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Javinani A, Qaderi S, Hessami K, Shainker SA, Shamshirsaz AA, Fox KA, Mustafa HJ, Subramaniam A, Khandelwal M, Sandlin AT, Duzyj CM, Lyell DJ, Zuckerwise LC, Newton JM, Kingdom JC, Harrison RK, Shrivastava VK, Greiner AL, Loftin R, Genc MR, Atasi LK, Abdel-Razeq SS, Bennett KA, Carusi DA, Einerson BD, Gilner JB, Carver AR, Silver RM, Shamshirsaz AA. Delivery outcomes in the subsequent pregnancy following the conservative management of placenta accreta spectrum disorder: a systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:485-492.e7. [PMID: 37918506 DOI: 10.1016/j.ajog.2023.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE Cesarean hysterectomy is generally presumed to decrease maternal morbidity and mortality secondary to placenta accreta spectrum disorder. Recently, uterine-sparing techniques have been introduced in conservative management of placenta accreta spectrum disorder to preserve fertility and potentially reduce surgical complications. However, despite patients often expressing the intention for future conception, few data are available regarding the subsequent pregnancy outcomes after conservative management of placenta accreta spectrum disorder. Thus, we aimed to perform a systematic review and meta-analysis to assess these outcomes. DATA SOURCES PubMed, Scopus, and Web of Science databases were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA We included all studies, with the exception of case studies, that reported the first subsequent pregnancy outcomes in individuals with a history of placenta accreta spectrum disorder who underwent any type of conservative management. METHODS The R programming language with the "meta" package was used. The random-effects model and inverse variance method were used to pool the proportion of pregnancy outcomes. RESULTS We identified 5 studies involving 1458 participants that were eligible for quantitative synthesis. The type of conservative management included placenta left in situ (n=1) and resection surgery (n=1), and was not reported in 3 studies. The rate of placenta accreta spectrum disorder recurrence in the subsequent pregnancy was 11.8% (95% confidence interval, 1.1-60.3; I2=86.4%), and 1.9% (95% confidence interval, 0.0-34.1; I2=82.4%) of participants underwent cesarean hysterectomy. Postpartum hemorrhage occurred in 10.3% (95% confidence interval, 0.3-81.4; I2=96.7%). A composite adverse maternal outcome was reported in 22.7% of participants (95% confidence interval, 0.0-99.4; I2=56.3%). CONCLUSION Favorable pregnancy outcome is possible following successful conservation of the uterus in a placenta accreta spectrum disorder pregnancy. Approximately 1 out of 4 subsequent pregnancies following conservative management of placenta accreta spectrum disorder had considerable adverse maternal outcomes. Given such high incidence of adverse outcomes and morbidity, patient and provider preparation is vital when managing this population.
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Affiliation(s)
- Ali Javinani
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Shohra Qaderi
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Kamran Hessami
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Amir A Shamshirsaz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, IN; Fetal Center at Riley Children's Health, Indiana University Health, Indianapolis, IN
| | - Akila Subramaniam
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Christina M Duzyj
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
| | - Deirdre J Lyell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, CA
| | - Lisa C Zuckerwise
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - John C Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Rachel K Harrison
- Department of Maternal-Fetal Medicine, Advocate Aurora Health, Chicago, IL
| | - Vineet K Shrivastava
- Miller Children's and Women's Hospital Long Beach, Long Beach Memorial Medical Center, Long Beach, CA
| | - Andrea L Greiner
- Department of Obstetrics and Gynecology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Ryan Loftin
- Department of Maternal-Fetal Medicine, Advocate Aurora Health, Chicago, IL; Allina Health System, Minneapolis, MN
| | - Mehmet R Genc
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL
| | - Lamia K Atasi
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO
| | - Sonya S Abdel-Razeq
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, CT
| | - Kelly A Bennett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, CA; Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | | | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Jennifer B Gilner
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | | | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Hessami K, Mitts M, Zargarzadeh N, Jamali M, Berghella V, Shamshirsaz AA. Ultrasonographic cervical length assessment in pregnancies with placenta previa and risk of perinatal adverse outcomes: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2024; 6:101172. [PMID: 37778698 DOI: 10.1016/j.ajogmf.2023.101172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/21/2023] [Accepted: 09/26/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE This study aimed to examine the association between cervical length and the risk of adverse outcomes in placenta previa pregnancies. In addition, the diagnostic accuracy of cervical length in predicting emergency cesarean delivery due to hemorrhage was evaluated. DATA SOURCES PubMed, Web of Science, and Embase were systematically searched up to January 21, 2023. STUDY ELIGIBILITY CRITERIA Observational studies investigating the relationship between cervical length and maternal adverse outcomes in patients with placenta previa were considered eligible. The primary outcome was the diagnostic accuracy of cervical length measured at 28 to 34 weeks of gestation for the prediction of emergency cesarean delivery due to hemorrhage. The secondary outcomes were the probability of antenatal bleeding, preterm birth (both iatrogenic and spontaneous), and postpartum hemorrhage >2000 mL. Insufficient data were available on the transfusion procedure in cases where the cervical length was <30 mm. METHODS For prognostic analysis, the random-effects model was used to pool the odds ratios and the corresponding 95% confidence intervals. For the diagnostic part, we used a summary receiver-operating characteristic curve, pooled sensitivities and specificities, area under the curve, and summary likelihood ratios. RESULTS A total of 13 studies presenting data on 1462 pregnancies with placenta previa were included. Cervical length ≤30 mm at 28 to 34 weeks of gestation had a sensitivity of 61% (95% confidence interval, 43-77), specificity of 83% (95% confidence interval, 76-88), and area under the curve of 0.83 (95% confidence interval, 0.80-0.86) for the prediction of emergency cesarean delivery. Furthermore, cervical length ≤30 mm was associated with antenatal bleeding (odds ratio, 3.62; 95% confidence interval, 2.09-6.26; P<.001; I2=54.8%), preterm birth (odds ratio, 8.46; 95% confidence interval, 3.05-23.44; P<.001; I2=83.6%), and postpartum hemorrhage (odds ratio, 6.89; 95% confidence interval, 4.51-10.53; P<.001; I2=0.00%). CONCLUSION Short cervical length (≤30 mm) measured at 28 to 34 weeks of gestation can assist in predicting the risk of emergency cesarean delivery due to hemorrhage in pregnancies with placenta previa. Furthermore, short cervical length is significantly associated with the risk of antenatal bleeding, preterm birth, and postpartum hemorrhage in pregnancies with placenta previa.
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Affiliation(s)
- Kamran Hessami
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Drs Hessami, Zargarzadeh, Jamali, and Shamshirsaz)
| | - Matthew Mitts
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Mitts)
| | - Nikan Zargarzadeh
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Drs Hessami, Zargarzadeh, Jamali, and Shamshirsaz)
| | - Marzieh Jamali
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Drs Hessami, Zargarzadeh, Jamali, and Shamshirsaz); Gene Therapy Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran (Dr Jamali)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Drs Hessami, Zargarzadeh, Jamali, and Shamshirsaz).
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Norooznezhad AH, Zargarzadeh N, Javinani A, Nabavian SM, Qaderi S, Mostafaei S, Berghella V, Oyelese Y, Shamshirsaz AA. The effect of cervical pessary on increasing gestational age at delivery in twin pregnancies with asymptomatic short cervix: a systematic review and meta-analysis of randomized controlled trials. AJOG Glob Rep 2024; 4:100347. [PMID: 38655568 PMCID: PMC11036094 DOI: 10.1016/j.xagr.2024.100347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024] Open
Abstract
Objective The incidence of preterm delivery is much higher in twin pregnancies than in singletons and even higher if a short cervical length is detected in the second trimester. Studies are contradictory regarding the efficacy of a cervical pessary to decrease preterm birth in twin pregnancies and short cervical length. To conduct a systematic review and meta-analysis investigating the efficacy of cervical pessary in prolonging gestation, preventing preterm birth, and reducing adverse neonatal outcomes in twin pregnancies with an asymptomatic short cervix. Data sources PubMed, Scopus, Web of Science, and ClinicalTrials.org were searched for randomized controlled trials from inception to June 2023. Study eligibility criteria In this study, randomized controlled trials comparing the cervical pessary to expectant management in the pregnant population with twin gestations and asymptomatic short cervix were included. Methods The Cochrane risk-of-bias-2 tool for randomized controlled trials was used for the evaluation of the risk of bias in included studies. A meta-analysis was performed by calculating risk ratio and mean difference with their 95% confidence interval using the random effects model or fixed effect model on the basis of heterogeneity and accounting for potential covariates among the included randomized controlled trials. Results A total of 6 randomized controlled trials were included in the analysis. Cervical pessary did not significantly increase the gestational age at delivery in twin pregnancies with asymptomatic patients (mean difference, 0.36 weeks [-0.27 to 0.99]; P=.270; I2=72.0%). Moreover, the cervical pessary use did not result in a reduction of spontaneous or all-preterm birth before 37 weeks of gestation (risk ratio, 0.88 [0.77-1.00]; P=.061; I2=0.0%). There was no statistically significant difference in the composite neonatal adverse outcomes (risk ratio, 1.001 [0.86-1.16]; P=.981; I2=20.9%), including early respiratory morbidity, intraventricular hemorrhage, necrotizing enterocolitis, and confirmed sepsis. Conclusion The use of cervical pessary in twin pregnancies with asymptomatic short cervix does not seem to be effective in increasing the gestational age at delivery, preventing preterm birth, or reducing adverse neonatal outcomes. This indicates that alternative interventions should be sought for the management of this patient population.
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Affiliation(s)
- Amir Hossein Norooznezhad
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran (Dr. Norooznezhad and Dr. Nabavian)
| | - Nikan Zargarzadeh
- Maternal Fetal Care Center, Division of Maternal Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Zargarzadeh, Dr. Javinani, Dr. Qaderi, Dr. Oyelese, and Dr Shamshirsaz)
| | - Ali Javinani
- Maternal Fetal Care Center, Division of Maternal Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Zargarzadeh, Dr. Javinani, Dr. Qaderi, Dr. Oyelese, and Dr Shamshirsaz)
| | - Seyedeh Maedeh Nabavian
- Medical Biology Research Center, Health Technology Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran (Dr. Norooznezhad and Dr. Nabavian)
| | - Shohra Qaderi
- Maternal Fetal Care Center, Division of Maternal Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Zargarzadeh, Dr. Javinani, Dr. Qaderi, Dr. Oyelese, and Dr Shamshirsaz)
| | - Shayan Mostafaei
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden (Dr. Mostafaei)
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (Dr. Berghella)
| | - Yinka Oyelese
- Maternal Fetal Care Center, Division of Maternal Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Zargarzadeh, Dr. Javinani, Dr. Qaderi, Dr. Oyelese, and Dr Shamshirsaz)
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Oyelese)
| | - Alireza A. Shamshirsaz
- Maternal Fetal Care Center, Division of Maternal Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Zargarzadeh, Dr. Javinani, Dr. Qaderi, Dr. Oyelese, and Dr Shamshirsaz)
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4
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Mustafa HJ, Sambatur EV, Pagani G, D'Antonio F, Maisonneuve E, Maurice P, Zwiers C, Verweij JEJT, Flood A, Shamshirsaz AA, Jouannic JM, Khalil A. Intravenous immunoglobulin for the treatment of severe maternal alloimmunization: individual patient data meta-analysis. Am J Obstet Gynecol 2024:S0002-9378(24)00508-8. [PMID: 38588966 DOI: 10.1016/j.ajog.2024.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 03/18/2024] [Accepted: 03/26/2024] [Indexed: 04/10/2024]
Abstract
OBJECTIVE This study aimed to investigate the outcomes associated with the administration of maternal intravenous immunoglobulin in high-risk red blood cell-alloimmunized pregnancies. DATA SOURCES Medline, Embase, and Cochrane Library were systematically searched until June 2023. STUDY ELIGIBILITY CRITERIA This review included studies reporting on pregnancies with severe red blood cell alloimmunization, defined as either a previous fetal or neonatal death or the need for intrauterine transfusion before 24 weeks of gestation in the previous pregnancy as a result of hemolytic disease of the fetus and newborn. METHODS Cases were pregnancies that received intravenous immunoglobulin, whereas controls did not. Individual patient data meta-analysis was performed using the Bayesian framework. RESULTS Individual patient data analysis included 8 studies consisting of 97 cases and 97 controls. Intravenous immunoglobulin was associated with prolonged delta gestational age at the first intrauterine transfusion (gestational age of current pregnancy - gestational age at previous pregnancy) (mean difference, 3.19 weeks; 95% credible interval, 1.28-5.05), prolonged gestational age at the first intrauterine transfusion (mean difference, 1.32 weeks; 95% credible interval, 0.08-2.50), reduced risk of fetal hydrops at the time of first intrauterine transfusion (incidence rate ratio, 0.19; 95% credible interval, 0.07-0.45), reduced risk of fetal demise (incidence rate ratio, 0.23; 95% credible interval, 0.10-0.47), higher chances of live birth at ≥28 weeks (incidence rate ratio, 1.88; 95% credible interval, 1.31-2.69;), higher chances of live birth at ≥32 weeks (incidence rate ratio, 1.93; 95% credible interval, 1.32-2.83), and higher chances of survival at birth (incidence rate ratio, 1.82; 95% credible interval, 1.30-2.61). There was no substantial difference in the number of intrauterine transfusions, hemoglobin level at birth, bilirubin level at birth, or survival at hospital discharge for live births. CONCLUSION Intravenous immunoglobulin treatment in pregnancies at risk of severe early hemolytic disease of the fetus and newborn seems to have a clinically relevant beneficial effect on the course and severity of the disease.
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Affiliation(s)
- Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, IN; Fetal Center at Riley Children's and Indiana University Health, Indianapolis, IN.
| | - Enaja V Sambatur
- Division of Fetal Medicine and Surgery, Maternal Fetal Care Center, Boston Children's Hospital and Harvard School of Medicine, Boston, MA
| | - Giorgio Pagani
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Azienda Socio-Sanitaria Territoriale-Papa Giovanni XXIII, Bergamo, Italy
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Center for Fetal Care and High-Risk Pregnancy, University Hospital of Chieti, Chieti, Italy
| | - Emeline Maisonneuve
- Materno-Fetal and Obstetrics Research Unit, Woman-Mother-Child Department, Lausanne University Hospital, Lausanne, Switzerland; Fetal Medicine Department and French Referral National Centre for Perinatal Hemobiology, Armand Trousseau Hospital, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
| | - Paul Maurice
- Fetal Medicine Department and French Referral National Centre for Perinatal Hemobiology, Armand Trousseau Hospital, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
| | - Carolien Zwiers
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Joanne E J T Verweij
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Anna Flood
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Alireza A Shamshirsaz
- Division of Fetal Medicine and Surgery, Maternal Fetal Care Center, Boston Children's Hospital and Harvard School of Medicine, Boston, MA
| | - Jean-Marie Jouannic
- Fetal Medicine Department and French Referral National Centre for Perinatal Hemobiology, Armand Trousseau Hospital, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Paris, France
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
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5
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Oyelese Y, Javinani A, Gudanowski B, Krispin E, Rebarber A, Akolekar R, Catanzarite V, D'Souza R, Bronsteen R, Odibo A, Scheier MA, Hasegawa J, Jauniaux E, Lees C, Srinivasan D, Daly-Jones E, Duncombe G, Melcer Y, Maymon R, Silver R, Prefumo F, Tachibana D, Henrich W, Cincotta R, Shainker SA, Ranzini AC, Roman AS, Chmait R, Hernandez-Andrade EA, Rolnik DL, Sepulveda W, Shamshirsaz AA. Vasa previa in singleton pregnancies: diagnosis and clinical management based on an international expert consensus. Am J Obstet Gynecol 2024:S0002-9378(24)00442-3. [PMID: 38494071 DOI: 10.1016/j.ajog.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/01/2024] [Accepted: 03/09/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND There are limited data to guide the diagnosis and management of vasa previa. Currently, what is known is largely based on case reports or series and cohort studies. OBJECTIVE This study aimed to systematically collect and classify expert opinions and achieve consensus on the diagnosis and clinical management of vasa previa using focus group discussions and a Delphi technique. STUDY DESIGN A 4-round focus group discussion and a 3-round Delphi survey of an international panel of experts on vasa previa were conducted. Experts were selected on the basis of their publication record on vasa previa. First, we convened a focus group discussion panel of 20 experts and agreed on which issues were unresolved in the diagnosis and management of vasa previa. A 3-round anonymous electronic survey was then sent to the full expert panel. Survey questions were presented on the diagnosis and management of vasa previa, which the experts were asked to rate on a 5-point Likert scale (from "strongly disagree"=1 to "strongly agree"=5). Consensus was defined as a median score of 5. Following responses to each round, any statements that had median scores of ≤3 were deemed to have had no consensus and were excluded. Statements with a median score of 4 were revised and re-presented to the experts in the next round. Consensus and nonconsensus statements were then aggregated. RESULTS A total of 68 international experts were invited to participate in the study, of which 57 participated. Experts were from 13 countries on 5 continents and have contributed to >80% of published cohort studies on vasa previa, as well as national and international society guidelines. Completion rates were 84%, 93%, and 91% for the first, second, and third rounds, respectively, and 71% completed all 3 rounds. The panel reached a consensus on 26 statements regarding the diagnosis and key points of management of vasa previa, including the following: (1) although there is no agreement on the distance between the fetal vessels and the cervical internal os to define vasa previa, the definition should not be limited to a 2-cm distance; (2) all pregnancies should be screened for vasa previa with routine examination for placental cord insertion and a color Doppler sweep of the region over the cervix at the second-trimester anatomy scan; (3) when a low-lying placenta or placenta previa is found in the second trimester, a transvaginal ultrasound with Doppler should be performed at approximately 32 weeks to rule out vasa previa; (4) outpatient management of asymptomatic patients without risk factors for preterm birth is reasonable; (5) asymptomatic patients with vasa previa should be delivered by scheduled cesarean delivery between 35 and 37 weeks of gestation; and (6) there was no agreement on routine hospitalization, avoidance of intercourse, or use of 3-dimensional ultrasound for diagnosis of vasa previa. CONCLUSION Through focus group discussion and a Delphi process, an international expert panel reached consensus on the definition, screening, clinical management, and timing of delivery in vasa previa, which could inform the development of new clinical guidelines.
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Affiliation(s)
- Yinka Oyelese
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA.
| | - Ali Javinani
- Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA
| | - Brittany Gudanowski
- Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Eyal Krispin
- Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Andrei Rebarber
- Division of Maternal Fetal Medicine, Mount Sinai West, New York, NY; Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY; Carnegie Imaging for Women, PLLC, New York, NY
| | - Ranjit Akolekar
- Medway Fetal and Maternal Medicine Centre, Medway NHS Foundation Trust, Gillingham, United Kingdom; Institute of Medical Sciences, Canterbury Christ Church University, Chatham, United Kingdom
| | - Val Catanzarite
- Maternal-Fetal Medicine, Rady Children's Specialists of San Diego, San Diego, CA
| | - Rohan D'Souza
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Richard Bronsteen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Corewell Health William Beaumont University Hospital, Royal Oak, MI
| | - Anthony Odibo
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Washington University School of Medicine, St. Louis, MO
| | | | - Junichi Hasegawa
- Department of Perinatal Development Pathophysiology, St. Marianna University Graduate School of Medicine, Kawasaki, Japan
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Christoph Lees
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom; Institute of Reproductive and Developmental Biology, Imperial College London, London, United Kingdom; Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Deepa Srinivasan
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Elizabeth Daly-Jones
- Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Gregory Duncombe
- Department of Obstetrics and Gynaecology, Logan Hospital, Metro South Health, Meadowbrook, Australia
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, Shamir Medical Center, Tzrifin, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, Shamir Medical Center, Tzrifin, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Silver
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT
| | - Federico Prefumo
- Obstetrics and Gynaecology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Daisuke Tachibana
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Osaka City University, Osaka, Japan
| | - Wolfgang Henrich
- Department of Obstetrics, Campus Virchow-Klinikum, Campus Charité Mitte, Universitätsmedizin Berlin, Berlin, Germany; Department of Obstetrics, Charité - University Medical Center, Berlin, Germany
| | - Robert Cincotta
- Department of Maternal Fetal Medicine, Mater Mothers' Hospital, South Brisbane, Australia
| | - Scott A Shainker
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA
| | - Angela C Ranzini
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, MetroHealth System, Case Western Reserve University, Cleveland, OH
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY
| | - Ramen Chmait
- Department of Obstetrics & Gynecology, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Edgar A Hernandez-Andrade
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Waldo Sepulveda
- Fetal Imaging Unit, FETALMED Maternal-Fetal Diagnostic Center, Santiago, Chile
| | - Alireza A Shamshirsaz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA; Division of Fetal Medicine and Surgery, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Sciences, Harvard Medical School, Boston, MA.
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6
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Krispin E, Javinani A, Odibo A, Carreras E, Emery SP, Sepulveda Gonzalez G, Habli M, Hecher K, Ishii K, Miller J, Papanna R, Johnson A, Khalil A, Kilby MD, Lewi L, Bennasar Sans M, Otaño L, Zaretsky MV, Sananes N, Turan OM, Slaghekke F, Stirnemann J, Van Mieghem T, Welsh AW, Yoav Y, Chmait R, Shamshirsaz AA. Consensus protocol for management of early and late twin-twin transfusion syndrome: Delphi study. Ultrasound Obstet Gynecol 2024; 63:371-377. [PMID: 37553800 DOI: 10.1002/uog.27446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/11/2023] [Accepted: 07/21/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVE Fetoscopic laser photocoagulation (FLP) is a well-established treatment for twin-twin transfusion syndrome (TTTS) between 16 and 26 weeks' gestation. High-quality evidence and guidelines regarding the optimal clinical management of very early (prior to 16 weeks), early (between 16 and 18 weeks) and late (after 26 weeks) TTTS are lacking. The aim of this study was to construct a structured expert-based clinical consensus for the management of early and late TTTS. METHODS A Delphi procedure was conducted among an international panel of experts. Participants were chosen based on their clinical expertise, affiliation and relevant publications. A four-round Delphi survey was conducted using an online platform and responses were collected anonymously. In the first round, a core group of experts was asked to answer open-ended questions regarding the indications, timing and modes of treatment for early and late TTTS. In the second and third rounds, participants were asked to grade each statement on a Likert scale (1, completely disagree; 5, completely agree) and to add any suggestions or modifications. At the end of each round, the median score for each statement was calculated. Statements with a median grade of 5 without suggestions for change were accepted as the consensus. Statements with a median grade of 3 or less were excluded from the Delphi process. Statements with a median grade of 4 were modified according to suggestions and reconsidered in the next round. In the last round, participants were asked to agree or disagree with the statements, and those with more than 70% agreement without suggestions for change were considered the consensus. RESULTS A total of 122 experts met the inclusion criteria and were invited to participate, of whom 53 (43.4%) agreed to take part in the study. Of those, 75.5% completed all four rounds. A consensus on the optimal management of early and late TTTS was obtained. FLP can be offered as early as 15 weeks' gestation for selected cases, and can be considered up to 28 weeks. Between 16 and 18 weeks, management should be tailored according to Doppler findings. CONCLUSIONS A consensus-based treatment protocol for early and late TTTS was agreed upon by a panel of experts. This protocol should be modified at the discretion of the operator, according to their experience and the specific demands of each case. This should advance the quality of future studies, guide clinical practice and improve patient care. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Krispin
- Maternal Fetal Care Center (MFCC), Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - A Javinani
- Maternal Fetal Care Center (MFCC), Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - A Odibo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine, St Louis, MO, USA
| | - E Carreras
- Maternal-Fetal Medicine Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - S P Emery
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - G Sepulveda Gonzalez
- Instituto de Salud Fetal (ISF), Hospital Regional Materno Infantil, Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
| | - M Habli
- Department of Pediatric Surgery, Fetal Care Center of Cincinnati, Good Samaritan Hospital, Cincinnati, OH, USA
| | - K Hecher
- Department of Obstetrics and Prenatal Medicine, University Medical Center Eppendorf, Hamburg, Germany
| | - K Ishii
- Maternal-Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - J Miller
- The Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - R Papanna
- Fetal Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas McGovern Medical School at Houston, Houston, TX, USA
| | - A Johnson
- Fetal Center, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas McGovern Medical School at Houston, Houston, TX, USA
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, Liverpool, UK
| | - M D Kilby
- Fetal Medicine Center, Birmingham Women's and Children's Foundation Trust, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Illumina UK, Great Abbington, Cambridge, UK
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - M Bennasar Sans
- BCNatal, Maternal-Fetal Medicine Center, Hospital Clínic i Hospital Sant Joan de Déu, Barcelona, Spain
| | - L Otaño
- Maternal-Fetal Medicine Unit, Obstetric Division, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - M V Zaretsky
- Colorado Fetal Care Center, Children's Hospital of Colorado, University of Colorado, Denver, CO, USA
| | - N Sananes
- Obstetrics and Gynecology Department, Strasbourg University Hospital, Strasbourg, France
- Inserm 1121 'Biomaterials and Bioengineering', Strasbourg University, Strasbourg, France
| | - O M Turan
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - F Slaghekke
- Department of Obstetrics, Fetal Medicine Unit, Leiden University Medical Center, Leiden, The Netherlands
| | - J Stirnemann
- Department of Obstetrics and Maternal-Fetal Medicine, Necker-Enfants Malades Hospital, University of Paris, Paris, France
| | - T Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - A W Welsh
- Maternal-Fetal Medicine, Royal Hospital for Women, University of New South Wales, Sydney, Australia
| | - Y Yoav
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Chmait
- Los Angeles Fetal Surgery, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A A Shamshirsaz
- Maternal Fetal Care Center (MFCC), Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Donepudi RV, Javinani A, Mostafaei S, Habich A, Miller J, Chmait RH, Shamshirsaz AA. Perinatal survival following intrauterine transfusion for red cell alloimmunized pregnancies: systematic review and meta-regression. Am J Obstet Gynecol 2024; 230:e1-e2. [PMID: 37839589 DOI: 10.1016/j.ajog.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Roopali V Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine, 6651 S Main St, Houston, TX 77030.
| | - Ali Javinani
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Shayan Mostafaei
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Annegret Habich
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden; University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Jena Miller
- The Johns Hopkins Center for Fetal Therapy, Johns Hopkins School of Medicine, Baltimore, MD
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
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8
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Modest AM, Einerson BD, Nieto AJ, Shrivastava VK, Shamshirsaz AA, Shainker SA. Risk Profiling In Vitro Fertilization Pregnancies that Develop Placenta Accreta Spectrum. Am J Perinatol 2024. [PMID: 38290554 DOI: 10.1055/a-2257-3864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
OBJECTIVE The objective of this study is to assess whether, among a cohort of placenta accreta spectrum (PAS) patients, antenatal suspicion of PAS was less likely in in vitro fertilization (IVF) compared with non-IVF patients. In addition, we aimed to assess whether IVF patients exhibited similar risk factors for PAS compared with non-IVF patients. STUDY DESIGN This is an international multicenter retrospective study of patients with pathologically confirmed PAS (accreta, increta, percreta) between 1998 and 2021. PAS patients were identified through a central international PAS database. Antenatal and pathological criteria are specific to each institution. Pregnancies that resulted from IVF were compared with non-IVF pregnancies. Comparisons were made using a chi-square or Fisher's exact test for categorical variables and Wilcoxon rank-sum test for continuous variables. RESULTS Of the 692 pregnancies included, 44 were in the IVF group and 648 were in the non-IVF group. The IVF group was less likely to have had a prior cesarean delivery (70.5 vs. 91%, p < 0.01) but a similar prevalence of placenta previa (63.6 vs. 68.1%, p = 0.12) compared with the non-IVF group. The IVF group was also less likely to have either a prior cesarean delivery or placenta previa than the non-IVF group (79.5 vs. 95.4%, p < 0.01). Antenatal detection of PAS was less common in the IVF group compared with the non-IVF group (40.9 vs. 60.5%, p < 0.01, respectively), even when adjusted for maternal age, prior cesarean delivery, prior uterine surgery, placenta previa and site (risk ratio: 0.70, 95% confidence interval: 0.62-0.81). The IVF group had less severe pathological disease compared with the non-IVF group (p = 0.02). CONCLUSION Pregnant people with PAS who underwent IVF are less likely to have an antenatal suspicion compared with non-IVF patients. This finding may be explained by the lower incidence of prior cesarean deliveries and/or placenta previa as well as less severe forms of PAS. KEY POINTS · IVF group is less likely to have antenatal PAS suspicion.. · IVF group is less likely to have had prior cesarean delivery.. · Risk profile for PAS differs in IVF pregnancies..
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Affiliation(s)
- Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Albaro J Nieto
- Departamento de Ginecología y Obstetricia, Unidad de Alta Complejidad Obstétrica, Fundación Clínica Valle del Lili, Cali, Colombia
| | - Vineet K Shrivastava
- Department of Obstetrics and Gynecology, Miller Children's & Women's Hospital/Long Beach, Long Beach, California
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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9
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Oyelese Y, Javinani A, Shamshirsaz AA. Perinatal Mortality Despite Prenatal Diagnosis of Vasa Previa: A Systematic Review. Obstet Gynecol 2024; 143:e22. [PMID: 38237163 DOI: 10.1097/aog.0000000000005486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Yinka Oyelese
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Maternal Fetal Care Center, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts
| | | | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, and Harvard Medical School, Boston, Massachusetts
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Malek J, Shamshirsaz AA, Wilpers A, Premkumar A, Bahtiyar MO. The Right to Refuse Obstetrical Interventions: In Principle, in Practice. Am J Bioeth 2024; 24:44-45. [PMID: 38295264 DOI: 10.1080/15265161.2023.2296428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
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11
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Shannon KJ, VanLoh S, Espinoza J, Sanz-Cortes M, Donepudi R, Shamshirsaz AA, Koh CJ, Roth DR, Braun MC, Angelo J, Belfort MA, Nassr AA. Fetal bladder morphology as a predictor of outcome in fetal lower urinary tract obstruction. Prenat Diagn 2024; 44:124-130. [PMID: 36919753 DOI: 10.1002/pd.6343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE We evaluate survival of fetuses with severe Lower Urinary Tract Obstruction (LUTO) based on bladder morphology. We hypothesize that fetuses with a "floppy" appearing bladder on initial prenatal ultrasound will have worse infant outcomes than fetuses with full/rounded bladders. METHOD We retrospectively reviewed all cases of LUTO evaluated in our fetal center between January 2013 and December 2021. Ultrasonographic assessment, renal biochemistry, and bladder refilling contributed to a "favorable" or "unfavorable" evaluation. Bladder morphology on initial ultrasound was classified as "floppy" or "full/rounded." Vesicoamniotic shunting was offered for favorably evaluated fetuses. Baseline demographics, ultrasound parameters, prenatal evaluations of fetal renal function, and infant outcomes were collected. Fetuses diagnosed with severe LUTO were included in analysis using descriptive statistics. The primary outcome measured was survival at 6 months of life. RESULTS 104 LUTO patients were evaluated; 24 were included in analysis. Infant survival rate at 6 months was 60% for rounded bladders and 0% for floppy bladders (p = 0.003). Bladder refill adequacy was lower in fetuses with floppy bladders compared with rounded bladders (p value < 0.00001). CONCLUSION We propose that bladder morphology in fetuses with severe LUTO may be a prognostication factor for predicting infant outcomes and provides a valuable, noninvasive assessment tool.
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Affiliation(s)
| | - Sarah VanLoh
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Jimmy Espinoza
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Magdalena Sanz-Cortes
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Roopali Donepudi
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Chester J Koh
- Division of Pediatric Urology, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - David R Roth
- Division of Pediatric Urology, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Michael C Braun
- Division of Pediatric Nephrology, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Joseph Angelo
- Division of Pediatric Nephrology, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Michael A Belfort
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - Ahmed A Nassr
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
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12
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Krispin E, Didier R, Shaniker SA, Duffy CR, Hecht J, Shamshirsaz AA. Diagnostic fetoscopy: important resource for prenatal assessment. Ultrasound Obstet Gynecol 2024; 63:282-283. [PMID: 37676469 DOI: 10.1002/uog.27469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/15/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Affiliation(s)
- E Krispin
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - R Didier
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - S A Shaniker
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - C R Duffy
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - J Hecht
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - A A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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13
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Masse O, Brumfield O, Ahmad E, Velasco-Annis C, Zhang J, Rollins CK, Connolly S, Barnewolt C, Shamshirsaz AA, Qaderi S, Javinani A, Warfield SK, Yang E, Gholipour A, Feldman HA, Grant PE, Mulliken JB, Pierotich L, Estroff J. Divergent growth of the transient brain compartments in fetuses with nonsyndromic isolated clefts involving the primary and secondary palate. Cereb Cortex 2024; 34:bhae024. [PMID: 38365268 PMCID: PMC10872676 DOI: 10.1093/cercor/bhae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/29/2023] [Accepted: 12/30/2023] [Indexed: 02/18/2024] Open
Abstract
Cleft lip/palate is a common orofacial malformation that often leads to speech/language difficulties as well as developmental delays in affected children, despite surgical repair. Our understanding of brain development in these children is limited. This study aimed to analyze prenatal brain development in fetuses with cleft lip/palate and controls. We examined in utero MRIs of 30 controls and 42 cleft lip/palate fetal cases and measured regional brain volumes. Cleft lip/palate was categorized into groups A (cleft lip or alveolus) and B (any combination of clefts involving the primary and secondary palates). Using a repeated-measures regression model with relative brain hemisphere volumes (%), and after adjusting for multiple comparisons, we did not identify significant differences in regional brain growth between group A and controls. Group B clefts had significantly slower weekly cerebellar growth compared with controls. We also observed divergent brain growth in transient brain structures (cortical plate, subplate, ganglionic eminence) within group B clefts, depending on severity (unilateral or bilateral) and defect location (hemisphere ipsilateral or contralateral to the defect). Further research is needed to explore the association between regional fetal brain growth and cleft lip/palate severity, with the potential to inform early neurodevelopmental biomarkers and personalized diagnostics.
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Affiliation(s)
- Olivia Masse
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Olivia Brumfield
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Esha Ahmad
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Clemente Velasco-Annis
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Jennings Zhang
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Caitlin K Rollins
- Department of Neurology Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Susan Connolly
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Carol Barnewolt
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Shohra Qaderi
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Ali Javinani
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Simon K Warfield
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Edward Yang
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Ali Gholipour
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Henry A Feldman
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Patricia E Grant
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - John B Mulliken
- Department of Plastic and Oral Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Lana Pierotich
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Judy Estroff
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
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14
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Sanz Cortes M, Corroenne R, Pyarali M, Johnson RM, Whitehead WE, Espinoza J, Donepudi R, Castillo J, Castillo H, Mehollin-Ray AR, Shamshirsaz AA, Nassr AA, Belfort MA. Ambulation after in-utero fetoscopic and open spina bifida repair: predictors for ambulation at 30 months. Ultrasound Obstet Gynecol 2024. [PMID: 38243917 DOI: 10.1002/uog.27589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/04/2023] [Accepted: 01/15/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVE Ambulatory outcomes from children who underwent a new minimally invasive fetal spina bifida surgery approach are included in this study for the first time. Identifying cases with better chances of independent ambulation from fetal life can have an important impact on patient counseling. The objectives of this study were: (1) To compare the ambulatory status of a cohort of children who had a prenatal spina bifida repair using two different methods (fetoscopic and open) with a cohort who underwent postnatal repair; and (2) to identify the best predictors for ambulation. METHODS Retrospective review of a cohort of children who had spina bifida repair from 2011-2023 using prenatal fetoscopic surgery (N=73), prenatal open-hysterotomy surgery (N=37) or postnatal repair (N=51) in a single tertiary hospital. Consecutive sample of cases who underwent a spina bifida repair in utero following MoMs trial criteria and cases who underwent postnatal repair, meeting same criteria, also followed up after birth at the same institution. Motor function (MF) assessment by ultrasound was recorded at initial evaluation (MF1), 6 postoperative weeks or equivalent (MF2) and prior to delivery (MF3). Clinical exams to assess MF at birth and at 12 months were recorded. First sacral myotome (S1) MF was classified as "intact MF". Ambulatory status data at each follow-up visit was collected. The proportion of cases who were able to walk independently were compared between fetoscopic and open prenatal surgeries and between prenatal (by fetoscopic or open surgery) and postnatal spina bifida repair. Logistic regression analyses were performed to identify predictors for independent ambulation. RESULTS At 30 months, the proportion of independent ambulators was higher in prenatally vs. postnatally repaired cases (51.8% vs.15.7%; p<0.01). No differences in ambulatory outcomes were seen in the comparison between fetoscopic (52%) vs. open (51.3%; p=0.95) prenatal repair. In the prenatal repair group, having an "intact MF" at 12 months [Odds ratio 7.71 (95%CI: 2.77-21.47), p<0.01] and at birth [4.38 (1.53-12.56), p<0.01], predicted significantly being an independent ambulator by 30 months; the anatomical level of lesion below L2 was also predictive for this outcome [3.68(1.33-9.88), p=0.01]. CONCLUSION Ambulatory status by 30 months can be predicted by observing S1 MF postnatally. Results from this study have implications for parental counseling and planning for supportive therapies. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- M Sanz Cortes
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - R Corroenne
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M Pyarali
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - R M Johnson
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - W E Whitehead
- Department of Neurosurgery, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - J Castillo
- Department of Pediatrics, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - H Castillo
- Department of Pediatrics, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A R Mehollin-Ray
- Department of Radiology, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, TX, USA
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Mitts MD, Whitehead W, Corroenne R, Johnson R, Donepudi R, Espinoza J, Shamshirsaz AA, Sanz Cortes M, Belfort MA, Nassr AA. Prenatal surgery in fetal myelomeningocele with severe ventriculomegaly. Ultrasound Obstet Gynecol 2024. [PMID: 38224552 DOI: 10.1002/uog.27585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/14/2023] [Accepted: 01/07/2024] [Indexed: 01/17/2024]
Abstract
OBJECTIVES Prenatal myelomeningocele (MMC) repair is performed to decrease risk for treatment of hydrocephalus after birth and to preserve motor function. Some centers may not consider patients candidates for surgery if severe ventriculomegaly is present and there is no expected benefit in decreased risk for hydrocephalus treatment. This study sought to compare postnatal outcomes of fetuses with MMC and severe ventriculomegaly (>15mm) who underwent prenatal repair, with fetuses with severe ventriculomegaly who underwent postnatal repair and fetuses with ventriculomegaly (<15mm) who underwent prenatal repair. METHODS This was a retrospective study of fetuses with MMC that underwent prenatal or postnatal repair between 2012 and 2021 at a single institution. The cohort was divided based on preoperative fetal ventricular size into two groups, those with severe ventriculomegaly (≥15 mm) and those without severe ventriculomegaly (<15 mm). Fetal ventricular size was measured by MRI prior to surgery using the standardized approach and the mean of the left and right ventricle was used for analysis. Motor function of lower extremities was assessed at the time of referral by ultrasound and if flexion-extension movements of the ankle were seen, it was considered as preserved S1 motor function. Postnatal outcomes including motor function of lower extremities assessed at birth and need for diversion procedure for hydrocephalus treatment during the first year of life were collected and compared between groups. Data was presented as median and range or number and percentages as appropriate. P value >0.05 was considered statistically significant. Multivariate regression analysis was used to adjust for potential confounders. RESULTS 154 patients were included in this study: 145 patients underwent fetal surgery (101 fetoscopic and 44 open hysterotomy) and 9 patients with severe ventriculomegaly underwent postnatal repair. Among the 145 patients who underwent fetal surgery, 22 presented with severe ventriculomegaly. Prenatally repaired fetuses with severe ventriculomegaly at referral were at a significantly higher need for hydrocephalus treatment by 12 months than those without severe ventriculomegaly (62% vs. 29%, p<0.01). However, motor function assessment at birth was similar between both prenatally repaired groups (OR=0.92, 95% CI [0.33-2.59], p=0.88) adjusted for the anatomical level of the lesion. The prenatally repaired group with severe ventriculomegaly had better preserved motor function levels at birth compared to the postnatal repair group with severe ventriculomegaly (L3 with 11.1% S1 motor function; p=<0.01 and p=<0.01). Prenatally repaired patients with severe ventriculomegaly had an 18.9 times chance of having an intact motor function at birth [95% CI (1.2 - 290.1)] adjusted for ethnicity, presence of clubfeet at referral, and gestational age at delivery compared to postnatal repair. There was not a significant difference in the need for hydrocephalus treatment in the first year of life between prenatal and postnatal repair of patients with severe ventriculomegaly (61.9% vs 87.5%, p=0.18). CONCLUSIONS Although fetuses with MMC and severe ventriculomegaly do not seem to benefit from fetal surgery in terms of postnatal hydrocephalus treatment, they benefit from increased chance of preserved motor function at birth. Results from this study highlight the benefits of having prenatal MMC repair for cases with severe ventriculomegaly at referral to preserve motor function. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- M D Mitts
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - W Whitehead
- Department of Neurosurgery, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - R Corroenne
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - R Johnson
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - R Donepudi
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - J Espinoza
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - A A Shamshirsaz
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - M Sanz Cortes
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - M A Belfort
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
| | - A A Nassr
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine & Texas Children's Hospital, Houston, Texas, USA
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16
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Conyers S, Oyelese Y, Javinani A, Jamali M, Zargarzadeh N, Akolekar R, Hasegawa J, Melcer Y, Maymon R, Bronsteen R, Roman A, Shamshirsaz AA. Incidence and causes of perinatal death in prenatally diagnosed vasa previa: a systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:58-65. [PMID: 37321285 DOI: 10.1016/j.ajog.2023.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/26/2023] [Accepted: 06/07/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE This study aimed to estimate the perinatal mortality associated with prenatally diagnosed vasa previa and to determine what proportion of those perinatal deaths are directly attributable to vasa previa. DATA SOURCES The following databases have been searched from January 1, 1987, to January 1, 2023: PubMed, Scopus, Web of Science, and Embase. STUDY ELIGIBILITY CRITERIA Our study included all studies (cohort studies and case series or reports) that had patients in which a prenatal diagnosis of vasa previa was made. Case series or reports were excluded from the meta-analysis. All cases in which prenatal diagnosis was not made were excluded from the study. METHODS The programming language software R (version 4.2.2) was used to conduct the meta-analysis. The data were logit transformed and pooled using the fixed effects model. The between-study heterogeneity was reported by I2. The publication bias was evaluated using a funnel plot and the Peters regression test. The Newcastle-Ottawa scale was used to assess the risk of bias. RESULTS Overall, 113 studies with a cumulative sample size of 1297 pregnant individuals were included. This study included 25 cohort studies with 1167 pregnancies and 88 case series or reports with 130 pregnancies. Moreover, 13 perinatal deaths occurred among these pregnancies, consisting of 2 stillbirths and 11 neonatal deaths. Among the cohort studies, the overall perinatal mortality was 0.94% (95% confidence interval, 0.52-1.70; I2=0.0%). The pooled perinatal mortality attributed to vasa previa was 0.51% (95% confidence interval, 0.23-1.14; I2=0.0%). Stillbirth and neonatal death were reported in 0.20% (95% confidence interval, 0.05-0.80; I2=0.0%) and 0.77% (95% confidence interval, 0.40-1.48; I2=0.0%) of pregnancies, respectively. CONCLUSION Perinatal death is uncommon after a prenatal diagnosis of vasa previa. Approximately half of the cases of perinatal mortality are not directly attributable to vasa previa. This information will help in guiding physicians in counseling and will provide reassurance to pregnant individuals with a prenatal diagnosis of vasa previa.
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Affiliation(s)
- Steffany Conyers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Yinka Oyelese
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - Ali Javinani
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Marzieh Jamali
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Nikan Zargarzadeh
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Ranjit Akolekar
- Medway Fetal and Maternal Medicine Centre, Medway NHS Foundation Trust, Gillingham, United Kingdom; Institute of Medical Sciences, Canterbury Christ Church University, Chatham, Kent, United Kingdom
| | - Junichi Hasegawa
- Department of Obstetrics and Gynecology, St. Marianna School of Medicine, Kanagawa, Japan
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Richard Bronsteen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Corewell Health, Royal Oak, MI
| | - Ashley Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
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17
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Qaderi S, Javinani A, Blumenfeld YJ, Krispin E, Papanna R, Chervenak FA, Shamshirsaz AA. Mammalian target of rapamycin inhibitors: A new-possible approach for in-utero medication therapy. Prenat Diagn 2024; 44:88-98. [PMID: 38177082 DOI: 10.1002/pd.6492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
The mammalian/mechanistic target of rapamycin (mTOR) is a protein kinase that plays a crucial role in regulating cellular growth, metabolism, and survival. Although there is no absolute contraindication for the use of mTOR inhibitors during pregnancy, the specific fetal effects remain unknown. Available data from the past 2 decades have examined the use of mTOR inhibitors during pregnancy in patients with solid organ transplantation, showing no clear link to fetal complications or structural abnormalities. Recently, a handful of case reports and series have described transplacental therapy of mTOR inhibitors to control symptomatic and complicated pathologies in the fetus. The effect of these agents includes a significant reduction in lesion size in the fetus and a reduced need for mechanical ventilation in neonates. In this context, we delve into the potential of mTOR inhibitors as in-utero therapy for fetal abnormalities, with a primary focus on lymphatic malformation (LM) and cardiac rhabdomyoma (CR). While preliminary reports underscore the efficacy of mTOR inhibitors for the treatment of fetal CR and fetal brain lesions associated with tuberous sclerosis complex, chylothorax, and LMs, additional investigation and clinical trials are essential to comprehensively assess the safety and efficacy of these medications.
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Affiliation(s)
- Shohra Qaderi
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Javinani
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yair J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, California, USA
| | - Eyal Krispin
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ramesha Papanna
- Division of Fetal Intervention, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at UT Health Houston, Houston, Texas, USA
| | - Frank A Chervenak
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, New York, USA
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Division of Fetal Medicine and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Fitzgerald GD, Newton JM, Atasi L, Buniak CM, Burgos-Luna JM, Burnett BA, Carver AR, Cheng C, Conyers S, Davitt C, Deshmukh U, Donovan BM, Easter SR, Einerson BD, Fox KA, Habib AS, Harrison R, Hecht JL, Licon E, Nino JM, Munoz JL, Nieto-Calvache AJ, Polic A, Ramsey PS, Salmanian B, Shamshirsaz AA, Shamshirsaz AA, Shrivastava VK, Woolworth MB, Yurashevich M, Zuckerwise L, Shainker SA. Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care. Am J Obstet Gynecol MFM 2024; 6:101229. [PMID: 37984691 DOI: 10.1016/j.ajogmf.2023.101229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/02/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.
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Affiliation(s)
- Garrett D Fitzgerald
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Dr Fitzgerald).
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Newton)
| | - Lamia Atasi
- Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO (Dr Atasi)
| | - Christina M Buniak
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA (Dr Buniak)
| | | | - Brian A Burnett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Dr Burnett)
| | - Alissa R Carver
- Department of Obstetrics and Gynecology, Wilmington Maternal-Fetal Medicine, Wilmington, NC (Dr Carver)
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Health Science Center at San Antonio, University of Texas, San Antonio, TX (Dr Cheng)
| | - Steffany Conyers
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Caroline Davitt
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Uma Deshmukh
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Bridget M Donovan
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
| | - Sara Rae Easter
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Easter)
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (Dr Einerson)
| | - Karin A Fox
- Baylor College of Medicine, Houston, TX (Dr Fox)
| | - Ashraf S Habib
- Duke University School of Medicine, Durham, NC (Dr Habib)
| | - Rachel Harrison
- Department of Obstetrics and Gynecology, Advocate Aurora Health, Chicago, IL (Dr Harrison)
| | - Jonathan L Hecht
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker)
| | - Ernesto Licon
- Miller Women's & Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Licon)
| | - Julio Mateus Nino
- Department of Obstetrics and Gynecology, Atrium Health Wake Forest School of Medicine, Winston-Salem, NC (Dr Nino)
| | - Jessian L Munoz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX (Dr Munoz)
| | | | | | - Patrick S Ramsey
- University of Texas Health/University Health San Antonio, San Antonio, TX (Dr Ramsey)
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, University of Colorado Health Anschutz Medical Campus, Boulder, CO (Dr Salmanian)
| | | | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Davitt and Am Shamshiraz)
| | - Vineet K Shrivastava
- Miller Women's and Children's Hospital/Long Beach Memorial Medical Center, Orange, CA (Dr Shrivastava)
| | | | - Mary Yurashevich
- Department of Anesthesiology, Duke Health, Durham, NC (Dr Yurashevich)
| | - Lisa Zuckerwise
- and Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Zuckerwise)
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Drs Conyers, Deshmukh, Donovan, Hecht, and Shainker); Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA (Drs Donovan and Shainker)
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19
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Salmanian B, Shamshirsaz AA, Fox KA, Asl NM, Erfani H, Detlefs SE, Coburn M, Espinoza J, Nassr A, Belfort MA, Clark SL, Shamshirsaz AA. Clinical Outcomes of a False-Positive Antenatal Diagnosis of Placenta Accreta Spectrum. Am J Perinatol 2024; 41:187-192. [PMID: 34666389 DOI: 10.1055/a-1673-5103] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Antenatal diagnosis of placenta accreta spectrum (PAS) is critical to reduce maternal morbidity. While clinical outcomes of women with PAS have been extensively described, little information is available regarding the women who undergo cesarean delivery with a presumptive PAS diagnosis that is not confirmed by histopathologic examination. We sought to examine resource utilization and clinical outcomes of this group of women with a false-positive diagnosis of PAS. STUDY DESIGN This is a retrospective analysis of patients with prenatally diagnosed PAS cared for between 2015 and 2020 by our multidisciplinary PAS team. Maternal outcomes were examined. Univariate analysis was performed and a multivariate model was employed to compare outcomes between women with and without histopathologically confirmed PAS. RESULTS A total of 162 patients delivered with the preoperative diagnosis of PAS. Of these, 146 (90%) underwent hysterectomy and had histopathologic confirmation of PAS. Thirteen women did not undergo the planned hysterectomy. Three women underwent hysterectomy but pathologic examination did not confirm PAS. In comparing women with and without pathologic confirmation of PAS, the false-positive PAS group delivered later in pregnancy (34 vs. 33 weeks of gestation, p = 0.015) and had more planned surgery (88 vs. 47%, p = 0.002). There was no difference in skin incision type or hysterotomy placement for delivery. No significant difference in either the estimated blood loss or blood components transfused was noted between groups. CONCLUSION Careful intraoperative evaluation of women with preoperatively presumed PAS resulted in a 3/149 (2%) retrospectively unnecessary hysterectomy. Management of women with PAS in experienced centers benefits patients in terms of both resource utilization and avoidance of unnecessary maternal morbidity, understanding that our results are produced in a center of excellence for PAS. We also propose a management protocol to assist in the avoidance of unnecessary hysterectomy in women with the preoperative diagnosis of PAS. KEY POINTS · Evaluation and delivery planning of patients with suspected placenta accreta spectrum in experienced centers provides acceptable outcomes.. · Under specific circumstances, delivery of placenta may be attempted if placenta accreta is suspected.. · Patients with suspected placenta accreta rarely undergo unindicated hysterectomy..
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Affiliation(s)
- Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Karin A Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | | | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Sarah E Detlefs
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Michael Coburn
- Department of Urology, Baylor College of Medicine, Houston, Texas
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Ahmed Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Steven L Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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20
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Ezazi Bojnordi T, Eslamian L, Marsoosi V, Golbabaei A, Sheikh Vatan M, Shamshirsaz AA, Eshraghi N, Ghaemi M. Doppler Finding, Cardiovascular Function Assessment, and Fetuses' Survival Following the Fetoscopic Laser in Twin-to-Twin Transfusion Syndrome. J Lasers Med Sci 2023; 14:e64. [PMID: 38318221 PMCID: PMC10843211 DOI: 10.34172/jlms.2023.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 10/08/2023] [Indexed: 02/07/2024]
Abstract
Introduction: This study aimed to evaluate the effectiveness of selective laser photocoagulation of communicating vessels (SLPCV) on cardiac function in twins with twin-to-twin transfusion syndrome (TTTS). Methods: This retrospective cohort study evaluated 178 women with twin pregnancies complicated with TTTS and scheduled for SLPCV between 16 and 26 weeks of gestation. The severity of TTTS was determined by Quintero staging and the severity of cardiovascular disorders by the CHOP (Children's Hospital of Philadelphia) score. Patient survival was evaluated through a one-month-after-birth follow-up of fetuses. Results: The study revealed significant improvements in Doppler indices in both donors and recipients after SLPCV. The CHOP score also significantly decreased after the intervention. One-month-after-birth survival rates were 55.1% in donors and 56.7% in recipients. Some Doppler indexes of fetuses before SLPCV could predict survival until one month after birth. Conclusion: The study suggests that SLPCV can improve cardiac function in fetuses with TTTS and that some Doppler indexes can predict survival outcomes. Additionally, the severity of TTTS can be a powerful indicator of the severity of cardiovascular complications.
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Affiliation(s)
- Tahmineh Ezazi Bojnordi
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Laleh Eslamian
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Vajiheh Marsoosi
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Golbabaei
- Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrdad Sheikh Vatan
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza A. Shamshirsaz
- Maternal Fetal Care Center, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Nasim Eshraghi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Marjan Ghaemi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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21
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Ahmad E, Brumfield O, Masse O, Velasco-Annis C, Zhang J, Rollins CK, Connolly S, Barnewolt C, Shamshirsaz AA, Qaderi S, Javinani A, Warfield SK, Yang E, Gholipour A, Feldman HA, Estroff J, Grant PE, Vasung L. Atypical fetal brain development in fetuses with non-syndromic isolated musculoskeletal birth defects (niMSBDs). Cereb Cortex 2023; 33:10793-10801. [PMID: 37697904 PMCID: PMC10629896 DOI: 10.1093/cercor/bhad323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 09/13/2023] Open
Abstract
Non-syndromic, isolated musculoskeletal birth defects (niMSBDs) are among the leading causes of pediatric hospitalization. However, little is known about brain development in niMSBDs. Our study aimed to characterize prenatal brain development in fetuses with niMSBDs and identify altered brain regions compared to controls. We retrospectively analyzed in vivo structural T2-weighted MRIs of 99 fetuses (48 controls and 51 niMSBDs cases). For each group (19-31 and >31 gestational weeks (GW)), we conducted repeated-measures regression analysis with relative regional volume (% brain hemisphere) as a dependent variable (adjusted for age, side, and interactions). Between 19 and 31GW, fetuses with niMSBDs had a significantly (P < 0.001) smaller relative volume of the intermediate zone (-22.9 ± 3.2%) and cerebellum (-16.1 ± 3.5%,) and a larger relative volume of proliferative zones (38.3 ± 7.2%), the ganglionic eminence (34.8 ± 7.3%), and the ventricles (35.8 ± 8.0%). Between 32 and 37 GW, compared to the controls, niMSBDs showed significantly smaller volumes of central regions (-9.1 ± 2.1%) and larger volumes of the cortical plate. Our results suggest there is altered brain development in fetuses with niMSBDs compared to controls (13.1 ± 4.2%). Further basic and translational neuroscience research is needed to better visualize these differences and to characterize the altered development in fetuses with specific niMSBDs.
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Affiliation(s)
- Esha Ahmad
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Olivia Brumfield
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Olivia Masse
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Clemente Velasco-Annis
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Jennings Zhang
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Caitlin K Rollins
- Department of Neurology Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Susan Connolly
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Carol Barnewolt
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Shohra Qaderi
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Ali Javinani
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Simon K Warfield
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Edward Yang
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Ali Gholipour
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Henry A Feldman
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Judy Estroff
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA 02115, United States
| | - Patricia E Grant
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
- Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
| | - Lana Vasung
- Division of Newborn Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, United States
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22
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Nassr AA, Hessami K, D'Alberti E, Giancotti A, Meshinchiasl N, Evans MI, Di Mascio D, Shamshirsaz AA. Obstetrical outcomes following amniocentesis performed after 24 weeks of gestation: A systematic review and meta-analysis. Prenat Diagn 2023; 43:1425-1432. [PMID: 37684739 DOI: 10.1002/pd.6435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/09/2023] [Accepted: 08/27/2023] [Indexed: 09/10/2023]
Abstract
To evaluate obstetrical outcomes for women having late amniocentesis (on or after 24 weeks). Electronic databases were searched from inception to January 1st, 2023. The obstetrical outcomes evaluated were gestational age at delivery, preterm birth (PTB) < 37 weeks, PTB within 1 week from amniocentesis, premature prelabor rupture of membranes (pPROM), chorionamnionitis, placental abruption, intrauterine fetal demise (IUFD) and termination of pregnancy (TOP). The incidence of PTB <37 weeks was 4.85% (95% CI 3.48-6.56), while the incidence of PTB within 1 week was 1.42% (95% CI 0.66-2.45). The rate of pPROM was 2.85% (95% CI 1.21-3.32). The incidence of placental abruption was 0.91% (95% CI 0.16-2.25), while the rate of IUFD was 3.66% (95% CI 0.00-14.04). The rate of women who underwent TOP was 6.37% (95%CI 1.05-15.72). When comparing amniocentesis performed before or after 32 weeks, the incidence of PTB within 1 week was 1.48% (95% CI 0.42-3.19) and 2.38% (95% CI 0.40-5.95). Amniocentesis performed late after 24 weeks of gestation is an acceptable option for patients needing prenatal diagnosis in later gestation.
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Affiliation(s)
- Ahmed A Nassr
- Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Kamran Hessami
- Department of Obstetrics & Gynecology, Baylor College of Medicine, Houston, Texas, USA
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elena D'Alberti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Mark I Evans
- Comprehensive Genetics, PLLC, New York, New York, USA
- Department of Obstetrics & Gynecology, Icahn School of Medicine at Mt. Sinai, New York, New York, USA
| | - Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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23
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Horgan R, Hessami K, Hage Diab Y, Scaglione M, D'Antonio F, Kanaan C, Erfani H, Abuhamad A, Shamshirsaz AA. Prophylactic ureteral stent placement for the prevention of genitourinary tract injury during hysterectomy for placenta accreta spectrum: systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:101120. [PMID: 37549736 DOI: 10.1016/j.ajogmf.2023.101120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 08/01/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE This study aimed to assess the effectiveness of prophylactic ureteral stent placement for the prevention of genitourinary tract injury at the time of cesarean hysterectomy for placenta accreta spectrum. The secondary objectives were to assess mean blood loss, operative time, number of packed red blood cells transfused, and rates of urinary tract infection among patients undergoing cesarean hysterectomy for placenta accreta spectrum with and without prophylactic ureteral stent placement. DATA SOURCES The search was performed using PubMed, Cochrane Library, and ClinicalTrials.gov from inception to February 2022 to December 2022. The protocol for this review was registered with the International Prospective Register of Systematic Reviews before data collection (registration number: CRD42022372817). STUDY ELIGIBILITY CRITERIA All studies that examined differences in the rate of genitourinary tract injury among women undergoing cesarean hysterectomy for prenatally suspected placenta accreta spectrum with and without placement of prophylactic ureteral stents were included. Genitourinary injury was defined as cystotomy, ureteral injury, and/or bladder fistula. Cases of both intentional and unintentional genitourinary injuries were included in the analysis. METHODS For all studies meeting the inclusion criteria, the following data were extracted: number of included patients, maternal demographic information, obstetrical history, type of invasive placentation, placement of stents (yes or no), type of stent placed, blood loss, operative time, genitourinary tract injury, and urinary tract infection. Pooled data analysis was completed using the Review Manager (version 5.3; Nordic Cochrane Centre, Copenhagen, Denmark; Cochrane Collaboration, 2014). The summary measures were reported as summary relative risk or as summary mean difference. The quality and risk of biases of the included studies were assessed according to the Newcastle-Ottawa Scale. RESULTS Overall, 9 studies, including 848 patients, fulfilled our inclusion criteria and were included in our analysis. Moreover, 523 patients (61.7%) had prophylactic ureteral stents placed, and 325 patients (38.3%) did not. Genitourinary injury occurred in 138 of 523 patients (26.4%) in the ureteral stent group vs 83 of 325 patients (25.5%) in the no ureteral stent group (relative risk, 0.94; 95% confidence interval, 0.74-1.20). The mean number of packed red blood cells transfused did not differ between the 2 groups. The pooled analysis demonstrated decreased blood loss among patients who received prophylactic ureteral stents, with a mean difference of 392 mL (95% confidence interval, 52.74-738.13). CONCLUSION Our systematic review and meta-analysis demonstrated no difference in the rates of genitourinary tract injury with the use of prophylactic ureteral stent placement among cases of prenatally suspected placenta accreta spectrum undergoing cesarean hysterectomy.
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Affiliation(s)
- Rebecca Horgan
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Horgan, Diab, Kanaan, and Abuhamad).
| | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Hessami and Erfani); Maternal-Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Drs Hessami and Shamshirsaz)
| | - Yara Hage Diab
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Horgan, Diab, Kanaan, and Abuhamad)
| | - Morgan Scaglione
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT (Dr Scaglione)
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Centre for High-Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy (Dr D'Antonio)
| | - Camille Kanaan
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Horgan, Diab, Kanaan, and Abuhamad)
| | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX (Drs Hessami and Erfani)
| | - Alfred Abuhamad
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA (Drs Horgan, Diab, Kanaan, and Abuhamad)
| | - Alireza A Shamshirsaz
- Maternal-Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Drs Hessami and Shamshirsaz)
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Goulding AN, Fox KA, Reed CC, Salmanian B, Shamshirsaz AA, Aagaard KM. A Retrospective Review of Social Deprivation Index and Maternal Outcomes with Placenta Accreta Spectrum from a Single Referral Center. Am J Perinatol 2023; 40:1383-1389. [PMID: 37364598 PMCID: PMC11107423 DOI: 10.1055/s-0043-1770162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Little is known about how community characteristics influence placenta accreta spectrum (PAS) outcomes. Our objective was to evaluate whether adverse maternal outcomes among pregnant people (gravidae) with PAS delivering at a single referral center differ by community-level measures of social deprivation. STUDY DESIGN We conducted a retrospective cohort study of singleton gravidae with histopathology confirmed PAS delivering from January 2011 to June 2021 at a referral center. Data abstraction collected relevant patient information, including resident zip code, which was linked to Social Deprivation Index (SDI) score (a measure of area-level social deprivation). SDI scores were divided into quartiles for analysis. Primary outcome was a composite of maternal adverse outcomes. Bivariate analyses and multivariable logistic regression were performed. RESULTS Among our cohort (n = 264), those in the lowest (least deprived) SDI quartile were older, had lower body mass index, and were more likely to identify as non-Hispanic white. Composite maternal adverse outcome occurred in 81 (30.7%), and did not differ significantly by SDI quartile. Intraoperative transfusion of ≥4 red blood cell units occurred more often among those living in deprived areas (31.2% in the highest [most deprived] vs. 22.7% in the lowest [least deprived] SDI quartile, p = 0.04). No other outcomes differed by SDI quartile. In multivariable logistic regression, a quartile increase in SDI was associated with 32% increased odds of transfusion of ≥4 red blood cell units (adjusted odds ratio: 1.32, 95% confidence interval: 1.01-1.75). CONCLUSION Within a cohort of gravidae with PAS delivered at a single referral center, we found that those living in more socially deprived communities were more likely to receive transfusion of ≥4 red blood cell units, but other maternal adverse outcomes did not differ. Our findings highlight the importance of considering how characteristics of the surrounding community can impact PAS outcomes and may assist with risk stratification and resource deployment. KEY POINTS · Little is known about how community characteristics influence PAS outcomes.. · In a referral center, transfusion was more common in gravidae living in socially deprived areas.. · Future research should consider how community characteristics can impact PAS outcomes..
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Affiliation(s)
- Alison N. Goulding
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Karin A. Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Christina C. Reed
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | | | - Kjersti M. Aagaard
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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Abstract
Vasa previa refers to unprotected fetal vessels running through the membranes over the cervix. Until recently, this condition was associated with an exceedingly high perinatal mortality rate attributable to fetal exsanguination when the membranes ruptured. However, ultrasonography has made it possible to diagnose the condition prenatally, allowing cesarean delivery before labor or rupture of the membranes. Several recent studies have indicated excellent outcomes with prenatally diagnosed vasa previa. However, outcomes continue to be dismal when vasa previa is undiagnosed before labor. Risk factors for vasa previa include second-trimester placenta previa and low-lying placentas, velamentous cord insertion, placentas with accessory lobes, in vitro fertilization, and multifetal gestations. Recognition of individuals who are at risk and screening them will greatly decrease the mortality rate from this condition. Because of the relative rarity of vasa previa, there are no randomized controlled trials to guide management. Therefore, recommendations on the diagnosis and management of vasa previa are based largely on cohort studies and expert opinion. This Clinical Expert Series review addresses the epidemiology, pathophysiology, natural history, diagnosis and management of vasa previa, as well as innovative treatments for the condition.
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Affiliation(s)
- Yinka Oyelese
- Department of Obstetrics & Gynecology, Beth Israel Deaconess Medical Center/Harvard Medical School and Maternal Fetal Care Center at Boston Children's Hospital/Harvard Medical School, Boston, Massachusetts
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26
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Nassr AA, Hessami K, Corroenne R, Sanz Cortes M, Donepudi R, Espinoza J, Yamamoto R, Stirnemann J, Ishii K, Belfort MA, Chmait RH, Shamshirsaz AA. Outcome of laser photocoagulation in monochorionic diamniotic twin pregnancy complicated by Type-II selective fetal growth restriction. Ultrasound Obstet Gynecol 2023; 62:369-373. [PMID: 36704956 DOI: 10.1002/uog.26165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/05/2022] [Accepted: 01/09/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES To evaluate the outcome of monochorionic diamniotic (MCDA) twins complicated by Type-II selective fetal growth restriction (sFGR) who underwent fetoscopic laser photocoagulation and to validate a previously proposed subclassification system for Type-II sFGR in a large multicenter cohort. METHODS This retrospective multicenter cohort study included all MCDA twins complicated by Type-II sFGR who underwent laser photocoagulation of placental anastomoses at four large tertiary fetal-care centers between 2006 and 2020. Cases were subclassified according to a recently proposed system based on Doppler evaluation of the ductus venosus (DV) and middle cerebral artery (MCA) into Type-IIA (normal DV flow and MCA peak systolic velocity (PSV) of the growth-restricted fetus) or Type-IIB (absent or reversed flow in the DV during atrial contraction and/or MCA-PSV ≥ 1.5 multiples of the median of the growth-restricted fetus). Demographic characteristics and pregnancy outcomes were compared between the groups. Data are presented as mean ± SD or n (%) as appropriate. P-values < 0.05 were considered statistically significant. RESULTS A total of 98 patients with MCDA twins met our inclusion criteria, with 56 subclassified as Type IIA and 42 as Type IIB. Demographic characteristics were similar between the groups; however, Type-IIB cases had a significantly earlier gestational age at diagnosis and at laser surgery, as well as larger intertwin estimated fetal weight discordance, which may be a reflection of disease severity. Postnatal survival of the growth-restricted fetus to 30 days of age was significantly lower in Type-IIB compared to Type-IIA cases (23.8% vs 46.4%; P = 0.034). CONCLUSIONS In MCDA twins complicated by Type-II sFGR and treated with laser photocoagulation of placental anastomoses, preoperative Doppler assessment of the DV and MCA helped identify a subset of patients at increased risk of demise of the growth-restricted fetus following intervention. This study provides valuable information for guiding surgical management and patient counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - K Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R Corroenne
- Department of Obstetrics and Gynecology, University Paris Descartes, Hopital Necker-Enfants Malades, Paris, France
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R Yamamoto
- Department of Maternal-Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - J Stirnemann
- Department of Obstetrics and Gynecology, University Paris Descartes, Hopital Necker-Enfants Malades, Paris, France
| | - K Ishii
- Department of Maternal-Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - R H Chmait
- Department of Obstetrics and Gynecology, Los Angeles Fetal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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27
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Hessami K, Espinoza J, Salmanian B, Castro E, Shamshirsaz AA, Shamshirsaz AA. Letter to editor - Placental basal plate myofibers and risk of hypertensive disorders of pregnancy. Pregnancy Hypertens 2023; 33:32-33. [PMID: 37423003 DOI: 10.1016/j.preghy.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/13/2023] [Accepted: 07/02/2023] [Indexed: 07/11/2023]
Affiliation(s)
- Kamran Hessami
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Jimmy Espinoza
- McGovern Medical School at the University of Texas Health Science Center, Houston, TX, United States
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
| | - Eumenia Castro
- Department of Pathology, Baylor College of Medicine, Houston, TX, United States
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States.
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, United States
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28
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Nassr AA, Hessami K, Zargarzadeh N, Krispin E, Mostafaei S, Habli MA, Papanna R, Emery SP, Shamshirsaz AA. Fetoscopic laser photocoagulation versus expectant management for stage I twin-to-twin transfusion syndrome: A systematic review and meta-analysis. Prenat Diagn 2023; 43:1229-1238. [PMID: 37539833 DOI: 10.1002/pd.6413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/24/2023] [Accepted: 07/21/2023] [Indexed: 08/05/2023]
Abstract
To investigate the outcomes of asymptomatic stage I twin-to-twin transfusion syndrome (stage I TTTS) among patients treated with fetoscopic laser photocoagulation (FLP) versus expectant management. Databases such as PubMed, Web of Science and Scopus were systematically searched from inception up to March 1st, 2022. The primary outcome was at least one fetal survival at birth and secondary outcomes included gestational age at delivery, preterm premature rupture of membranes < 32 weeks, preterm birth < 32 weeks, and single and dual fetal survival. Five studies were included in the meta-analysis. There was no significant difference in terms of at least one survival (odds ratio (OR) = 1.40, 95%CI= (0.26, 7.43), P = 0.70), single survival (OR = 0.87, 95%CI= (0.51, 1.48), P = 0.60) and dual survival (OR = 1.63, 95%CI= (0.74, 3.62), P = 0.23) among FLP and expectant groups. Gestational age at delivery (mean difference = 1.19, 95%CI= (-0.25, 2.63), P = 0.10), the risk of PTB<32 weeks (OR = 0.88, 95%CI= (0.50, 1.54), P = 0.65), and pPROM<32 weeks (OR = 1.80, 95% CI= (0.41, 7.98), P = 0.44) were also comparable between the groups. Routine FLP of the placental anastomoses before 26 weeks of gestation is unlikely to be beneficial among asymptomatic stable stage I TTTS patients without cervical shortening as the procedure does not offer a survival advantage compared with expectant management.
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Affiliation(s)
- Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Kamran Hessami
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical Center, Boston, Massachusetts, USA
| | - Nikan Zargarzadeh
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical Center, Boston, Massachusetts, USA
| | - Eyal Krispin
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical Center, Boston, Massachusetts, USA
| | - Shayan Mostafaei
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Mounira A Habli
- Department of Maternal-Fetal Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology and Reproductive Sciences, UT Health Science Center at Houston, Houston, Texas, USA
| | - Stephen P Emery
- Department of Obstetrics and Gynecology, UPMC Magee Women's Hospital, Pittsburgh, Pennsylvania, USA
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical Center, Boston, Massachusetts, USA
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29
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Shamshirsaz AA, Silver R. Passing through the Past to Future of Placenta Accreta Spectrum (PAS): Unraveling the Complexities and Hidden Facets of PAS. Am J Perinatol 2023; 40:960-961. [PMID: 37336212 DOI: 10.1055/s-0043-1769594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Affiliation(s)
- Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Robert Silver
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center (UUHSC), Salt Lake City, Utah
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30
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Einerson BD, Shamshirsaz AA, Stephenson ML, Khandelwal M, Holt R, Duzyj CM, Shrivastava VK. The Need for Presurgical Evaluation for Placenta Accreta Spectrum. Am J Perinatol 2023; 40:996-1001. [PMID: 37336217 DOI: 10.1055/s-0043-1761639] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
Staging or grading of placenta accreta spectrum has historically relied on histopathologic evaluation of placental and uterine specimens. This approach has limited utility, since it is retrospective in nature and does not allow for presurgical planning. Here, we argue for a paradigm shift to use of clinical and imaging characteristics to define the presurgical stage. We summarize past attempts at staging, and define a new data-driven approach to determining the stage prior to delivery. Use of this model may help hospitals direct patients to the most appropriate level of care for workup and management of placenta accreta spectrum. KEY POINTS: · Staging systems that rely on histopathologic grade (accreta, increta, percreta) are unhelpful in antenatal planning for placenta accreta spectrum.. · Past attempts at pre-delivery (pre-surgical) staging have failed to account for key factors that contribute to risk and morbidity.. · We developed a data-driven model that could be easily incorporated as a decision aid into clinical practice to help clinicians decide an individual patient's risk for placenta accreta spectrum..
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Affiliation(s)
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Boston, Massachusetts
- Brigham and Women's Hospital Harvard Medical School, Boston, Massachusetts
| | - Megan L Stephenson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Kaiser Permanente, Santa Clara, California
| | - Meena Khandelwal
- Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Roxane Holt
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | - Christina M Duzyj
- Massachusetts General Hospital, Department of Obstetrics and Gynecology, Boston, Massachusetts
- Harvard Medical School, Department of Obstetrics, Gynecology and Reproductive Biology, Boston, Massachusetts
| | - Vineet K Shrivastava
- MemorialCare Miller Children's & Women's Hospital, Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Long Beach, California
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31
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Erfani H, Hessami K, Salmanian B, Castro EC, Kopkin RH, Hecht J, Gogia S, Jackson J, Dong E, Fox K, Gessner M, Fang M, Shainker SA, Baroni M, Merport Modest A, A Shamshirsaz A, Nassr A, Espinoza J, Aagaard K, Shamshirsaz AA. Basal plate myofibers (BPMF) and the risk of placenta accreta spectrum in the subsequent pregnancy: A large single center cohort. Am J Perinatol 2023. [PMID: 37311540 DOI: 10.1055/a-2109-3977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE We aimed to evaluate whether there is a significant association between a placental pathology diagnosis basal plate myofibers (BPMF) in an index pregnancy with PAS in the subsequent pregnancy. STUDY DESIGN We conducted a retrospective nested cohort study of all cases with a histopathologic finding of BPMF between August 2012 and March 2020 at a single tertiary referral center. Data were collected for all subjects (cases and controls) with at least two consecutive pregnancies (the initial index pregnancy and at least one subsequent pregnancy) accompanied by a concomitant record of histopathologic study of the placenta at our center. The primary outcome was pathologically confirmed PAS in the subsequent pregnancy. Data are presented as percentage or median, interquartile range (IQR) accordingly. RESULTS A total of n=1,344 participants were included, of which n=119 (index cases) carried a contemporaneous histopathologic diagnosis of BPMF during the index pregnancy and n=1,225 did not (index controls). Among the index cases, patients with BPMF were older (31.0 [20, 42] vs 29.0 [15, 43], p <0.001), more likely to have undergone IVF for conception (10.9% vs 3.8%, p=0.001) and were of a more advanced gestational age at delivery (39.0 [25, 41] vs 38.0 [20, 42], p=0.006). In the subsequent pregnancy, the rate of PAS was significantly higher among the BPMF index cases (6.7% versus 1.1%, p<0.001). After adjusting for maternal age and IVF, a histopathologic diagnosis of BPMF in an index pregnancy was shown to be a significant risk factor for PAS in the subsequent gestation (HR 5.67 [95% CI: 2.28, 14.06], p <0.001). CONCLUSION Our findings support that a histopathologic diagnosis of BPMF is an independent risk factor for PAS in the subsequent pregnancy.
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Affiliation(s)
- Hadi Erfani
- Obstetrics & Gynecology, Baylor College of Medicine, Houston, United States
| | | | | | - Eumenia C Castro
- Pathology and Immunology, Baylor College of Medicine, Houston, United States
| | - Rachel H Kopkin
- Obstetrics & Gynecology, Baylor College of Medicine, Houston, United States
| | | | - Soumya Gogia
- Vanderbilt University Medical Center, Nashville, United States
| | | | - Elaine Dong
- Baylor College of Medicine, Houston, United States
| | - Karin Fox
- Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, United States
| | | | - Mary Fang
- Baylor College of Medicine, Houston, United States
| | - Scott A Shainker
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, United States
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, United States
| | - Mariana Baroni
- Center of Excellence in Health Equity, Training & Research, Baylor College of Medicine, Orlando, United States
| | - Anna Merport Modest
- Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, United States
| | - Amir A Shamshirsaz
- Obstetrics and Gynecology, Baylor College of Medicine, Houston, United States
| | - Ahmed Nassr
- Baylor College of Medicine, Houston, United States
| | | | | | - Alireza A Shamshirsaz
- Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, United States
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Salmanian B, Hessami K, Shamshirsaz AA. Reply to Letter to the Editors on the timing of delivery for placenta accreta spectrum: the Pan-American Society for the Placenta Accreta Spectrum experience. Am J Obstet Gynecol MFM 2023; 5:100852. [PMID: 36586586 DOI: 10.1016/j.ajogmf.2022.100852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 12/23/2022] [Indexed: 12/30/2022]
Affiliation(s)
- Bahram Salmanian
- Department of Obstetrics and Gynecology, University of Colorado, Denver, CO
| | - Kamran Hessami
- Maternal Fetal Care Center, Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave., Boston, MA
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Harvard Medical School, Boston Children's Hospital, 300 Longwood Ave., Boston, MA.
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Masse O, Kraft E, Ahmad E, Rollins CK, Velasco-Annis C, Yang E, Warfield SK, Shamshirsaz AA, Gholipour A, Feldman HA, Estroff J, Grant PE, Vasung L. Abnormal prenatal brain development in Chiari II malformation. Front Neuroanat 2023; 17:1116948. [PMID: 37139180 PMCID: PMC10149737 DOI: 10.3389/fnana.2023.1116948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
Introduction The Chiari II is a relatively common birth defect that is associated with open spinal abnormalities and is characterized by caudal migration of the posterior fossa contents through the foramen magnum. The pathophysiology of Chiari II is not entirely known, and the neurobiological substrate beyond posterior fossa findings remains unexplored. We aimed to identify brain regions altered in Chiari II fetuses between 17 and 26 GW. Methods We used in vivo structural T2-weighted MRIs of 31 fetuses (6 controls and 25 cases with Chiari II). Results The results of our study indicated altered development of diencephalon and proliferative zones (ventricular and subventricular zones) in fetuses with a Chiari II malformation compared to controls. Specifically, fetuses with Chiari II showed significantly smaller volumes of the diencephalon and significantly larger volumes of lateral ventricles and proliferative zones. Discussion We conclude that regional brain development should be taken into consideration when evaluating prenatal brain development in fetuses with Chiari II.
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Affiliation(s)
- Olivia Masse
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Emily Kraft
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Esha Ahmad
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Caitlin K. Rollins
- Department of Neurology Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Clemente Velasco-Annis
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Edward Yang
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Simon Keith Warfield
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | | | - Ali Gholipour
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Henry A. Feldman
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Judy Estroff
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
- Maternal Fetal Care Center, Boston Children’s Hospital, Boston, MA, United States
| | - Patricia Ellen Grant
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Lana Vasung
- Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
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Espinoza J, King A, Shamshirsaz AA, Nassr AA, Donepudi R, Sanz Cortes M, Meholin-Ray AR, Krispin E, Johnson R, Mendez Martinez Y, Keswani SG, Lee TC, Joyeux L, Espinoza AF, Olutoye Ii O, Garcia-Prats JA, Fernandes CJ, Coleman RD, Lohmann P, Rhee CJ, Davies J, Belfort MA. Characterization of suboptimal responses to fetoscopic endoluminal tracheal occlusion in congenital diaphragmatic hernia. Fetal Diagn Ther 2023:000530549. [PMID: 37040717 DOI: 10.1159/000530549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/24/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION To characterize the changes in fetal lung volume following endoluminal tracheal occlusion (FETO) that are associated with infant survival and need for extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH). METHODS Fetuses with CDH who underwent FETO at a single institution were included. CDH cases were reclassified by MRI metrics, [observed-to-expected total lung volume (O/E TLV) and percent liver herniation]. The percent changes of MRI metrics after FETO were calculated. ROC-derived cutoffs of these changes were derived to predict infant survival to discharge. Regression analyses were done to determine the association between these cutoffs with infant survival and ECMO need, adjusted for site of CDH, gestational age at delivery, fetal sex, and CDH severity. RESULTS Thirty CDH cases were included. ROC analysis demonstrated that post-FETO increases in O/E TLV had an area under the curve of 0.74 (p=0.035) for the prediction of survival to hospital discharge; a cutoff of less than 10% was selected. Fetuses with a <10% post-FETO increase in O/E TLV had lower survival to hospital discharge [44.8% vs. 91.7%; p=0.018] and higher ECMO use [61.1% vs. 16.7%; p=0.026] compared to those with an O/E TLV increase ≥10%. Similar results were observed when the analyses were restricted to left-sided CDH cases. A post-FETO <10% increase in O/E TLV was independently associated with lower survival at hospital discharge (aOR: 0.073, 95% CI: 0.008 - 0.689; p=0.022) and at 12 months of age (aOR: 0.091, 95% CI: 0.01 - 0.825; p=0.036) as well as with higher ECMO use (aOR: 7.88, 95% CI: 1.31 - 47.04; p=0.024). DISCUSSION/CONCLUSION Fetuses with less than 10% increase in in O/E TLV following the FETO procedure are at increased risk for requiring ECMO and for death in the postnatal period when adjusted for gestational age at delivery, CDH severity, and other confounders.
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Krispin E, Mustafa HJ, Espinoza J, Nassr AA, Sanz Cortes M, Donepudi R, Harman C, Mostafaei S, Turan O, Belfort MA, Shamshirsaz AA. Prediction of dual survival following fetoscopic laser photocoagulation for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 2023; 61:511-517. [PMID: 36191157 DOI: 10.1002/uog.26089] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/02/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To develop a model based on factors available at the time of diagnosis of twin-twin transfusion syndrome (TTTS) for predicting the probability of dual twin survival following fetoscopic laser photocoagulation (FLP) using a machine-learning algorithm. METHODS This was a retrospective study of data collected at two university-affiliated tertiary fetal centers between 2012 and 2021. The cohort included monochorionic diamniotic twin pregnancies complicated by TTTS that underwent FLP. Data were stratified based on survival 30 days after delivery, and cases with dual survival were compared to those without dual survival. A random forest machine-learning algorithm was used to construct a prediction model, and the relative importance value was calculated for each parameter that presented a statistically significant difference between the two study groups and was included in the model. The holdout method was applied to check overfitting of the random forest algorithm. A prediction model for dual twin survival 30 days after delivery was presented based on the test set. RESULTS The study included 537 women with monochorionic diamniotic twin pregnancy, of whom 346 (64.4%) had dual twin survival at 30 days after delivery and were compared with 191 (35.6%) cases that had one or no survivors. Univariate analysis demonstrated no differences in demographic parameters between the groups. At the time of diagnosis, the dual-survival group had lower rates of estimated fetal weight (EFW) < 10th centile for gestational age in the donor twin (56.4% vs 69.4%; P = 0.004), intertwin EFW discordance > 25% (40.8% vs 56.5%; P = 0.001) and anterior placenta (40.5% vs 50.0%; P = 0.034). Comparison of Doppler findings between the two groups demonstrated significant differences in the donor twin, with a lower rate of pulsatility index (PI) > 95th centile in the umbilical artery and ductus venosus and a lower rate of PI < 5th centile in the fetal middle cerebral artery in the dual-survival group. Relative importance values for each of these six parameters were calculated, allowing the construction of a prediction model with an area under the receiver-operating-characteristics curve of 0.916 (95% CI, 0.887-0.946). CONCLUSIONS We developed a predictive model for dual survival in monochorionic twin pregnancies following FLP for TTTS, which incorporates six variables obtained at the time of diagnosis of TTTS, including donor EFW < 10th centile, intertwin EFW discordance > 25%, anterior placenta and abnormal PI in the umbilical artery, ductus venosus and middle cerebral artery of the donor twin. This clinically applicable tool may improve treatment planning and patient counseling. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Krispin
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - H J Mustafa
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - C Harman
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - S Mostafaei
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - O Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
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Hessami K, Evans MI, Nassr AA, Espinoza J, Donepudi RV, Sanz Cortes M, Krispin E, Mostafaei S, Belfort MA, Shamshirsaz AA. Fetal Reduction of Triplet Pregnancies to Twins vs Singletons: A Meta-analysis of Survival and Pregnancy Outcome. Obstet Gynecol Surv 2023. [DOI: 10.1097/ogx.0000000000001137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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O'Brien KL, Shainker SA, Callum J, Chmait RH, Ladhani NNN, Lin Y, Roseff SD, Shamshirsaz AA, Uhl L, Haspel RL. Primum, non nocere: Whole blood, prehospital transfusion and anti-D hemolytic disease of the fetus and newborn. Transfusion 2023; 63:249-256. [PMID: 36449373 DOI: 10.1111/trf.17209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/13/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Kerry L O'Brien
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Scott A Shainker
- Division of Maternal Fetal Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Los Angeles Fetal Surgery, University of Southern California, Los Angeles, California, USA
| | - Noor Niyar N Ladhani
- Division of Maternal Fetal Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Susan D Roseff
- Department of Pathology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Alireza A Shamshirsaz
- Division of Maternal Fetal Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lynne Uhl
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Richard L Haspel
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Shamshirsaz AA, Chmait RH, Stirnemann J, Habli MA, Johnson A, Hessami K, Mostafaei S, Nassr AA, Donepudi RV, Sanz Cortes M, Espinoza J, Krispin E, Belfort MA. Solomon versus selective fetoscopic laser photocoagulation for twin-twin transfusion syndrome: A systematic review and meta-analysis. Prenat Diagn 2023; 43:72-83. [PMID: 36184777 DOI: 10.1002/pd.6246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/07/2022] [Accepted: 09/28/2022] [Indexed: 01/27/2023]
Abstract
This meta-analysis aims to compare the perinatal outcome of twin-twin transfusion syndrome (TTTS) pregnancies undergoing selective versus vascular equator (Solomon) fetoscopic laser photocoagulation (FLP). We performed a systematic search in PubMed and Web of Science from inception up to 25 July 2021. Studies comparing the Solomon and selective techniques of FLP for treatment of TTTS pregnancies were eligible. Random-effects or fixed-effect models were used to pool standardized mean differences (SMD) and log odds ratio. Seven studies with a total of 1664 TTTS pregnancies (n = 671 undergoing Solomon and n = 993 selective techniques) were included. As compared to the selective FLP, Solomon was associated with a lower risk of recurrent TTTS compared to the selective technique (Log odds ratio [OR]: -1.167; 95% credible interval [CrI]: -2.01, -0.33; p = 0.021; I2 : 67%). In addition, Solomon was significantly associated with a higher risk of placental abruption than the selective technique (Log [OR]: 1.44; 95% CrI: 0.45, 2.47; p = 0.012; I2 : 0.0%). Furthermore, a trend for the higher risk of preterm premature rupture of membranes was observed among those undergoing Solomon (Log [OR]: 0.581; 95% CrI: -0.43, 1.49; p = 0.131; I2 : 17%). As compared to selective FLP, the Solomon technique for TTTS pregnancies is associated with a significantly lower recurrence of TTTS; however, it significantly increases the risk of placental abruption.
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Affiliation(s)
- Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Julien Stirnemann
- Department of Obstetrics and Maternal-Fetal Medicine, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - Mounira A Habli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, Ohio, USA
| | - Anthony Johnson
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Kamran Hessami
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shayan Mostafaei
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinksa Institutet, Stockholm, Sweden
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Roopali V Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Eyal Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
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Sanz Cortes M, Corroenne R, Johnson B, Sangi-Haghpeykar H, Mandy G, VanLoh S, Nassr A, Espinoza J, Donepudi R, Shamshirsaz AA, Whitehead WE, Belfort M. Effect of preoperative low-normal cervical length on perinatal outcome after laparotomy-assisted fetoscopic spina bifida repair. Ultrasound Obstet Gynecol 2023; 61:74-80. [PMID: 36099454 DOI: 10.1002/uog.26070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/26/2022] [Accepted: 09/01/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To determine if preoperative cervical length in the low-normal range increases the risk of adverse perinatal outcome in patients undergoing fetoscopic spina bifida repair. METHODS This was a retrospective cohort study of patients who underwent fetal spina bifida repair between September 2014 and May 2022 at a single center. Cervical length was measured on transvaginal ultrasound during the week before surgery. Eligibility for laparotomy-assisted fetoscopic spina bifida repair was as per the criteria of the Management of Myelomeningocele Study, although maternal body mass index (BMI) up to 40 kg/m2 was allowed. Laparotomy-assisted fetoscopic spina bifida repair was performed, with carbon dioxide insufflation via two 12-French ports in the exteriorized uterus. All patients received the same peri- and postoperative tocolysis regimen, including magnesium sulfate, nifedipine and indomethacin. Postoperative follow-up ultrasound scans were performed either weekly (< 32 weeks' gestation) or twice a week (≥ 32 weeks). Perinatal outcome was compared between patients with a preoperative cervical length of 25-30 mm vs those with a cervical length > 30 mm. Logistic regression analyses and generalized linear mixed regression analyses were used to predict delivery at less than 30, 34 and 37 weeks' gestation. RESULTS The study included 99 patients with a preoperative cervical length > 30 mm and 12 patients with a cervix 25-30 mm in length. One further case which underwent spina bifida repair was excluded because cervical length was measured > 1 week before surgery. No differences in maternal demographics, gestational age (GA) at surgery, duration of surgery or duration of carbon dioxide uterine insufflation were observed between groups. Cases with low-normal cervical length had an earlier GA at delivery (median (range), 35.2 (25.1-39.7) weeks vs 38.2 (26.0-40.9) weeks; P = 0.01), higher rates of delivery at < 34 weeks (41.7% vs 10.2%; P = 0.01) and < 30 weeks (25.0% vs 1.0%; P < 0.01) and a higher rate of preterm prelabor rupture of membranes (PPROM) (58.3% vs 26.3%; P = 0.04) at an earlier GA (mean ± SD, 29.3 ± 4.0 weeks vs 33.0 ± 2.4 weeks; P = 0.05) compared to those with a normal cervical length. Neonates of cases with low-normal cervical length had a longer stay in the neonatal intensive care unit (20 (7-162) days vs 9 (3-253) days; P = 0.02) and higher rates of respiratory distress syndrome (50.0% vs 14.4%; P < 0.01), sepsis (16.7% vs 1.0%; P = 0.03), necrotizing enterocolitis (16.7% vs 0%; P = 0.01) and retinopathy (33.3% vs 1.0%; P < 0.01). There was an association between preoperative cervical length and risk of delivery at < 30 weeks which was significant only for patients with a maternal BMI < 25 kg/m2 (odds ratio, 0.37 (95% CI, 0.07-0.81); P = 0.02). CONCLUSIONS Low-normal cervical length (25-30 mm) as measured before in-utero laparotomy-assisted fetoscopic spina bifida repair may increase the risk of adverse perinatal outcomes, including PPROM and preterm birth, leading to higher rates of neonatal complications. These data warrant further research and are of critical relevance for clinical teams considering the eligibility of patients for in-utero spina bifida repair. Based on this evidence, patients with a low-normal cervical length should be aware of their increased risk for adverse perinatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M Sanz Cortes
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - R Corroenne
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics, University Hospital of Angers, Angers, France
| | - B Johnson
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - H Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - G Mandy
- Department of Pediatrics, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - S VanLoh
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - A Nassr
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - W E Whitehead
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
| | - M Belfort
- Department of Obstetrics and Gynecology, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
- Department of Neurosurgery, Texas Children's Hospital & Baylor College of Medicine, Houston, TX, USA
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Seaman RD, Salmanian B, Shamshirsaz AA, Espinoza J, Sanz-Cortes M, Donepudi R, Johnson R, Krispin E, Sun R, Belfort MA, Nassr AA. Pregnancy outcomes following early fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome at 16 weeks' gestation. Am J Obstet Gynecol MFM 2023; 5:100771. [PMID: 36244623 DOI: 10.1016/j.ajogmf.2022.100771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/05/2022] [Accepted: 10/08/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Ample evidence supports fetoscopic laser photocoagulation of placental anastomoses as a first-line treatment for twin-to-twin transfusion syndrome, but little is known about the outcomes following procedures conducted in the early second trimester. OBJECTIVE This study aimed to evaluate perinatal outcomes following early fetoscopic laser placental photocoagulation performed for twin-to-twin transfusion syndrome at 16 weeks' gestation. STUDY DESIGN This retrospective review included monochorionic twin pregnancies complicated by twin-to-twin transfusion syndrome necessitating fetoscopic laser photocoagulation at a single tertiary center from 2012 to 2021. The 2 cohorts were defined as cases undergoing laser surgery at 16+0/7 to 16+6/7 weeks' gestation (early laser group) and those undergoing laser surgery ≥17 weeks' gestation (standard laser group), respectively. Primary outcomes included rates of immediate chorioamniotic membrane separation, preterm premature rupture of membranes, and clinical chorioamnionitis. Secondary outcomes included twin survival rates at birth and 30 days of life. Outcomes were compared between cohorts with a P value of <.05 denoting statistical significance. RESULTS A total of 343 cases were included (35 early laser participants and 308 standard laser participants). The early laser group typically had higher Quintero staging at the time of the procedure. Following intervention, the early laser group had significantly higher rates of chorioamniotic separation than the standard laser group (34.3% vs 1.3% of cases; P<.001) and higher rates of preterm prelabor rupture of membranes (45.7% vs 25.0%; P=.009) and chorioamnionitis (11.4% vs 1.3%; P=.005). Even after adjustment for higher Quintero staging in the early laser group, twin survival was not significantly different between study groups. CONCLUSION Early laser surgery for twin-to-twin transfusion syndrome performed at 16 weeks' gestation is associated with significantly higher rates of chorioamniotic separation, preterm rupture of membranes, and chorioamnionitis. However, twin survival does not seem to be negatively impacted following early laser surgery.
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Affiliation(s)
- Rachel D Seaman
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr)
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr)
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr)
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr)
| | - Magdalena Sanz-Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr)
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr)
| | - Rebecca Johnson
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr)
| | - Eyal Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr)
| | - Raphael Sun
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr); Michael DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (Drs Sun and Belfort)
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr); Michael DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX (Drs Sun and Belfort)
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, Houston, TX (Drs Seaman, Salmanian, Shamshirsaz, Espinoza, Sanz-Cortes, and Donepudi, Ms Johnson, and Drs Krispin, Sun, Belfort, and Nassr).
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Salmanian B, Hessami K, Fox KA, Erfani H, Castro E, Hecht J, Soumya gogia, Jackson JN, Dong E, Gessner M, Fang M, Baroni MD, Alipour S, Shainker SA, Modest AM, Shamshirsaz AA, Shamshirsaz AA. Risk factors and clinical significance of placental basal plate myometrial fiber: a single center experience. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Barrozo ER, Burgess AP, Carmona A, Zietsman MS, Seferovic MD, Shamshirsaz AA, Belfort MA, Aagaard KM. Distinct neuronal subtypes in fetal CSF characterized by single-cell transcriptomics. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Salmanian B, Clark SL, Hui SKR, Detlefs S, Aalipour S, Meshinchi Asl N, Shamshirsaz AA. Massive Transfusion Protocols in Obstetric Hemorrhage: Theory versus Reality. Am J Perinatol 2023; 40:95-98. [PMID: 33990124 DOI: 10.1055/s-0041-1728833] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Massive transfusion protocols are widely implemented in obstetrical practice in case of severe hemorrhage; however, different recommendations exist regarding the appropriate ratios of blood product components to be transfused. We report our extensive experience with massive component transfusion in a referral center in which the standard massive transfusion protocol is modified by ongoing clinical and laboratory evaluation. STUDY DESIGN A retrospective chart review of all patients who had massive transfusion protocol activation in a level 4 referral center for obstetrical practice was performed from January 2014 to January 2020. Data collected included the etiology of obstetrical hemorrhage, number of blood products of each type transfused, crystalloid infusion, and several indices of maternal morbidity and mortality. Data are presented with descriptive statistics. RESULTS A total of 62 patients had massive transfusion protocol activation, of which 97% received blood products. Uterine atony was found to be the most common etiology for massive hemorrhage (34%), followed by placenta accreta spectrum (32%). The mean estimated blood loss was 1,945 mL. A mean of 6.5 units of packed red blood cells, 14.8 units of fresh frozen plasma and cryoprecipitate, and 8.3 units of platelets were transfused per patient. No maternal deaths were seen. CONCLUSION The ratios of transfused packed red blood cell to fresh frozen plasma/cryoprecipitate and of packed red blood cell to platelet units varied significantly from the fixed initial infusion ratio called for by our massive transfusion protocol resulting in universally favorable maternal outcomes. When rapid laboratory evaluation of hematologic and clotting parameters is available, careful use of this information may facilitate safe modification of an initial fixed transfusion ratio based on etiology of the hemorrhage and individual patient response. KEY POINTS · Massive transfusion protocols in obstetrics follow fixed ratios of blood products.. · Actual usage of blood components is different than the standardized protocols.. · We recommend to modify the initial fixed transfusion ratio according to clinical response..
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Affiliation(s)
- Bahram Salmanian
- Depatment of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Steven L Clark
- Depatment of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Shiu-Ki R Hui
- Depatment of Pathology and Immunology, Baylor College of Medicine, Houston, Texas
| | - Sarah Detlefs
- Depatment of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Soroush Aalipour
- Depatment of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
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Krispin E, Shamshirsaz AA, Mustafa HJ, Sun RC, Espinoza J, Nassr AA, Sanz-Cortes M, Ugoji CH, Harman C, Turan O, Belfort MA, Donepudi R. Impact of middle cerebral artery pulsatility index on donor survival in twin-twin transfusion syndrome. Prenat Diagn 2023; 43:102-108. [PMID: 36539914 DOI: 10.1002/pd.6288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess outcomes in twin-twin transfusion syndrome (TTTS) according to middle cerebral artery pulsatility index (MCA-PI) prior to fetoscopic laser photocoagulation (FLPC) surgery. METHODS A retrospective cohort analysis of monochorionic-twin pregnancies complicated by TTTS who underwent FLPC at two fetal centers (2012-2021). The cohort was stratified according to abnormal MCA-PI of the donor twin, defined as below fifth centile for gestational age. RESULTS Abnormal MCA-PI of the donor twin was detected in 46 (17.7%) cases compared to 213 (83.3%) controls with no such abnormality. The abnormal PI group presented with higher rates of sFGR (56.5% vs. 36.8% in controls, p = 0.014) and lower donor survival rates within 48 h after FLPC (73.9 vs. 86.8%, p = 0.029). Donor twin survival rates at the time of delivery and 30 days after birth were lower in the abnormal MCA-PI. Multivariate logistic regression analysis controlling for sFGR and MCA-PI <fifth centile demonstrated the latter to be independently associated with lower survival rates at the time of delivery and 30 days after birth [OR = 0.497 95%CI (0.250-0.986) p = 0.045, and OR = 0.499 95%CI (0.252-0.986), p = 0.046, respectively]. Recipient's survival rates did not differ between the groups. CONCLUSIONS Donor survival at the time of delivery and 30 days after birth was lower in TTTS cases with MCA-PI<fifth centile for gestational age prior to laser surgery. This parameter may be considered when evaluating prognosis for TTTS.
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Affiliation(s)
- Eyal Krispin
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Hiba J Mustafa
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Raphael C Sun
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Magdalena Sanz-Cortes
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Chilaka H Ugoji
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Christopher Harman
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ozhan Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Maternal-Fetal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Division of Fetal Therapy and Surgery, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
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Aalipour S, Salmanian B, Fox KA, Clark SL, Shamshirsaz AA, Asl NM, Castro EC, Erfani H, Spinoza J, Nassr A, Belfort MA, Shamshirsaz AA. Placenta Accreta Spectrum: Correlation between FIGO Clinical Classification and Histopathologic Findings. Am J Perinatol 2023; 40:149-154. [PMID: 33934319 DOI: 10.1055/s-0041-1728834] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Placenta accreta spectrum (PAS) covers a wide spectrum of placental adherence/invasion with varied clinical significance. Histopathologic examination is considered the confirmatory gold standard, but is only obtained sometime after definitive treatment. The International Federation of Gynecology and Obstetrics (FIGO) has published a new clinical classification that can be assigned at delivery, and we aimed to investigate the association between this new FIGO classification and histopathology and also to assess its correlation with maternal outcomes. STUDY DESIGN We studied a retrospective cohort of 185 patients with histopathologically proven PAS managed at our referral center between September 2012 and January 2019. Two experienced surgeons retrospectively reviewed charts and assigned the FIGO grading based on findings reported at delivery. A third experienced reviewer adjudicated to determine the classification used for final analysis. Categorical outcomes were compared with the use of chi-squared and the Fisher exact test, as appropriate. A multivariate model was designed to adjust outcomes in different FIGO groups for the involvement of a formal multidisciplinary management team. RESULTS Among 185 patients, there were 41 (22%) placenta accreta, 44 (24%) placenta increta, and 100 (54%) placenta percreta on histopathology. The inter-rater reliability was found to be substantial with Kappa = 0.661 (p < 0.001), and 95% confidence interval (CI): 0.449-0.872. There was a significant association between all histopathology groupings and the FIGO clinical classification (p < 0.001). However, we found no association between FIGO classifications and maternal complications. CONCLUSION The new FIGO clinical classification is strongly associated with histopathologic findings. A better understanding of the depth and extent of invasion as afforded by the clinical classification system will help standardize reporting and future research. KEY POINTS · PAS includes a wide spectrum of placental invasion with varied clinical significance.. · Histopathological examination is considered the confirmatory gold standard.. · The new FIGO clinical classification is strongly associated with histopathologic findings..
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Affiliation(s)
- Soroush Aalipour
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Bahram Salmanian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Karin A Fox
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Steven Leigh Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Nazlisadat Meshinchi Asl
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Eumenia C Castro
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Jimmy Spinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Ahmed Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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Detlefs SE, Carusi DA, Modest AM, Einerson BD, Lyell D, Grace MR, Shrivastava VK, Khandelwal M, Salmanian B, Shainker SA, Fox KA, Subramaniam A, Crosland A, Duryea EL, Shamshirsaz AA, Shrestha K, Belfort MA, Silver RM, Clark SL, Shamshirsaz AA. The Association between Placenta Accreta Spectrum Severity and Incidence of Small for Gestational Age Neonates. Am J Perinatol 2023; 40:9-14. [PMID: 36096136 DOI: 10.1055/s-0042-1757261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The aim of the study is to evaluate whether pathologic severity of placenta accreta spectrum (PAS) is correlated with the incidence of small for gestational age (SGA) and neonatal birthweight. STUDY DESIGN This was a multicenter cohort study of viable, non-anomalous, singleton gestations delivered with histology-proven PAS. Data including maternal history, neonatal birthweight, and placental pathology were collected and deidentified. Pathology was defined as accreta, increta, or percreta. The primary outcome was rate of SGA defined by birth weight less than the 10th percentile. The secondary outcomes included incidence of large for gestational age (LGA) babies as defined by birth weight greater than the 90th percentile as well as incidence of SGA and LGA in preterm and term gestations. Statistical analysis was performed using Chi-square, Kruskal-Wallis, and log-binomial regression. Increta and percreta patients were each compared with accreta patients. RESULTS Among the cohort of 1,008 women from seven United States centers, 865 subjects were included in the analysis. The relative risk (RR) of SGA for increta and percreta did not differ from accreta after adjusting for confounders (adjusted RR = 0.63, 95% confidence interval [CI]: 0.36-1.10 for increta and aRR = 0.72, 95% CI: 0.45-1.16 for percreta). The results were stratified by placenta previa status, which did not affect results. There was no difference in incidence of LGA (p = 1.0) by PAS pathologic severity. The incidence of SGA for all PAS patients was 9.2% for those delivered preterm and 18.7% for those delivered at term (p = 0.004). The incidence of LGA for all PAS patients was 12.6% for those delivered preterm and 13.2% for those delivered at term (p = 0.8203). CONCLUSION There was no difference in incidence of SGA or LGA when comparing accreta to increta or percreta patients regardless of previa status. Although we cannot suggest causation, our results suggest that PAS, regardless of pathologic severity, is not associated with pathologic fetal growth in the preterm period. KEY POINTS · PAS severity is not associated with SGA in the preterm period.. · PAS severity is not associated with LGA.. · Placenta previa does not affect the incidence of SGA in women with PAS..
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Affiliation(s)
- Sarah E Detlefs
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anna M Modest
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Brett D Einerson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Deirdre Lyell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Matthew R Grace
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Vineet K Shrivastava
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Miller Children's and Women's Hospital, Long Beach, California
| | - Meena Khandelwal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cooper University Hospital, Princeton, New Jersey
| | - Bahram Salmanian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Akila Subramaniam
- Department of Obstetrics and Gynecology, University of Alabama, Birmingham, Alabama
| | - Adam Crosland
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Miller Children's and Women's Hospital, Long Beach, California
| | - Elaine L Duryea
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Amir A Shamshirsaz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Kevin Shrestha
- Department of Obstetrics and Gynecology, University of Alabama, Birmingham, Alabama
| | - Michael A Belfort
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Robert M Silver
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Steven L Clark
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Alireza A Shamshirsaz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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Mustafa HJ, Javinani A, Krispin E, Tadbiri H, Espinoza J, Shamshirsaz AA, Nassr AA, Donepudi R, Belfort MA, Cortes MS, Harman C, Turan OM. Fetoscopic laser surgery for twin-to-twin transfusion syndrome in DCTA triplets compared to MCDA twins: collaborative study and literature review. J Matern Fetal Neonatal Med 2022; 35:10348-10354. [PMID: 36529927 DOI: 10.1080/14767058.2022.2128649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To compare the outcomes of dichorionic triamniotic (DCTA) triplets with that of monochorionic diamniotic (MCDA) twin gestations undergoing fetoscopic laser surgery (FLS) for treatment of twin-to-twin transfusion syndrome (TTTS). METHODS Retrospective cohort study of prospectively collected data of consecutive DCTA triplet and MCDA twin pregnancies with TTTS that underwent FLS at two fetal treatment centers between 2012 and 2020. Preoperative, operative and, postoperative variables were collected. Perinatal outcomes were investigated. Primary outcome was survival to birth and to neonatal period. Secondary outcomes were gestational age (GA) at birth and procedure-to-delivery interval. Literature review was conducted in which PubMed, Web of Science, and Scopus were searched from inception to September, 2020. RESULTS Twenty four sets of DCTA triplets were compared to MCDA twins during the study period. There were no significant differences in survival (no survivor, single, or double survivors) to birth and to the neonatal period of the MC twin pairs of the DCTA triplets vs MCDA twins. Median GA at delivery was approximately three weeks earlier in DCTA triplets compared to MCDA twins (28.4 weeks vs 31.4 weeks, p = .035, respectively). Rates of preterm birth (PTB) less than 32 and less than 28 weeks were significantly higher in DCTA triplets compared to twins (<32 weeks: 70.8% vs 51.1%, p = .037, respectively, and <28 weeks: 37.5% vs 20.8%, p = .033, respectively). CONCLUSION Perinatal survival including fetal and neonatal are comparable between DCTA triplets and MCDA twins. However, this might have resulted from the small sample size of the DCTA triplets. GA at delivery is earlier in triplets, which could be due to the nature of triplet gestation rather than to the laser procedure itself.
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Affiliation(s)
- Hiba J Mustafa
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ali Javinani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Eyal Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Hooman Tadbiri
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, USA
| | - Christopher Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Hessami K, Hutchinson-Colas JA, Chervenak FA, Shamshirsaz AA, Zargarzadeh N, Norooznezhad AH, Grünebaum A, Bachmann GA. Prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States: a systematic review and meta-analysis. J Perinat Med 2022:jpm-2022-0412. [PMID: 36394545 DOI: 10.1515/jpm-2022-0412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/24/2022] [Indexed: 11/18/2022]
Abstract
This systematic review and meta-analysis assessed the risk of inadequate prenatal care and pregnancy outcome among incarcerated pregnant individuals in the United States. PubMed/MedLine, Embase, ClinicalTrials.gov and Web of Science were searched from inception up to March 30th, 2022. Studies were included if they reported the risk of inadequate prenatal care and/or pregnancy outcomes among incarcerated pregnant individuals in the United States jails or prisons. Adequacy of prenatal care was quantified by Kessner index. The random-effects model was used to pool the mean differences or odds ratios (OR) and the corresponding 95% confidence intervals (CIs) using RevMan software. Nine studies were included in the final review. A total of 11,534 pregnant individuals, of whom 2,544 were incarcerated while pregnant, and 8,990 who were matched non-incarcerated pregnant individuals serving as control group, were utilized. Compared to non-incarcerated pregnancies, incarcerated pregnant individuals were at higher risk of inadequate prenatal care (OR 2.99 [95% CI: 1.60, 5.61], p<0.001) and were more likely to have newborns with low birthweight (OR 1.66 [95% CI: 1.19, 2.32], p=0.003). There was no significant difference between incarcerated and matched control pregnancies in the rates of preterm birth and stillbirth. The findings of the current systematic review and meta-analysis suggest that incarcerated pregnant individuals have an increased risk of inadequate prenatal care. Considering the limited number of current studies, further research is indicated to both assess whether the risk of inadequate prenatal care has negative impact on prenatal outcomes for this population and to determine the steps that can be taken to enhance prenatal care for all pregnant individuals incarcerated in the United States prisons.
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Affiliation(s)
- Kamran Hessami
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Juana A Hutchinson-Colas
- Department of Obstetrics and Gynecology, Women's Health Institute, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Frank A Chervenak
- Departments of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nikan Zargarzadeh
- Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Amos Grünebaum
- Departments of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - Gloria A Bachmann
- Department of Obstetrics and Gynecology, Women's Health Institute, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Hessami K, Aagaard KM, Castro EC, Arian SE, Nassr AA, Barrozo ER, Seferovic MD, Shamshirsaz AA. Placental Vascular and Inflammatory Findings from Pregnancies Diagnosed with Coronavirus Disease 2019: A Systematic Review and Meta-analysis. Am J Perinatol 2022; 39:1643-1653. [PMID: 35240710 DOI: 10.1055/a-1787-7933] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We aimed to perform a meta-analysis of the literature concerning histopathologic findings in the placentas of women with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection during pregnancy. Searches for articles in English included PubMed, Web of Science, Google Scholar, and reference lists (up to April 2021). Studies presenting data on placental histopathology according to the Amsterdam Consensus Group criteria in SARS-CoV-2 positive and negative pregnancies were identified. Lesions were categorized into: maternal and fetal vascular malperfusion (MVM and FVM, respectively), acute placental inflammation with maternal and fetal inflammatory response (MIR and FIR, respectively), chronic inflammatory lesions (CILs), and increased perivillous fibrin deposition (PVFD). A total of 15 studies reporting on 19,025 placentas, n = 699 of which were derived from women who were identified as being infected with SARS-CoV-2 and 18,326 as SARS-CoV-2-negative controls, were eligible for analysis. No significant difference in incidence of MVM (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 0.73-1.90), FVM (OR: 1.23, 95% CI: 0.63-2.42), MIR (OR: 0.66, 95% CI: 0.29-1.52) or FIR (OR: 0.85, 95% CI: 0.44-1.63), and CILs (OR: 0.97, 95% CI: 0.55-1.72) was found between placentae from gravida identified as being SARS-CoV-2 infected. However, placenta from gravida identified as being infected with SARS-CoV-2 were associated with significantly increased occurrence of PVFD (OR: 2.77, 95% CI: 1.06-7.27). After subgroup analyses based on clinical severity of COVID-19 infection, no significant difference was observed in terms of reported placental pathology between symptomatic or asymptomatic SARS-CoV-2 gravidae placenta. Current evidence based on the available literature suggests that the only pathologic finding in the placentae of women who are pregnant identified as having been infected with SARS-CoV-2 was an increased prevalence of PVFD. KEY POINTS: · No association between SARS-CoV-2 and maternal or fetal placental malperfusion.. · No association between SARS-CoV-2 and maternal or fetal inflammatory response.. · SARS-CoV-2 is associated with increased perivillous fibrin deposition in placenta..
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Affiliation(s)
- Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Kjersti M Aagaard
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Eumenia C Castro
- Department of Pathology and Immunology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Sara E Arian
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Enrico R Barrozo
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Maxim D Seferovic
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
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50
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Salmanian B, Einerson BD, Carusi DA, Shainker SA, Nieto-Calvache AJ, Shrivastava VK, Subramaniam A, Zuckerwise LC, Lyell DJ, Khandelwal M, Fitzgerald GD, Hessami K, Fox KA, Silver RM, Shamshirsaz AA. Timing of delivery for placenta accreta spectrum: the Pan-American Society for the Placenta Accreta Spectrum experience. Am J Obstet Gynecol MFM 2022; 4:100718. [PMID: 35977702 DOI: 10.1016/j.ajogmf.2022.100718] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/10/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND The Society for Maternal-Fetal Medicine recommends cesarean delivery with potential hysterectomy scheduled in the late preterm period between 34 0/7 and 35 6/7 weeks of gestation for prenatally suspected placenta accreta spectrum. OBJECTIVES We aimed to investigate clinical compliance with the recommended delivery timing window for placenta accreta spectrum and its impact on maternal and neonatal outcomes. STUDY DESIGN We performed a retrospective multicenter review of data from referral centers within the Pan-American Society for Placenta Accreta Spectrum. Patients with placenta accreta spectrum with both antenatal diagnosis and confirmed histopathologic findings were included. We investigated adherence to the Society for Maternal-Fetal Medicine-recommended gestational age window for delivery, and compliance was further stratified by scheduled and unscheduled delivery. We compared the outcomes for patients with scheduled delivery within vs immediately 2 weeks outside the recommended window. RESULTS Among 744 patients with a prenatal diagnosis of placenta accreta spectrum and placental histopathologic confirmation, 488 (66%) had scheduled delivery. Among all prenatally diagnosed placenta accreta spectrum patients, 252 (39%) delivered within the recommended window of 34 0/7 and 35 6/7 weeks gestation. For the subgroup of patients who underwent scheduled delivery (n=426), 209 (49%) had delivery in this window, 120 (28%) delivered before 34 weeks, and 97 (23%) delivered at or later than 36 weeks. In the patients with scheduled delivery, 27% of placenta accreta spectrum patients with accreta delivered in the 2 weeks immediately after the recommended window (36 0/7-37 6/7 weeks), and 22% of placenta accreta spectrum pregnancies with increta/percreta delivered in the 2 weeks immediately before the recommended delivery (32 0/7-33 6/7 weeks). The maternal outcomes among those who delivered within the recommended range vs those delivering 2 weeks before and after the recommended range were similar, regardless of placenta accreta spectrum severity. CONCLUSION Less than half of placenta accreta spectrum patients had scheduled delivery within the recommended gestational age of 34 0/7 to 35 6/7 weeks. The reasons for deviation from recommendations and the risks and benefits of individualized timing of delivery on the basis of risk factors and predicted outcomes warrant further investigation.
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Affiliation(s)
- Bahram Salmanian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX (Drs Salmanian, Hessami, Fox, and Shamshirsaz)
| | - Brett D Einerson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT (Drs Einerson and Silver)
| | - Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA (Dr Carusi)
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA (Dr Shainker)
| | - Albaro J Nieto-Calvache
- Department of Obstetrics and Gynecology, Fundación Clínica Valle del Lili, Universidad ICESI, Cali, Colombia (Dr Nieto)
| | - Vineet K Shrivastava
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Miller Children's and Women's Hospital, Long Beach, CA (Dr Shrivastava)
| | - Akila Subramaniam
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Dr Subramaniam)
| | - Lisa C Zuckerwise
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN (Dr Zuckerwise)
| | - Deirdre J Lyell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford University, Palo Alto, CA (Dr Lyell)
| | - Meena Khandelwal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Cooper University Hospital, Princeton, NJ (Dr Khandelwal)
| | - Garrett D Fitzgerald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI (Dr Fitzgerald)
| | - Kamran Hessami
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX (Drs Salmanian, Hessami, Fox, and Shamshirsaz)
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX (Drs Salmanian, Hessami, Fox, and Shamshirsaz)
| | - Robert M Silver
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT (Drs Einerson and Silver)
| | - Alireza A Shamshirsaz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX (Drs Salmanian, Hessami, Fox, and Shamshirsaz).
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