pregnant women may help reduce the rate of PROM and associated complications.

Three‐dimensional sonographic diagnosis of vasa previa

Vasa previa is said to occur when fetal vessels run in the membranes over the cervix, below the presenting part, without the support of placental tissue or umbilical cord1. Rupture of these vessels at the time of spontaneous or artificial rupture of the membranes not infrequently results in fetal exsanguination and death1. When the diagnosis is not made prenatally, over half of fetuses die, and median Apgar scores in survivors are low (median, 1 at 1 min and 4 at 5 min)2. In addition, over half of these survivors require neonatal blood transfusions2. Thus, a good outcome depends primarily on prenatal diagnosis by ultrasound and elective delivery before the membranes rupture1–8. Two variants of vasa previa have been described: Type 1 results from velamentous insertion of the cord, and Type 2 from vessels running between two lobes of a bilobed or succenturiate placenta3. Pregnancies with second-trimester low-lying placentae, placentae with accessory lobes, multiple pregnancies, and those resulting from in-vitro fertilization have previously been described as being at risk for vasa previa. Women with such conditions may benefit from routine prenatal determination of the placental cord insertion site1–3,5–7. We describe here the prenatal diagnosis and evaluation of vasa previa using three-dimensional (3D) sonography. In the first case, two-dimensional (2D) transvaginal sonography was performed on a woman at 30 weeks’ gestation because a bilobed placenta had been seen on 2D transabdominal sonography. Vasa previa was suspected. We then performed 3D transvaginal sonography with color and power Doppler using a Voluson Expert 730 (GE Medical Systems, Milwaukee, WI, USA) ultrasound machine. These confirmed the diagnosis of vasa previa. 3D multiplanar views revealed that a vessel overran the cervix in the anterior–posterior sagittal direction (Figures 1–3). The diagnosis of vasa previa and a bilobed placenta were confirmed at Cesarean delivery at 35 weeks’ gestation (Figure 4). Both mother and baby did well. In the second case, a 37-year-old woman was referred to our hospital at a gestational age of 24 weeks with a diagnosis of complete placenta previa and vaginal bleeding. Sonography at our center revealed an appropriately grown singleton live fetus, with normal amniotic fluid volume. On initial 2D transabdominal and transvaginal sonography, there appeared to be complete placenta previa. It was noted that the placental edge was just slightly to the right of the internal cervical os. When a mid-sagittal view of the cervix was obtained with 3D ultrasound, it became apparent that there were vessels overlying the cervix in an anterior–posterior direction, running through the membranes just along the lateral placental edge. Pulsed Doppler demonstrated a fetal umbilical arterial signal through these vessels. The patient was admitted to hospital. Steroids were administered for lung maturation and she was kept under close surveillance. At 33 weeks’ gestation, followup 3D transvaginal sonography was performed with color and power Doppler. Multiplanar imaging confirmed the diagnosis of vasa previa (Figures 5 and 6). An uncomplicated Cesarean delivery was performed at

Sonography and Magnetic Resonance Imaging in the Diagnosis of Cervico-Isthmic Pregnancy

Received April 23, 2003, from the Department of Obstetrics and Gynecology, Georgetown University Hospital, Washington, DC USA (Y.O., T.B.E., K.M.L.); and Departments of Obstetrics and Gynecology (N.A.) and Radiology (R.H., L.N.), Providence Hospital, Washington, DC USA. Revision requested April 29, 2003. Revised manuscript accepted for publication May 1, 2003. Address correspondence and reprint requests to Yinka Oyelese, MBBS, MRCOG, Division of MaternalFetal Medicine, Department of Obstetrics and Gynecology, University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, Clinical Academic Building, Second Floor, 125 Paterson St, New Brunswick, NJ 08901 USA. E-mail: yinkamd@aol.com. Case Report

Risk factors for perinatal mortality in patients admitted to the hospital with the diagnosis of placental abruption

Abstract Objective: Placental abruption is a clinical term used when premature separation of the placenta from the uterine wall occurs prior to delivery of the fetus. Hypertension, substance abuse, smoking, intrauterine infection and recent trauma are risk factors for placental abruption. In this study, we sought for clinical factors that increase the risk for perinatal mortality in patients admitted to the hospital with the clinical diagnosis of placental abruption. Materials and methods: We identified all placental abruption cases managed over the past 6 years at our Center. Those with singleton pregnancies and a diagnosis of abruption based on strict clinical criteria were selected. Eleven clinical variables that had potential for increasing the risk for perinatal mortality were selected, logistic regression analysis was used to identify variables associated with perinatal death. Results: Sixty-one patients were included in the study with 16 ending in perinatal death (26.2%). Ethnicity, maternal age, gravidity, parity, use of tobacco, use of cocaine, hypertension, asthma, diabetes, hepatitis C, sickle cell disease and abnormalities of amniotic fluid volume were not the main factors for perinatal mortality. Gestational age at delivery, birthweight and history of recent trauma were significantly associated with perinatal mortality. The perinatal mortality rate was 42% in patients who delivered prior to 30 weeks of gestation compared to 15% in patients who delivered after 30 weeks of gestation (p < 0.05). A three-fold increase in severe trauma was reported in the group of patients with perinatal mortality than in the group with perinatal survivors (25% versus 7%, respectively, p < 0.05). Conclusions: In patients admitted to hospital for placental abruption delivery prior to 30 weeks of gestation and a history of abdominal trauma are independent risk factors for perinatal death.

The sensitivity of the Kleihauer–Betke test for placental abruption

Abstract The Kleihauer–Betke (KB) test evaluates fetal blood in the maternal circulation, and is often used when placental abruption is suspected. At our centre, it is the protocol to perform a KB test in all suspected cases of abruption. We carried out a retrospective study of all cases of abruption that occurred at our centre over 6 years. Of the 68 confirmed cases of placental abruption, only three had positive KB tests, giving a sensitivity of only 4.4%. Thus, in the overwhelming majority of cases of confirmed abruption, the KB test was negative. Our findings indicate that the KB test has poor sensitivity for placental abruption and should not be used in the detection of abruption.

Vasa Praevia: a descriptive review of existing literature and the evolving role of ultrasound in prenatal screening

Introduction: Literature addressing the feasibility of prenatal detection of vasa praevia during the mid‐trimester morphology ultrasound scan is scarce, as is a lack of consensus about the appropriate management of pregnancies once it is detected.

Successful conservative management of hereditary hemorrhagic telangiectasia in pregnancy. A case report.

Background: Hereditary hemorrhagic telangiectasia (HHT) is a condition characterized by multiple telangiectases and arteriovenous malformations. Women with HHT may develop life-threatening complications in pregnancy. In particular, death from pulmonary hemorrhage has been reported. Consequently, these women are often advised not to conceive or to terminate their pregnancies. Case: We report a case of conservative management of HHT in pregnancy with a good outcome. Conclusion: This case demonstrates that in carefully selected cases, women with HHT who are managed conservatively may have good pregnancy outcomes. A diagnosis of HHT alone is not reason to advise women against pregnancy, nor should these women routinely be advised to undergo pregnancy termination.

Mode of Delivery in Stillbirth, 1995-2004

Objective: There are no national reports on the mode of delivery in pregnancies that end in stillbirth. We aimed at analyzing the cesarean delivery rates in pregnancies resulting in stillbirth over a 10-year period in the United States. Materials and Methods: This was a retrospective analysis evaluating data from the 1995 to 2004 US linked live birth–infant death files reported by the National Center for Health Statistics to examine the cesarean delivery rates in singleton pregnancies with and without stillbirth. Results: There were 39 797 616 singleton births registered in the database after the 20th week of gestation. During the study period, there were 243 979 stillbirths (0.61 per 100). Significant differences in stillbirths were noted in the African American population, nonmarried patients, in mothers who smoked, and at the extremes of the patients reproductive age (P < .01). The overall cesarean delivery rate in liveborn was 23.54% (9 309 961 cases) and 10.5% in stillbirth (25 558 cases; P < .01). The rate of cesarean delivery increased in liveborn (from 20.8% in 1995 to 28.9% in 2004; 28% overall increase) and in stillbirth (9.5% in 1995 to 11.23% in 2004; 15% overall increase). The rates of primary and repeat cesarean operations increased with gestational age in the stillbirth group. This pattern was not observed in the liveborn group. Conclusion: This analysis indicates that the cesarean delivery rates increased both in liveborn and in stillbirth from 1995 to 2004. This epidemiological observation deserves new clinical investigations to understand the clinical reasons, driving this obstetrical practice and the financial and societal impact that it portends.

The Uses and Limitations of the Fetal Biophysical Profile

In the second half of the twentieth century, true antepartum fetal assessment became possible, mainly due to the advent of real-time ultrasound. Initially, the most widely used form of antepartum fetal assessment was electronic fetal heart rate monitoring, through the nonstress test or the oxytocin-induced contraction stress test. It was soon realized, however, that these forms of monitoring had significant limitations. The biophysical profile allows a more thorough evaluation of fetal well-being and has the potential to significantly reduce the false-positive rate of the nonstress test/contraction stress test.

Persistent Funic Presentation Resulting From Marginal Cord Insertion into a Low-Lying Placenta

Cord prolapse is one of the most feared complications of pregnancy and is associated with high perinatal mortality and morbidity. While cord prolapse may be associated with malpresentation, unengagement of the presenting part, and prematurity, very often it occurs without warning. The advent of ultrasound has afforded the physician the ability to prenatally detect funic presentation, generally considered a precursor of cord prolapse1–4. This allows Cesarean delivery prior to the onset of labor, potentially avoiding cord prolapse, and therefore preventing the perinatal morbidity and mortality associated with this complication1,2. Recent studies, however, have suggested that funic presentation detected prenatally does not always result in cord prolapse in labor, since funic presentation not infrequently resolves spontaneously3,4. The challenge therefore is identifying which cases of prenatally diagnosed funic presentation are likely to persist until labor. We describe a case of funic presentation associated with a marginal cord insertion into the lower edge of a low-lying posterior placenta. A 33-year-old female in her fifth pregnancy had a sonogram at 20 weeks’ gestation that revealed a complete placenta previa. She had previously had four uncomplicated pregnancies that had delivered vaginally at term. Follow-up sonography at 27 weeks of gestation showed a posterior low-lying placenta, with its lower edge 1.5 cm from the internal os. Free loops of umbilical cord were noted overlying the cervix. The cord insertion was noted to be into the lower aspect of the placenta, but the insertion was not velamentous. The cervix measured 5 cm in length and was closed, without funneling or dynamic changes. Sonography was performed every 3 weeks to monitor the placenta. At each of the sonographic examinations the free loops of cord were consistently noted to overlie the cervix. At 34 + 4 weeks, sonography revealed the placenta to be posterior, with its lower edge 1.9 cm from the internal cervical os. Free loops of cord ran over the cervix, and the placental cord insertion was noted to be 2 cm from the lower placental edge (Figures 1 and 2). Fetal growth was appropriate for gestational age. Fetal heart tracing was reactive with accelerations. However, there were recurrent, shallow, variable, fetal heart rate decelerations. A Cesarean delivery was performed at 35 + 2 weeks. A live, male infant was delivered weighing 2400 g with Apgar scores of 8 and 9 at 1 and 5 min, respectively. The infant was admitted to the neonatal unit, had an uncomplicated hospital course and was discharged home on the seventh day of life. The marginal cord insertion was confirmed by placental examination after delivery. Figure 1 Sonogram demonstrating the free loops of cord in the lower uterine segment (small arrows). The large arrow points to the internal cervical os, and the arrowhead to the lower placental edge. cx, cervix; h, head; p, placenta.