Case Series of Reproductive Outcomes after Surgical Correction of Obstructed Hemivagina in OHVIRA

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) is a rare congenital developmental syndrome manifested by uterine duplication, lower genital tract obstruction, and unilateral renal anomaly. Literature on reproductive outcomes in this patient population is limited. The aim of this study is to describe obstetric outcomes after surgical correction of obstructed hemivagina in a longitudinal cohort of patients with a diagnosis of OHVIRA. All cases of OHVIRA presenting to a single tertiary care children's hospital from 1990 to 2021 were retrospectively reviewed. Three cases demonstrating a variety of clinically important reproductive outcomes are described in detail including risks such as retained products, endometritis, preterm labor, and malpresentation. Understanding the reproductive outcomes associated with this diagnosis is important for practitioners seeking to counsel and care for patients with this diagnosis. This case series demonstrates a wide array of potential gynecologic and obstetric risks, though ultimately with successful term and near-term pregnancies.

Risk factors for delayed termination of pregnancy following increased nuchal translucency

OBJECTIVES

Termination of pregnancy after increased nuchal translucency (NT) is a common occurrence. This study aimed to identify characteristics of a cohort with a NT ≥3.0 mm who underwent a pregnancy termination ≥15 weeks compared with those who terminated <15 weeks.

METHODS

All NT ≥3.0 mm identified within our department over an 11-year period (2010-2021) (n = 689) were retrospectively examined and characteristics of the cohort of increased NTs ending in termination were further categorized.

RESULTS

There were 221 (32.1%) individuals with an increased NT (≥3 mm) who underwent a termination of pregnancy within our study period (2010-2021). Pregnancy termination occurred at a gestational age <15 weeks in 162 (73.3%) and ≥15 weeks in 59 individuals. Pregnant individuals without positive NIPT for aneuploidy were at a higher risk for a ≥15-week termination (p = 0.004). In 29% (17/59) of late terminations, there were additional imaging findings after the NT scan (ultrasound, echocardiogram, magnetic resonance imaging) that ultimately triggered the decision to pursue termination.

CONCLUSIONS

As the options for workup of an increased NT expand, potential delays in decision-making surrounding termination increase. This study identifies multiple reasons for delayed termination and proposes several approaches to care aimed at maximizing diagnostic information by imaging and diagnostic testing in an expedited manner.

Increased use of diagnostic testing after increased nuchal translucency: The influence of non-invasive prenatal testing and chromosomal microarray

OBJECTIVE

The utilization of non-invasive prenatal testing (NIPT) and chromosomal microarray (CMA) has significantly altered the options for testing following the diagnosis of an increased nuchal translucency (NT). This study defines the rates of utilization of diagnostic testing in the pre-NIPT, pre-CMA, and post-CMA eras.

METHODS

We retrospectively examined NT scans performed in our department from January 2010 to December 2020 and identified all NTs ≥3.0 mm for analysis. We divided our data into three distinct periods (2010-2012, 2013-2016, and 2017-2020) corresponding to our institutional practice shifts in recommending and offering use of NIPT (2013) and CMA (2016), respectively.

RESULTS

689 patients with NT ≥ 3.0 mm met inclusion criteria in our study, of which 355 (51.5%) individuals underwent diagnostic testing and 334 (48.5%) did not. There was a significant decline in rates of diagnostic testing with NIPT (2013), which has returned to pre-NIPT levels with the availability of microarray.

CONCLUSIONS

Since the routine use of CMA (2016), the rates of diagnostic testing for increased NT have returned to pre-NIPT levels. This study validates data suggesting an initial decline in the rates of diagnostic testing following abnormal NT but suggests that the decline may be reversing in the post-CMA era due to a rise in rates of chorionic villus sampling.

Female adnexal tumor of probable Wolffian Origin - A report of two cases at one institution

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FATWOs are rare gynecologic neoplasms of low malignant potential derived from mesonephric (Wolffian) duct remnants.

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FATWOs have diverse presentations from vague abdominal symptoms to incidental diagnosis.

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In general, FATWOs require no additional management beyond initial surgical intervention.

The Dartmouth Dementia Directive: Experience with a Community-Based Workshop Pilot of a Novel Dementia-Specific Advance Directive

Dementia is a growing issue at the end of life that presents unique challenges for advance care planning. Advance directives are a useful and important component of end-of-life planning, but standard advance directives have less utility in cases of loss of capacity due to dementia. An advance directive designed to specifically address end-of-life issues in the setting of dementia can provide patients with increased autonomy and caregivers with improved information about the desires of the individual in question. The Dartmouth Dementia Directive is a dementia-specific advance directive, available online, that seeks to address common concerns of individuals who are planning for dementia-related end-of-life care. This directive was piloted in a community-based workshop, which provided important details and perspective on the best use of dementia-specific advance directives in the greater population.

Human embryo mosaicism: did we drop the ball on chromosomal testing?

There are newly recognized challenges presented by the occurrence of mosaicism in the context of trophectoderm (TE) biopsy for pre-implantation genetic screening (PGS) in in vitro fertilization (IVF) embryos. Chromosomal mosaicism, known to be significantly higher in IVF embryos than in later prenatal samples, may contribute to errors in diagnosis. In particular, PGS may result in discarding embryos diagnosed as aneuploid but in which the inner cell mass may be completely or mainly euploid, thus representing a false positive diagnosis. Although less likely, some embryos diagnosed as euploid could be mosaic and contain some aneuploid cells, possibly impacting their implantation potential. The ability of current diagnostic techniques to detect mosaicism is limited by the number and location of TE cells in the biopsy and by the methodology used for chromosomal assessment. The clinical consequences of mosaicism are dependent on the chromosome(s) involved, the developmental stage at which the mosaicism evolved, and whether TE biopsy accurately reflects the status of the inner cell mass that forms the fetus. Consequently, in patients with no euploid embryos identified on PGS, it may be appropriate to consider the transfer of diagnosed aneuploid embryos if the TE biopsy result is a non-viable chromosomal monosomy or triploidy that could not result in a birth. It should be acknowledged in consent forms that mosaicism has the potential to impact test results and that its detection may be below the resolution of the genetic tests being used. This concept represents a major shift in current IVF practice and ought to be considered given the data, or lack thereof, of the impact of mosaicism on IVF/PGS outcomes.