BackgroundSecond trimester pregnancy induction with misoprostol in women with prior caesarean delivery is not well studied.ObjectiveTo estimate the risk of uterine rupture using misoprostol as an induction agent for pregnancy termination in the second trimester of pregnancy in women with prior caesarean delivery.Search strategyCases of women with a history of prior caesarean delivery and subsequent misoprostol induction for pregnancy termination in the second trimester (16-28 weeks) were obtained from two main data sources. First, a retrospective chart analysis was performed at Thomas Jefferson University Hospital and Christiana Hospital between 1998 and 2004. Second, multiple Medline, Scopus and POPLINE literature searches were performed.Selection criteriaCase series and cohort studies of women with one or more prior caesarean delivery (of any type), and with a subsequent pregnancy with induction of labour for pregnancy termination at 16-28 weeks using misoprostol as the initial primary agent were included. Case reports were analysed separately.Data collection and analysisTotal cases were analysed by type and number of prior caesarean delivery, for the primary outcome of uterine rupture.Main resultsThe incidence of uterine rupture associated with second trimester misoprostol termination was 0.4% (2/461) in women with one prior low transverse, 0% (0/46) in those with two prior low transverse and 50% (1/2) in those with a prior classical caesarean delivery. One of the cases of uterine rupture in a woman with a prior low transverse caesarean required transfusion. None of the total eight cases (including case reports) of uterine rupture was associated with hysterectomy.ConclusionsSecond trimester misoprostol termination appears safe among women with one prior low transverse caesarean birth, as it is associated with incidences of uterine rupture of 0.4% (95% confidence interval 0.08-1.67%), of hysterectomy of 0% and of transfusion of 0.2%. There are insufficient data on risk with more than one prior caesarean birth or with prior classical caesarean birth.

JM is a 22 year old G2P1 who initially had a 13 week ultrasound which showed a thick membrane adjacent to the superior edge of the placenta, most likely representing a marginal hematoma. A 21 week ultrasound showed normal fetal anatomy, normal amniotic fluid and a normal left anterior placenta. A follow up 28 week ultrasound showed the following: turbid amniotic fluid filled with echoreflections, thick and heterogeneous placenta, numerous cystic structures emanating from the placenta, with no vascular flow, easily deformable by fetal body parts. The differential diagnosis at this point was: placental cyst (s), late amniotic rupture (extra-amniotic pregnancy), previously undiagnosed early amnion rupture with amniotic bands. A follow up 33 week ultrasound showed good growth (45 percentile) and normal amniotic fluid. A fetal echo showed mild tricuspid regurgitation and mild narrowing of the ductus arteriosis. A maternal hyperoxygenation pulmonary vascular test showed normal pulmonary vascular reactivity in response to oxygen, thus decreasing the likelihood for pulmonary hypoplasia. At 36 weeks, the fetus was less than the 10th percentile for size with preservation of the head/abdomen ratio. The fetus was tested with umbilical artery Doppler, NST and AFI. She was induced at 39 weeks and delivered a healthy neonate weighing 5 lbs, 9 ounces. There were no gross anomalies and no evidence of amniotic bands. The placenta grossly showed a 2 × 2 × 3 centimeter placental cyst on the fetal side. Placental pathology reported a marginal hematoma, multiple subchorionic cysts, intervillous thrombosis and old hemorrhage in the membranes. Pathology noted that while not specific, marginal hematoma and evidence of old hemorrhage are characteristic of extramembranous pregnancy.

converting the results in z-scores. ROC and ORs analyses were performed Results: Perinatal death occurred in 13 cases (25%). ROC analysis showed: Mod-MPI = 1.6 z-scores (95th percentile) had 84.6% sensitivity (Sen), 68.4% specificity (Spe), 47.2% positive predictive value (PPV), 93% negative predictive value (NPV), 2.68 positive likelihood ratio (LR+), 0.22 LR−; DV-PI = 6.74 z-scores had 46.2% Sen, 97.4% Spe, 85.7% PPV, 84.4% NPV, 18.00 LR+, 0.55 LR−; and IFI = −9.48 z-scores had 58.3% Sen, 80.6% Spe, 50% PPV, 85.3% NPV, 3.0 LR+,0.52 LR−. When 2 out of 3 parameters were altered, the risk of perinatal mortality increased significantly (OR: 6.2; 95% confidence intervals (CI) 1.59–24.18, p = 0.0001). Conversely none or only one altered parameter reduced significantly the risk (OR; 0.16; 95%CI 0.04–0.62 p = 0.0001). Conclusion: Mod-MPI = 1.6 z-scores has the highest sensitivity and negative predictive value. The combination of DV-PI, Mod-MPI and IFI (at least two altered) may be helpful in the identification of IUGR fetuses at risk of mortality.

To assess whether first-trimester nuchal translucency (NT) and ductus venosus (DV) are independent markers and thus be used in likelihood ratio schemes for Down syndrome risk assessment. Fifty-nine patients were seen at the Thomas Jefferson University Antenatal testing Unit for first-trimester screening. The NT size, DV pulsatility index (PI) and ‘a’ wave status were recorded. A normal NT value was based on previously published data. A normal DV value was based on the ‘a’ wave being above zero. A database was created using SPSS 13.0. A scatterplot was created comparing NT size and DV PI. Homoscedastisity and linearity were verified. A Chi square test for independence comparing categorical data (NT normal versus DV normal) showed a p = 0.094 thus indicating no association. A Pearson correlation analysis using continuous data showed an r = − 0.071 and a coefficient of determination = 0.005. Therefore, 5% of the variance in DV PI is explained by NT size. Using 2 different analyses, first-trimester NT and DV appear to be independent markers and thus may be used in likelihood ratio schemes for Down Syndrome risk assessment.

ObjectiveTo evaluate which risk factors are significantly associated with worsening maternal disease, focusing on chronic and active hepatitis C.Study designA retrospective review was completed for hepatitis C pregnant women from 2000-2003. Chronic hepatitis C is defined as hepatitis C viral RNA in the serum, while chronic active hepatitis C is defined as hepatitis C viral RNA plus abnormal liver function tests (LFT's).ResultsOf 76 pregnant women with known hepatitis c viral titers, 63 women had positive viral titers (chronic infection rate 83%). Within the chronic infection group with known LFT's, 33 had abnormal LFT's (52%). Smoking and previous drug use were significantly associated with chronic hepatits C. (Table)ConclusionTabled 1Non-viremic hep CChron hep C (viremic)p valueChron non-active hep CChron active hep Cp valueN13632933Age (mean)28.029.60.4929.029.90.48Duration (years)4.12.60.413.12.20.30HIV viral load1813.33156.80.603510.72941.50.88Methadone dose (mg)113.795.10.6091.398.60.55HIV pos2 (15%)8 (13%)0.792 (7%)6 (18%)0.18Hep B pos5 (38%)12 (19%)0.127 (24%)5 (15%)0.37Smoke10 (77%)60 (95%)0.0229 (100%)30 (91%)0.09Prev drug use8 (62%)63 (100%)0.0029 (100%)33 (100%)— Open table in a new tab ObjectiveTo evaluate which risk factors are significantly associated with worsening maternal disease, focusing on chronic and active hepatitis C. To evaluate which risk factors are significantly associated with worsening maternal disease, focusing on chronic and active hepatitis C. Study designA retrospective review was completed for hepatitis C pregnant women from 2000-2003. Chronic hepatitis C is defined as hepatitis C viral RNA in the serum, while chronic active hepatitis C is defined as hepatitis C viral RNA plus abnormal liver function tests (LFT's). A retrospective review was completed for hepatitis C pregnant women from 2000-2003. Chronic hepatitis C is defined as hepatitis C viral RNA in the serum, while chronic active hepatitis C is defined as hepatitis C viral RNA plus abnormal liver function tests (LFT's). ResultsOf 76 pregnant women with known hepatitis c viral titers, 63 women had positive viral titers (chronic infection rate 83%). Within the chronic infection group with known LFT's, 33 had abnormal LFT's (52%). Smoking and previous drug use were significantly associated with chronic hepatits C. (Table) Of 76 pregnant women with known hepatitis c viral titers, 63 women had positive viral titers (chronic infection rate 83%). Within the chronic infection group with known LFT's, 33 had abnormal LFT's (52%). Smoking and previous drug use were significantly associated with chronic hepatits C. (Table) ConclusionTabled 1Non-viremic hep CChron hep C (viremic)p valueChron non-active hep CChron active hep Cp valueN13632933Age (mean)28.029.60.4929.029.90.48Duration (years)4.12.60.413.12.20.30HIV viral load1813.33156.80.603510.72941.50.88Methadone dose (mg)113.795.10.6091.398.60.55HIV pos2 (15%)8 (13%)0.792 (7%)6 (18%)0.18Hep B pos5 (38%)12 (19%)0.127 (24%)5 (15%)0.37Smoke10 (77%)60 (95%)0.0229 (100%)30 (91%)0.09Prev drug use8 (62%)63 (100%)0.0029 (100%)33 (100%)— Open table in a new tab

To show that the maternal hyperoxygenation test for pulmonary vascular reactivity (HPVR) is useful for prognosis in the fetus with very small lungs associated with congenital diaphragmatic hernia (CDH). Twenty four fetuses with severe CDH underwent HPVR after 30 weeks gestation. Severe CDH was defined as lung smaller than the cardiac mass in the transverse image of the fetal thorax. Doppler studies of the mid right pulmonary artery were performed before and after 10 minutes of the mother oxygenation by mask. Before and after pulsatility indices (PI) of the flow patterns were compared. A positive change was considered as a greater than 20% decrease in PI indicating increased pulmonary blood flow. Of the 24 fetuses with CDH, 12 are alive and 12 died after delivery. Of those alive, 12 of 12 (100%) had a positive HPVR. Of those who died, 8 of 12 had a negative HPVR. Of those infants who died with a positive HPVR, all underwent CDH surgical repair with Gore-Tex patch: one died at 85 days with sepsis, one who died at 60 days had meconium aspiration syndrome and respiratory failure, one died at 29 days with sepsis, and one died at 13 days from sepsis who also had single kidney and cleft palate. The maternal hyperoxygenation test for pulmonary vascular reactivity can be useful for prognosis when fetuses are found to have CDH with small lungs. Surgical expertise and experience and a dedicated neonatal extracorporeal membrane oxygenation team are required to maintain these infants.

A 29 year old G1P0 at 32 5/7 weeks presented with a chief complaint of no fetal movement for the previous 24 hours. Her history of fetal movements showed decreased movements beginning 48 hours ago and no movement for the last 24 hours. Prior to that, movements were normal. A non-reactive non-stress test was noted. Ultrasound showed a living vertex fetus with estimated fetal weight of 2027 grams (44%) with an HC/AC of 1.03. The biometry was symmetric. The placenta was anterior grade 1 with no signs of retroplacental hemorrhage of intervillous thrombosis. The AFI was 10.2 centimeters. Anatomical survey was unremarkable. There was no signs of fetal hydrops. Doppler evaluation showed an umbilical S/D ratio of 1.92. The middle cerebral artery peak systolic velocity was 102 cm/sec, consistent with moderate to severe anemia. The ductus venosus S/A ratio was 3.8. There was no tricuspid regurgitation or venous pulsations. The non-stress test was non-reactive with a fetal tachycardia in the 160's noted. There were intermittent late decelerations and one prolonged deceleration. The BPP score was 2/10. A cesarean section was ultimately performed with the working diagnosis of acute fetal-maternal hemorrhage. Neonatology was notified and blood was made available. Apgars were 3, 6, and 7 at 1, 5, and 10 minutes. The neonate was pale and mottled at birth. Initial H/H was 4.1/12.2 and immediate transfusion was done. Weight was 5 pounds 4 ounces. The hemoglobin post transfusion was 16. Fetal stain returned as 1.5% consistent with a 30–40% blood loss. Parvo virus titers were negative and blood type was A+. The fetus had hyaline membrane disease which slowly improved. The neonate was discharged to home on DOL #14. This case illustrates the utility of MCA doppler studies in the diagnosis of a fetal-maternal hemorrhage. It may be used to predict anemia in a more subacute setting (after blood re-equilibration), such as a large fetal-maternal hemorrhage as seen in this case.

Objective: The purpose of this study was to determine if a reinforcing cerclage improves outcome in women with a history-indicated cerclage who develop a short cervix on ultrasound.Study design: The management of women with a history-indicated transvaginal cerclage who subsequently developed a short cervix (<= 25 mm) on transvaginal ultrasound before 24 weeks was retrospectively reviewed. Exposed subjects that received a reinforcing cerclage were compared with similar unexposed subjects that were followed with expectant management. The primary outcome was preterm delivery <35 weeks.Results: Twenty-four eligible women were identified, of which 5 received a reinforcing cerclage and 19 were managed expectantly. There was no difference in patient demographics and risk factors between the exposed and unexposed groups. Reinforcing cerclage was associated with a significantly earlier gestational age at delivery (20.8 vs 32.9 weeks, P =.002) as well as higher rates of both preterm delivery <35 weeks (100% vs 32%, P =.01) and previable delivery <24 weeks (80% vs 16%, P =.01).Conclusion: In pregnancies with a history-indicated cerclage and subsequently diagnosed ultrasound cervical shortening before 24 weeks, placement of a reinforcing cerclage is associated with earlier delivery than expectant management. (C) 2005 Mosby, Inc. All rights reserved.

To evaluate the use of fetal fibronectin (FFN) and transvaginal ultrasound cervical length (CL) to triage women being evaluated for possible preterm labor. Prospective study of all women evaluated for threatened preterm labor with a CL and/or a FFN between 24-34 weeks gestation in our triage area between November 2004 and April 2005 with intact membranes. Those with cervical dilatation 3cm, triplets, indicated PTD or cerclage were excluded. Outcome variables were spontaneous preterm delivery (SPTD) < 35 weeks and interval to delivery interval (ITD). Statistical analysis was performed with 2, Fisher´s exact test and Student´s t-test. Of 79 women who met criteria, 45 (56%) underwent sonographic cervical length assessment. Overall mean gestational age at presentation was 29.6 ±2.7 weeks and delivery was 37.7 ±2.7 weeks. The prevalence of SPTD <35 weeks was 10.1 % (8/79) and 62.5% (5/8) of these had PPROM. Mean ITD from evaluation was 8.1 ±3.7 weeks. Women with a + FFN had a RR of 24.9 (CI 4.6-152.6) for SPTD<35 wks and a significantly greater mean interval to delivery (Table). The presence or frequency of contractions did not predict SPTD<35 weeks. No one with a +FFN delivered <35 weeks if the CL was >3.0 cm. In symptomatic women evaluated for possible PTL, FFN was much more predictive than CL for SPTD<35. Even with a +FFN and/or a CL20 the ITD was still over 6 weeks.Tabled 1SPTD<35 weeks (n)P valueMean interval to delivery ±SDP valueFFN+ (n = 16)43.8% (7)<0.0016.3 ±2.9.006FFN− (n = 57)1.8% (1)9.0 ±3.4CL20 (=9)18.2% (2)∗1 of 2 had a +FFN0.17.1 ±2.5.125CL>20 (n = 24)0%8.8 ±2.9∗ 1 of 2 had a +FFN Open table in a new tab

We present the prenatal diagnosis in a fetus of an absent ductus venosus resulting hepatic vascular malformation and congestive heart failure. The infant was delivered at 33 weeks by cesarean section. The neonate presented with congestive heart failure and respiratory distress and with thrombocytopenia, disseminated intravascular coagulation, and hemolytic anemia as seen in the Kasabach-Merrit syndrome. The infant underwent coil embolization of the right hepatic artery and later resection of the right hepatic lobe and the gallbladder. Anatomic and hemodynamic features of the mass resembled a hemangioendothelioma, but histological analysis showed absence of endothelial cells, indicating a venous to venous malformation.

To determine the size of the ductus venosus in growth restricted fetuses and to compare these against normally grown fetuses. In a cross sectional study, normally grown fetuses and growth restricted fetuses age 16 to 38 weeks were evaluated for Doppler flow in the ductus venosus with the measurements of sizes at the narrowest segment of the DV. In a magnified image, the DV was identified by aliasing at the end of the intraabdominal umbilical vein. Measurements were made by two observers who were in agreement prior to the placement of the calipers. SPSS software was used to create a normogram for DV size against gestational age. The eight growth restricted fetuses were also plotted on the same graph for comparison. In 5 of the 8 growth restricted restricted fetuses, the DV size was greater than the 95th percentile for gestational age. In these 5 fetuses, 1 had both a normal umbilical artery PI and MCA PI, 2 had both an abnormal umbilical artery PI and MCA PI, and 2 had either the umbilical artery or the MCA as abnormal. Almost two thirds of the growth restricted fetuses had a ductus venosus diameter greater than the 95th percentile for gestational age. This study provides a potential biologic explanation for the redistribution of umbilical venous blood flow in the fetal liver in growth restricted fetuses. Prior literature has shown that the peak systolic velocity in the ductus venosus in growth restricted fetuses remains normal. We postulate that the ductus venosus dilates in growth restricted fetuses, thus providing a low resistance pathway to redirect blood toward the fetal heart and thus maintaining a normal peak systolic velocity in the ductus venosus.

Objective: Women with uterine anomalies have higher rates of preterm birth, but the reason for this has not been elucidated. Transvaginal ultrasound examination has been shown to be an accurate test for the prediction of preterm birth but has not been studied specifically in this population.Methods: Pregnant women with uterine anomalies were followed prospectively with transvaginal ultrasound examination of the cervix, performed between 14 and 23 6/7 weeks of gestation. A short cervical length was defined as less than 25 mm of cervical length. The primary outcome was spontaneous preterm birth, defined as birth at less than 35 weeks.Results: Of the 64 pregnancies available for analysis, there were 2 8 with a bicornuate uterus, 13 with a septate uterus, 11 with a uterine didelphys, and 12 with a unicornuate uterus. The overall incidence of spontaneous preterm birth at less than 35 weeks was 11%. Of the 10 (16%) women with a short cervical length, 5 (50%) had spontaneous preterm birth. Of the 54 women without a short cervical length, only 2 (4%) had a spontaneous preterm birth. The sensitivity, specificity, and positive and negative predictive values of a short cervical length for spontaneous preterm birth were 71%, 91%, 50%, and 96%, respectively (relative risk 13.5, 95% confidence interval 3.49-54.74). Of the 7 women with both short cervical length and preterm birth, all uterine subtypes were represented except septate uterus.Conclusion: A short cervical length on transvaginal ultrasonography in women with uterine anomalies has a 13-fold risk for preterm birth. Unicornuate uterus had the highest rate of cervical shortening and preterm delivery.

To determine if placement of an interval reinforcing cerclage improves outcome in patients with a prophylactic cerclage who develop a short cervix on ultrasound. Patients who received a prophylactic transvaginal cerclage and subsequently developed a short cervix (cervical length <25 mm) on transvaginal ultrasound (TVU) at <24 weeks between 1991 and 2001 at our institution were retrospectively reviewed. Pregnancies that received a reinforcing cerclage (RC) because of cervical changes were compared to similar pregnancies which were followed without a reinforcing cerclage (NRC). The primary outcome was preterm birth (PTB) <35 weeks. Exclusion criteria included multiple gestation, concomitant pessary use, manual exam diagnosis of the cervical changes, or incomplete records. The Mann-Whitney U test and and Fisher's exact test were used to compare descriptive statistical data. Twenty-four patients with prophylactic cerclage and subsequent cervical shortening by TVU were identified, of which 5 had RC and 19 had NRC. There was no difference in patient demographics (age, race, smoking status and insurance status) and risk factors (parity, history of prior cerclage, failed cerclage, PTB, midtrimester loss, and cone biopsy) between the two groups. RC was associated with a significantly earlier gestional age at delivery as well as higher rates of both PTB <35 weeks and PTB <24 weeks (Table). In patients with a prophylactic cerclage already in place and ultrasonographically diagnosed cervical shortening before 24 weeks, placement of a reinforcing cerclage is associated with a worse outcome than expectant management. None of the patients who received an interval reinforcing cerclage after prior prophylactic cerclage achieved a gestational age greater than 25 weeks. Reinforcing cerclages are not beneficial and should not be performed.Tabled 1Reinforcing cerclage (RC) vs. no reinforcing cerclage (NRC)RC (n = 5)NRC (n = 19)SignificanceMean GA del20.8 wk32.9 wksP = .002PTB <35 wk5 (100%)6 (31.6%)P = .011PTB <24wk4 (80%)3 (15.8%)P = .014 Open table in a new tab