INTRODUCTION: Intrapartum fetal heart rate (FHR) monitoring although sensitive, lacks specificity for predicting fetal acidosis. Category II tracings, within the last hour of labor, occur in >/=96% of uncomplicated, term, laboring patients. Most result in delivery of well oxygenated neonates. Neonatal acidosis occurs in <3% of term neonates and may result in neonatal encephalopathy. Currently, there is no standard approach to management of Category II tracings. METHODS: We retrospectively reviewed Category II tracings in singleton, uncomplicated, term patients, during the last hour prior to delivery, in women who delivered neonates with cord blood pH /=8 (Group 1) and pH ≥ 7.20, base excess. RESULTS: In Group 1 (n=414), 91% of tracings exhibited good/moderate variability, 17.5% demonstrated minimal/absent variability, 13% had accelerations (≥15 bpm, lasting ≥15 secs). In Group 2 (n = 913), 97% showed moderate/good variability, 9% minimal/absent variability, 92% demonstrated accelerations (P<0.05). Duration of second stage labor was comparable in both Groups, (Group 1 = 3.5 hours, Group 2 = 3.1 hours), as were rates of chorioamnionitis, Pitocin use. Apgar scores and rates of NICU interventions were also similar in the two Groups. CONCLUSION: Minimal/decreased variability and the absence of accelerations, in Category II tracings, reliably predict fetal acidosis. Thus, expedited delivery should be considered in this clinical setting.

INTRODUCTION: Postpartum hemorrhage is an obstetrical emergency which requires aggressive volume repletion. Serum lactate levels are used in the management of trauma patients because they reliably indicate tissue hypoperfusion. METHODS: A retrospective chart review was performed from June 01, 2013 through Sept 30, 2016 in patients undergoing an Obstetric Hemorrhage Team (OHT) alert, defined at our institution as a quantified blood loss of 900 cc after vaginal delivery and 1500 cc after Cesarean section. Stat venous lactate levels were correlated with hematocrit levels, vital signs (BP and pulse), urine output, crystalloid fluid resuscitation and blood transfusion. RESULTS: There were 1314 OHTs. Of these, 891 patients had venous lactate values. When the venous lactate level was “elevated”, i.e. 4.0 (range 3.4 to 6.6), 632 patients (71%), required at least one unit blood transfusion in addition to the usual resuscitative measures, (statistically significant). Of these, only 347 patients (39%) were hemodynamically unstable (BP less than 60/40 and/or pulse rate greater than 120 bpm); and only 276 (31%) demonstrated a 10 point hematocrit drop from the admission value. When venous lactate levels were “normal”, i.e. 2.0 (range 1.6 to 3.2), only 80 (9%) required blood transfusions. CONCLUSION: Venous lactate is a reliable indicator of tissue hypoperfusion in postpartum hemorrhage, and may help to identify patients who, regardless of hemodynamic status or hematocrit level, would most benefit from blood transfusion during the management of this condition.

BACKGROUND:In vitro fertilization (IVF) data suggest improved live birth rates for embryos transferred at the blastocyst versus the cleavage stage. Embryos that have not reached the blastocyst stage by day 5 postthaw have diminished potential for implantation and live birth. Few data exist regarding embryogenesis and optimal timing of transfer for embryos derived from previously cryopreserved oocytes, but we report the case of 100% implantation following transfer of 3 developmentally-delayed embryos derived from cryopreserved oocytes.CASE:A 38-year-old woman cryopreserved 20 oocytes for the purpose of future childbearing. At age 42 she returned to thaw and fertilize 8 oocytes using donor sperm. Embryos were cultured to day 5 postthaw, at which time 1 morula and 2 cleavage-stage embryos were available for transfer. Three-embryo transfer resulted in a heterotopic tubal pregnancy and twin intrauterine gestation. Laparoscopic salpingectomy was performed for the ectopic gestation. The twin intrauterine pregnancy spontaneously reduced to singleton, and the patient delivered a live-born infant.CONCLUSION:While heterotopic and multifetal pregnancy are known risks of multiembryo transfer, 3 lesser-quality embryos derived from cryopreserved oocytes would be unlikely to have high implantation potential. Future studies are needed to delineate timing of embryogenesis events in previously cryopreserved oocytes.

Massive ovarian edema is a rare disorder in which there is marked accumulation of interstitial fluid in the stroma of the ovary. Grossly, the involved ovary is an enlarged solid mass with a smooth tan-white surface, easily confused with a neoplasm. Microscopically, it features diffuse interstitial edema sparing follicles and outer cortex, dilated lymphatic vessels, thick-walled veins, fibromatosis, and luteinized stromal cells. It is believed that massive ovarian edema arises from interference in lymphatic drainage and venous return of the ovary secondary to partial torsion among other etiologies. Herein we provide the first description of unilateral ovarian edema in association with a large leiomyoma in the ipsilateral broad ligament. It is important to recognize the various presentations of this benign entity and to consider it in the differential diagnosis of an adnexal mass in a reproductive age woman.

ABSTRACTObjectiveTo demonstrate the efficacy of placement and inflation of Foley balloon catheters prophylactically to prevent, or as an adjuvant therapy to control, bleeding in women undergoing treatment for Cesarean scar pregnancy (CSP) or cervical pregnancy (CxP).MethodsThis was a retrospective study of 18 women with either CSP (n = 16) or CxP (n = 2), who underwent Foley balloon catheter placement under continuous transvaginal or transabdominal ultrasound guidance to prevent or manage bleeding following treatment, which in most cases comprised local (intragestational sac) and intramuscular (IM) methotrexate (MTX) injections. In eight cases, the balloon catheter was placed immediately following local and/or IM MTX treatment, either because of bleeding or prophylactically; in eight cases, the catheter was placed as part of a two‐step protocol, with patients first treated with local and IM MTX injection, then suction aspiration on Day 4 or 5, followed by planned insertion of a balloon catheter; in one patient the balloon was placed on Day 21 after local and IM MTX treatment, due to sudden bleeding; and in one case of a heterotopic pregnancy, one intrauterine and one cervical, the balloon was placed due to severe bleeding. Human chorionic gonadotropin (hCG) levels were evaluated weekly following MTX injection.ResultsGestational ages at balloon placement ranged between 5 and 12 + 2 weeks. All embryos/fetuses, with the exception of the cervical heterotopic one, had heart activity and catheter placement was well‐tolerated by all women. The balloon tamponade effectively reduced or prevented maternal vaginal bleeding in all except one patient; this woman had a heterotopic CxP and required abdominal robotic cerclage to control the bleeding. Catheters were kept in place for a mean of 3.6 (range, 1–6) days. hCG levels returned to low or zero levels within 19–82 days following MTX injection. Fifteen women required antibiotic treatment following the procedure. One woman with CSP developed an arteriovenous malformation requiring uterine artery embolization.ConclusionUltrasound‐guided placement and inflation of Foley balloon catheters was easy to perform and well‐tolerated by patients undergoing treatment for CSP or CxP, and successfully prevented or helped in the management of bleeding complications. Based on our experience and previous publications we suggest having the option of balloon catheter insertion available when local treatment of CSP or CxP is undertaken. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd.

Obstetrical hemorrhage is life-threatening. We evaluated the hemostatic effect of using a Foley balloon catheter in cases of treated/bleeding CSP/CxP. This slows/stops bleeding until the vessels are occluded and full hemostasis takes place. We identified 16 patients from 2 centers using a Foley balloon catheter as an adjuvant to treat prevent/manage bleeding. Fifteen patients had CSP and 2 were CxP with gestational ages ranging between 5 wks/6 dys and 12 wks/2 dys with crown–rump lengths between 4 and 36mm and initial hCG levels between 5500 and 55.780 IU/mL. Silicon catheters with an inflatable balloon/volume capacity between 5 and 30 ml were placed under real time US guidance to achieve desired size/effect. The outer end of the catheter was affixed to the patients' thigh and kept in place for a mean of 3.6 days. Management of patient at the two centers were slightly different in terms of their initial treatment. Fourteen patients were treated with local intragestational sac and systemic injection of methotrexate and two patients with the Foley catheter. One center-7 patients-included additional suction aspiration of the sac on treatment day 5. Time for the hCG to return to levels below 25 IU/mL was between 27 and 32days. In the second series of 8 patients the time for the hCG to return to below 5 IU/mL was 34 -82 days. Pertinent data will be presented in form of a table at the meeting. The Foley balloon tamponade effectively reduced/prevented vaginal bleeding in all but one patient with heterotopic intrauterine/cervical pregnancy as the balloon may not have been inflated to a desirable volume fearing a traumatic effect on the live intrauterine gestation. Foley balloon tamponade, used as an “up-front” preventive/adjuvant treatment method to control bleeding from CSP and CxP is effective, easy to perform and can alleviate complications or make other more involved/risky surgical interventions redundant.

Journal of Ultrasound in MedicineVolume 30, Issue 6 p. 865-867 Clinical Letters Term Singleton Pregnancy After Conservative Management of a Complicated Triplet Gestation Including a Heterotopic Cornual Monochorionic Twin Pair Eran Bornstein MD, Eran Bornstein MD Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USASearch for more papers by this authorRobert Berg MD, Robert Berg MD Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USASearch for more papers by this authorRosalba Santos RDMS, Rosalba Santos RDMS Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USASearch for more papers by this authorAna Monteagudo MD, Ana Monteagudo MD Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USASearch for more papers by this authorIlan E. Timor-Tritsch MD, Ilan E. Timor-Tritsch MD Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USASearch for more papers by this author Eran Bornstein MD, Eran Bornstein MD Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USASearch for more papers by this authorRobert Berg MD, Robert Berg MD Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USASearch for more papers by this authorRosalba Santos RDMS, Rosalba Santos RDMS Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USASearch for more papers by this authorAna Monteagudo MD, Ana Monteagudo MD Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USASearch for more papers by this authorIlan E. Timor-Tritsch MD, Ilan E. Timor-Tritsch MD Division of Obstetric and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, New York University Medical Center, New York, New York USASearch for more papers by this author First published: 01 June 2011 https://doi.org/10.7863/jum.2011.30.6.865Citations: 5Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume30, Issue6June 2011Pages 865-867 RelatedInformation

A 29 year old G5 P0040 presented for evaluation of a multifetal gestation at 8 postmenstrual weeks. The patient had an extensive obstetrical history significant for prior right tubal pregnancy and right salpingectomy, two 1st trimester miscarriages, and a subsequent IVF pregnancy resulting in a simultaneous bilateral, ovarian heterotopic pregnancy, which was managed by laparoscopic resections and left salpingectomy. The index pregnancy was assisted by IVF/ET. Two frozen embryos were transferred. Ultrasound detected a heterotopic triplet gestation. 2D ultrasound and 3D reconstruction were instrumental in depicting the location of the three embryos. This was significant for an intrauterine singleton, and a right cornual monochorionic diamniotic twin pair. Extensive counseling was performed regarding the different management options. Given that this was a highly desired pregnancy and that a normally implanted intrauterine singleton was seen, selective reduction of the cornual twin pair was performed by transcervical ultrasound guided KCl injection. Following the procedure, serial clinical and sonographic evaluation were performed. This surveillance revealed increased amount of fluid accumulating in the cul-de-sac, suggesting bleeding from the cornual pregnancy. The patient therefore, underwent laparotomy in which evacuation of the hemiperitoneum and cornual pregnancy were followed by closure of the cornual gestations’ bed. During the surgery, caution was exercised using gentle handling of the uterus to maintain the intrauterine singleton embryo intact. Ultrasound demonstrated a reasonably large distance from it to the affected cornua which was interpreted as a positive prognostic factor. After recovery, outpatient surveillance confirmed an otherwise uncomplicated prenatal course. Scheduled cesarean delivery was performed at 37 weeks. This unusual case highlights the efforts to conservatively manage this extremely rare and complicated heterotopic pregnancy.

Isolated fallopian tube torsion (IFTT) is a rare clinical entity with a reported incidence of 1 in 1.5 million women.1 Prompt recognition maximizes the likelihood that surgery will be able to preserve fallopian tube viability and prevent secondary ischaemic injury of the ovary; however, the diagnosis is rarely established preoperatively as the presentation is non-specific with symptoms common to many other conditions.2,3 IFTT is particularly infrequent in the adolescent population4 with a review from 2008 identifying a series of only eight cases, in addition to 13 sporadic case reports.5 Furthermore, IFTT has never been reported in association with either a congenital uterine anomaly or renal agenesis.2,6

Limb deformities are frequent features found during prenatal sonographic screening for malformations. Some anomalies of the hand such as the clenched hands and overlapping fingers in trisomy 18 or the outwardly turned feet in fibular hemimelia are pathognomonic. Others, such as preaxial and postaxial polydactyly, are part of a long list of skeletal anomalies and syndromes. We present a case with several skeletal anomalous features, which clustered around a rare syndrome involving a deletion in the GLI-Kruppel family member 3 (GLI3) gene of chromosome 7. The diagnosis presented a challenge to all involved, It started with the sonographic description of the features of the fetus. The genetic diagnosis was achieved by a comparative genomic hybridization (CGH) microarray.