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Abstract Background Myomectomy at time of cesarean delivery is traditionally discouraged because of the risk of hemorrhage. A retrospective cohort study was performed to determine whether myomectomy at time of cesarean delivery leads to an increased incidence of intrapartum and short-term postpartum complications. Methods A computer search of medical records from May 1991 to April 2001 identified a total of 111 women who underwent myomectomy at time of cesarean delivery and 257 women with documented fibroids during the index pregnancy who underwent cesarean delivery alone. Charts were reviewed for the following outcome variables: change in hematocrit from preoperative to postoperative period, length of operation, length of postpartum stay, incidence of postpartum fever, and incidence of hemorrhage. Hemorrhage was defined as a change in hematocrit of 10 points or the need for intraoperative blood transfusion. Results The incidence of hemorrhage in the study group was 12.6% as compared with 12.8% in the control group (p = 0.95). There was also no statistically significant increase in the incidence of postpartum fever, operating time, and length of postpartum stay. No patient in either group required hysterectomy or embolization. Size of fibroid did not appear to affect the incidence of hemorrhage. After stratifying the procedures by type of fibroid removed, intramural myomectomy was found to be associated with a 21.2% incidence of hemorrhage compared with 12.8% in the control group, but this difference was not statistically significant (p = 0.08). This study had 80% power to detect a two-fold increase in the overall incidence of hemorrhage. Conclusion In selected patients, myomectomy during cesarean delivery does not appear to result in an increased risk of intrapartum or short-term postpartum morbidity.

Objective: A majority of studies evaluating the risk of vertical transmission and adverse outcomes in pregnancies with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are mostly based on third-trimester infections. There is limited data available on pregnancy sequelae of maternal infection in the first or second trimester., Study Design: We present a patient with monochorionic-diamniotic twins that develops coronavirus disease 2019 infection at 15 weeks of gestation. The pregnancy is further complicated by stage II twin-twin transfusion syndrome. She undergoes laser ablation, which is complicated by development of a subchorionic hematoma. The patient then develops Escherichia coli bacteremia, resulting in septic shock and preterm labor followed by previable delivery at 21 weeks of gestation. Amniotic fluid and placenta were negative for SARS-CoV-2 by real-time polymerase chain reaction., Conclusion: This case of SARS-CoV-2 argues against transplacental transmission after a second-trimester infection but brings attention to the possible downstream complications that may arise following early infection., Key Points: · Vertical transmission of SARS-CoV-2 is not evident after a second-trimester infection.. · Antepartum coronavirus disease 2019 may cause vascular placental changes and placental insufficiency.. · SARS-CoV-2 is associated with a maternal hypercoagulable state with adverse perinatal outcomes.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: To investigate differences in perioperative outcomes by type of skin incision, transverse versus vertical, for planned cesarean hysterectomy for placenta accreta spectrum (PAS)., Methods: A retrospective cohort study of all women who underwent a planned cesarean hysterectomy for abnormal placentation at a single academic medical center over 5 years. The Student's t-test was used for continuous variables and Fisher's exact test compared categorical variables. Continuous data were presented as median and compared using the Wilcoxon-rank sum test., Results: Forty-two planned cesarean hysterectomies were identified. A transverse skin incision was made in 43% (n = 18); a vertical skin incision was made in 57% (n = 24). Skin incision was independent of BMI (30.3 vs 30.8 kg/m 2 , p = 0.37), placental location (p = 0.82), and PAS-subtype (p = 0.26). Mean estimated blood loss (EBL) was 2.73 l (L) (range 0.5-20) and was not significantly different between transverse and vertical skin incision (2.6 L vs 2.8 L, p = 0.8). There was significantly shorter operative time with transverse skin incision (180 vs 238 min, p = 0.03), with no difference in intraoperative complications, including cystotomy (p = 0.22) and ureteral injury (p = 0.73). Postoperatively, there was no difference in maternal length of stay (4.8 vs 4.4 days, p = 0.74) or post-operative opioid use (117 vs 180 morphine equivalents, p = 0.31)., Conclusion: Transverse skin incision is associated with shorter operative time for patients undergoing planned cesarean hysterectomy. There was no difference in EBL, intraoperative complications, postoperative length of stay, or opioid use. Given an increasing rate of cesarean hysterectomy, we should consider variables that optimize maternal outcomes and resource utilization.

Purpose: To evaluate whether cerclage in twins reduces the rate of spontaneous preterm birth <32 weeks when compared to expectant management., Methods: This is a retrospective cohort study of twin pregnancies with the following indications for cerclage from two institutions: history of prior preterm birth, ultrasound-identified short cervix ≤2.5 cm, and cervical dilation ≥1.0 cm. The "cerclage" cohort received a cerclage from a single provider at a single institution from 2003-2016. The "no cerclage" group included all patients with similar indications that were expectantly managed from 2010-2015, at a second institution where cerclages are routinely not performed in twin pregnancies. The primary outcome was the rate of spontaneous preterm birth at <32 weeks. Secondary outcomes were the rates of spontaneous and overall (including medically indicated) preterm births at <32 weeks, < 34 weeks, and <36 weeks, chorioamnionitis, birth weight, and neonatal mortality within 30 days of life. We also performed a planned subgroup analysis stratified by cerclage indication., Results: In all, 135 women were included in two cohorts: cerclage (n = 96) or no cerclage (n = 39). The rates of spontaneous preterm birth <32 weeks were 10.4% (n = 10) with cerclage versus 28.2% (n = 11) without cerclage (OR 0.23, CI 0.08-0.70, p = .017). After adjusting for cerclage indication, clinical history, age, chorionicity, insurance type, race, BMI, in-vitro fertilization, and multifetal reduction, there remained a significant reduction in the cerclage group of spontaneous preterm birth <32 weeks (adjusted odds ratio (aOR) 0.24, CI 0.06-0.90, p = .035), spontaneous preterm birth <36 weeks (aOR 0.34, CI 0.04-0.81, p = .013) as well as in overall preterm birth <32 weeks (aOR 0.31, CI 0.1-0.86, p = .018), and overall preterm birth <36 weeks (aOR 0.37, CI 0.10-0.84, p = .030). When stratified by short cervix or cervical dilation in the cerclage versus no cerclage groups, there was a significant decrease in spontaneous preterm birth <32 weeks in the cerclage group with cervical dilation (11.1 versus 41.2%, p = .01) but not in the cerclage group with short cervix only, even for cervical length <1.5 cm. Pregnancy latency was 91 days in the cerclage group versus 57 days in the no cerclage group (p = .001), with a median gestational age at delivery of 35 versus 32 weeks (p = .002). There was no increase in chorioamnionitis in the cerclage group. Furthermore, there was a significant increase in birth weight (median 2278 versus 1665 g, p < .001) and decrease in perinatal death <30 days (1.6 versus 12.9%, p = .001)., Conclusions: Cerclage in twin pregnancies significantly decreased the rate of spontaneous preterm birth <32 weeks compared to expectant management. However, when stratified by cerclage indication, this decrease in primary outcome only remained significant in the group with cervical dilation.

Background: Perioperative hemorrhage is a common complication of peripartum hysterectomy for morbidly adherent placenta. We present an application of a balloon uterine tamponade device in the setting of a cesarean delivery and subsequent supracervical hysterectomy for abnormal placentation., Case: A 33-year-old gravid woman, 6 para 3022, at 33 2/7 weeks of gestation was admitted in preterm labor, with placenta previa and suspected morbidly adherent placenta, for a planned cesarean delivery and hysterectomy. After supracervical hysterectomy, colloid resuscitation and packing failed to provide hemostasis. A transcervical balloon uterine tamponade device subsequently was placed intraperitoneally and left on tension owing to the need for further tamponade., Conclusion: Use of a balloon uterine tamponade device intraperitoneally posthysterectomy was associated with hemorrhage control. This application may facilitate timely management and streamlining of obstetric resources for postpartum hemorrhage.

Objectives: To evaluate whether the global area and circumference of the heart varies between two measurement techniques: the point-to-point trace and the electronic ellipse methods., Methods: The epicardial border of the 4-chamber view was measured in 200 fetuses between 20 and 40 weeks' gestation, from which the area and circumference using the point-to-point trace and electronic ellipse were measured. Analysis of variance, correlation, and regression analysis using fractional polynomials and 7 independent variables (head circumference, biparietal diameter, abdominal circumference, femur length, estimated fetal weight, mean ultrasound gestational age, and last menstrual period gestational age) were performed., Results: The correlation between the mean ultrasound gestational age and last menstrual period gestational age was 0.9880 (5% confidence limit, 0.9716; 95% confidence limit, 0.9880), with an R 2 of 0.9762. The R 2 value for the 7 independent variables regressed against the area and circumference using the point-to-point trace and electronic ellipse methods ranged between 0.885 and 0.965. Comparison of Z scores between this study and previous publications demonstrated that there were differences and similarities, depending on whether the area or circumference was measured., Conclusions: This study shows high R 2 values when comparing measurements of the area and circumference against 7 independent variables, irrespective of whether the point-to-point trace or the electronic ellipse method was used to obtain the measurements. A calculator to evaluate the area and circumference is provided, using 7 independent variables from which Z scores and percentiles for individual measurements can be computed., (© 2016 by the American Institute of Ultrasound in Medicine.)

Aim: The aim of this study is to determine whether psychiatric symptoms affect recurrence risk of hyperemesis gravidarum (HG)., Methods: The study sample included 108 women with HG treated with i.v. fluids in their first pregnancy. Women were divided into two groups based on recurrence of HG in their second pregnancy. Participants submitted medical records and completed a survey regarding pregnancy characteristics and psychiatric symptoms. The χ(2) -test and Student's t-test were performed to compare the two groups., Results: Eighty-four women (71%) had a recurrence of HG requiring i.v. fluid for dehydration, and were compared with 34 women (29%) who did not have a recurrence. There were no significant differences in obstetric history, although there was a trend toward greater time between first and second pregnancy in the recurrence group (P = 0.08). There were no differences in pre-existing psychiatric diagnoses including anxiety, depression, bipolar disorder, panic or eating disorders. Following the first HG pregnancy, participants in both groups were well matched for all post-traumatic stress symptoms., Conclusion: This study is the first to analyze the relationship of psychiatric factors to risk of recurrence of HG. No factors were identified that increase the risk of recurrence including stress symptoms following a HG pregnancy. Psychological sequelae associated with HG are probably a result of the physical symptoms of prolonged severe nausea and vomiting, medication and/or hospitalization, and likely play no role in disease etiology., (© 2014 The Authors. Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology.)

Bile duct cysts are a rare form of biliary disease characterized by single or multiple dilations anywhere along the biliary tree. Todani Type V bile duct cysts are intrahepatic and typically involve multiple fusiform dilations. We present the case of a neonate with an unusual prenatally identified solitary diverticular type V bile duct cyst that was evaluated, monitored, and subsequently resected with right lobectomy at the age of 6 months. The importance of imaging in diagnosis and approaches to management are discussed.

Objective: The purpose of this study is to determine the frequency of adverse perinatal outcome in women with hyperemesis gravidarum and identify prognostic factors., Study Design: This is a case-control study in which outcomes of first pregnancies were compared between 254 women with hyperemesis gravidarum treated with intravenous fluids and 308 controls. Prognostic factors were identified by comparing the clinical profile of patients with hyperemesis gravidarum with a normal and an adverse pregnancy outcome. Binary responses were analyzed using either a Chi-square or Fisher exact test and continuous responses were analyzed using a t-test., Results: Women with hyperemesis gravidarum have over a 4-fold increased risk of poor outcome including preterm birth and lower birth weight (p<0.0001). Among maternal characteristics, only gestational hypertension had an influence on outcome (p<0.0001). Treatment as an outpatient and/or by alternative medicine (acupuncture/acupressure/Bowen massage) was associated with a positive outcome (p<0.0089). Poor outcomes were associated with early start of symptoms (p<0.019), and treatment with methylprednisolone (p<0.0217), promethazine (p<0.0386), and other antihistamines [diphenhydramine (Benadryl), dimenhydrinate (Gravol), doxylamine (Unisom), hydroxyzine (Vistaril/Atarax), doxylamine and pyridoxine (Diclectin/Bendectin)] (p<0.0151) independent of effectiveness. Among these medications, only the other antihistamines were prescribed independent of severity: they were effective in less than 20% of cases and were taken by almost 50% of patients with an adverse outcome., Conclusion: Poor outcomes are significantly greater in women with HG and are associated with gestational hypertension, early symptoms, and antihistamine use. Given these results, there is an urgent need to address the safety and effectiveness of medications containing antihistamines in women with severe nausea of pregnancy., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: We implemented evidence-based interventions to reduce risk of surgical site infection (SSI) following low transverse cesarean section (LTCS)., Methods: An observational study was conducted to determine LTCS SSI rates and the impact of infection control interventions at an academic teaching hospital during the period October 2005 to December 2008, including the use of 2% chlorhexidine gluconate (CHG) for surgical skin preparation before LTCS and no-rinse CHG cloths for preoperative skin cleansing. We compared overall and risk strata specific SSI rates and standardized incidence ratios during 4 study periods and estimated cost savings., Results: Of 1,844 LTCSs performed, 99 patients were identified with SSI. SSI rates per 100 LTCS declined from 6.27 at baseline and 10.84 during the outbreak period to 5.92 in intervention 1 period and 2.29 in intervention 2 period. Overall, a 63.5% reduction in SSI rate from baseline was achieved by ensuring compliance with SSI prevention guidelines and improving skin antisepsis (P = .003). In intervention 2 period, the standardized incidence ratio was 0.99 compared with 2.64 at baseline and 4.50 during the outbreak period., Conclusion: A multidisciplinary approach including evidence-based SSI prevention practices, effective infection prevention products, and staff and patient engagement substantially reduced infection risk and improved patient safety following LTCS., (Copyright © 2012 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Objective: To establish normative measures of the biologic growth of fetal choroid plexus circumference (CPC) and ventricular circumference (VC) in normal pregnant women., Study Design: We studied 185 women with uncomplicated pregnancies ranging in gestational age from 14 to 26 weeks and undergoing ultrasound examination for genetic amniocentesis. CPC and VC were measured with a transverse scan of the fetal head to establish normative values. Following establishment of CPC/VC ratios for normocephalic fetuses, an additional eight fetuses with suspected ventriculomegaly at the time of routine ultrasound were scanned., Results: Of the 185 fetuses for normal pregnancies who met the criteria for this study, all were normocephalic at birth. Of the eight fetuses who were suspected to have ventriculomegaly on ultrasound, all were diagnosed as moderately to severely hydrocephalic on autopsy after second-trimester termination., Conclusion: The CPC/VC ratio is able to unequivocally distinguish between the overtly hydrocephalic and normocephalic fetus. The results of this study suggest that CPC and VC measurements may be valuable when hydrocephalus is suspected and there are equivocal ventricular/hemispheric width measurements.

We studied 693 consecutive early amniocenteses (prior to 15 weeks) and found a spontaneous abortion rate to 28 weeks' gestation of 1.5 per cent. A control group of women having standard amniocentesis (15-20 weeks) experienced a 0.6 per cent fetal loss in the same period. There were no other apparent differences between the two groups. Early amniocentesis results are generally available 4-6 weeks before standard amniocentesis and 1-3 weeks after chorionic villus sampling (CVS). Alpha-fetoprotein (AFP) can be accurately assayed in 11- to 15-week amniotic fluid samples but additional studies are necessary to determine the accuracy of neural tube defect (NTD) detection. Including the present study, over 5800 early amniocenteses have been reported and the results suggest that this is a relatively safe prenatal diagnostic test and an alternative to CVS and later amniocentesis.

Background: Sjögren-Larsson syndrome is an autosomal recessive disease with sequelae including ichthyosis, mental retardation, and spasticity. Although fetal skin biopsy has permitted prenatal diagnosis of Sjögren-Larsson syndrome in the late second trimester, it is accompanied by substantial risks, including fetal loss, premature labor, and detection at a gestational age close to the legal limit for pregnancy termination in most states. A new technique involving biochemical assay of cultured amniocytes for reduced levels of fatty alcohol:oxidized nicotinamide-adenine dinucleotide (NAD+)-oxidoreductase may allow earlier and less invasive detection of Sjögren-Larsson syndrome., Case: A 38-year-old Lebanese woman, gravida 6, para 3, presented for prenatal diagnosis of Sjögren-Larsson syndrome following a history of two children born with the disease. At 19 weeks' gestation, multiple fetal skin biopsies were obtained by ultrasound-guided transabdominal percutaneous insertion of biopsy forceps. Histologic examination of the specimen revealed no evidence of Sjögren-Larsson syndrome. However, assay of fatty alcohol:NAD(+)-oxidoreductase in cultured amniocytes obtained at fetal skin biopsy showed a profound enzymatic deficiency. Additional fetal skin biopsies were obtained at 23.5 weeks' gestation, and histologic examination was positive for Sjögren-Larsson syndrome. The patient elected to terminate the pregnancy, and a subsequent autopsy on the fetus confirmed Sjögren-Larsson syndrome., Conclusion: This case demonstrates the limitations of histologic examination of fetal skin specimens for the diagnosis of Sjögren-Larsson syndrome and indicates the potential value of biochemical detection from fetal amniocytes. This new technique may allow earlier diagnosis of Sjögren-Larsson syndrome, is less invasive, and may be less psychologically traumatic for the patient if she elects to terminate the pregnancy.

L-selectin is a leukocyte adhesion molecule important in the initial stages of the interaction of neutrophils with endothelium during neutrophil emigration from the bloodstream. Neutrophils and eosinophils from newborn infants express significantly less L-selectin than do neutrophils and eosinophils from adults. It is not known whether L-selectin expression on fetal granulocytes is similarly decreased. We studied fetal blood specimens obtained for a variety of clinical indications by percutaneous umbilical cord sampling at 23 to 34 wk of gestation and measured L-selectin expression by flow cytometry. Eosinophils constituted a large proportion of the granulocytes in these fetal specimens (42 +/- 26%, n = 8), with eosinophil counts ranging from 180 to 690/mm3 (mean +/- SD: 350 +/- 220). There was no difference in L-selectin expression of unstimulated fetal and adult neutrophils (mean +/- SD specific fluorescence: 53.0 +/- 6.8 versus 56.6 +/- 4.3, n = 6), and no difference between unstimulated fetal and adult eosinophils (16.0 +/- 6.5 versus 18.7 +/- 3.2, n = 6). Thus, neutrophils and eosinophils from fetuses as early as 23 wk express L-selectin at adult levels. Furthermore, fetal neutrophils and eosinophils shed the receptor normally in response to stimulation in vitro. We conclude that the reduction of L-selectin expression on neonatal neutrophils and eosinophils is not due to an inherent developmental limitation, but instead must be caused by changes occurring in the neonatal period. Elucidation of the etiology of these changes may aid in the development of therapeutic measures to correct the L-selectin-related defects of neonatal neutrophil adherence.

Objective: To evaluate multifetal pregnancy reduction as a treatment for patients seeking to reduce the risks of multiple gestation., Methods: One hundred thirty-one women had transabdominal multifetal pregnancy reduction performed by a single practitioner; 103 have delivered., Results: Multifetal pregnancy reduction was associated with a 7% pregnancy loss rate and no losses within the first 4 weeks after the procedure. The mean gestational age at delivery overall was 35.5 weeks. The mean gestational age at delivery for singletons was 37.5 weeks, for twins 35.5 weeks, and for triplets 35 weeks. The incidence of maternal and fetal complications was no more than that previously reported for nonreduced multiple gestations., Conclusions: Multifetal pregnancy reduction is a safe option for patients who desire to reduce the risks of multiple gestation. The ultimate successful outcome of reduced pregnancies may be enhanced by extensive experience with the procedure.

Prior to the development of the DNA-based technology reliable prenatal diagnosis of G6PD deficiency was not possible. We show that, using PCR amplification and restriction endonuclease digestion, prenatal diagnosis is possible. We have now been able to determine that the male fetus of a mother heterozygous for G6PD Mediterranean had inherited the maternal X chromosome with the normal G6PD gene.