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Critchlow E, Wodoslawsky S, Makhamreh MM, Rice SM, Turan OM, Firman B, McLaren R, Araji S, Al-Kouatly HB. Maternal outcomes of a cohort of pregnancies affected by non-immune hydrops fetalis. Int J Gynaecol Obstet 2024; 165:318-327. [PMID: 37897049 DOI: 10.1002/ijgo.15207] [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: 07/02/2023] [Revised: 09/09/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023]
Abstract
OBJECTIVE To describe the maternal outcomes of a prospective cohort of non-immune hydrops fetalis (NIHF) pregnancies with negative standard-of-care evaluations. METHODS This study was a secondary analysis of a prospective cohort study of NIHF pregnancies with negative work-ups (infection, alloimmune anemia, fetomaternal hemorrhage, and chromosomal disorders). Outcomes were obstetric complications, including pre-eclampsia, mirror syndrome, preterm birth, polyhydramnios, postpartum hemorrhage, and maternal mental health. RESULTS Forty pregnancies were included. Four patients developed pre-eclampsia (4/40, 10.0%); three occurred postpartum. None was diagnosed with mirror syndrome. Of the 31 continued pregnancies, 16 (51.6%) resulted in early fetal death or stillbirth and 15 (48.4%) resulted in live births. Of the 15 live births, 8 (53.3%) were delivered by primary cesarean delivery; 5 (62.5%) were for hydrops fetalis. Eleven live births (73.3%) were delivered preterm; 9 (81.8%) were indicated, most commonly for fetal indications (7/9, 77.8%). Polyhydramnios occurred in 14/40 (35.0%) cases. Where EBL was recorded (n=37), there were 5 (13.5%) cases of postpartum hemorrhage and an additional 3 (8.1%) had uterine atony without hemorrhage. Eighteen patients (18/40, 45.0%) had new-onset or exacerbated depression or anxiety symptoms. CONCLUSION Our study identified several important adverse outcomes of pregnancies complicated by NIHF with negative standard-of-care evaluations, including a high rate of postpartum pre-eclampsia and worsened mental health. We identified a higher rate of cesarean delivery and preterm birth, both primarily for fetal indications. We also observed the known relationship between polyhydramnios, hemorrhage, and atony, but noted that this risk included pregnancies concluding in dilation and evacuation. Counseling after a diagnosis of NIHF should include these adverse outcomes.
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Affiliation(s)
- Elizabeth Critchlow
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sascha Wodoslawsky
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mona M Makhamreh
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York, USA
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stephanie M Rice
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Maryland, Baltimore, Maryland, USA
| | - Brandy Firman
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Rodney McLaren
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sara Araji
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Mississippi, Jackson, Mississippi, USA
| | - Huda B Al-Kouatly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Turan OM, Liang Y, Kelley B, Turan S, Pepe GJ, Albrecht ED. B-flow/spatiotemporal image correlation M-mode ultrasound provides novel method to quantify spiral artery remodeling during normal human pregnancy. Ultrasound Obstet Gynecol 2024. [PMID: 38477161 DOI: 10.1002/uog.27636] [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: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024]
Abstract
OBJECTIVES During human pregnancy placental extravillous trophoblasts replace the vascular smooth muscle and elastic tissue within the walls of the uterine spiral arteries, thereby remodeling these arteries into distensible low resistance vessels to promote placental perfusion. The present study, determined whether B-flow/ spatio-temporal image correlation (STIC) M-mode ultrasonography provides an in vivo imaging method to digitally quantify spiral artery luminal distensibility, as a physiological index of spiral artery remodeling, during advancing stages of normal human pregnancy. METHODS A prospective longitudinal observational study was conducted to quantify spiral artery distensibility, i.e. vessel luminal diameter at systole minus diameter at diastole, by B-flow/STIC M-mode ultrasonography during the first, second and third trimesters in 290 women exhibiting normal pregnancy. Maternal serum levels of placental growth factor (PlGF) and soluble fms-like tyrosine kinase (sFlt-1), growth factors that modulate events important in spiral artery remodeling, were quantified in a subset of the subjects at the first, second and third semesters. RESULTS Median [first quartile, third quartile] spiral artery distensibility progressively increased (P < 0.0001) between the first trimester (0.17 [0.14, 0.21]), second (0.23 [0.18, 0.28]) and third (0.26 [0.21, 0.35]) trimesters of pregnancy. Spiral artery volume flow (ml/cardiac cycle) progressively increased (P < 0.001) between the first 2.49 [1.38, 4.99], second 3.86 [2.06, 6.91] and third 7.79 [3.83, 14.98] trimesters. Coinciding with the elevation in spiral artery distensibility, the median ratio of serum PlGF/sFlt-1 levels increased (P < 0.001) between the first (7.2 [4.5, 10], second (22.7 [18.6, 42.2]) and third (56.2 [41.9, 92.5] trimesters. CONCLUSIONS The present study shows that B-flow/STIC M-mode ultrasonography provides an in vivo imaging technology to digitally quantify structural/physiological expansion of the walls of the spiral arteries during the cardiac cycle as a consequence of their transformation into compliant vessels during advancing stages of normal human pregnancy. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- O M Turan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Y Liang
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - B Kelley
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - S Turan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - G J Pepe
- Department of Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA, USA
| | - E D Albrecht
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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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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Turan OM, Babischkin JS, Aberdeen GW, Turan S, Pepe GJ, Albrecht ED. B-Flow/Spatiotemporal Image Correlation M-Mode and Contrast-Enhanced/Microbubble Ultrasonography Quantification of Spiral Artery Distensibility and Placental Intervillous Perfusion in the First Trimester in a Primate Model of Impaired Spiral Artery Remodeling. Ultrasound Med Biol 2023; 49:2557-2564. [PMID: 37749012 PMCID: PMC10591761 DOI: 10.1016/j.ultrasmedbio.2023.08.021] [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: 02/17/2023] [Revised: 08/17/2023] [Accepted: 08/28/2023] [Indexed: 09/27/2023]
Abstract
OBJECTIVE During early human pregnancy, placental trophoblasts remodel spiral arteries into distensible low-resistance vessels to promote placental perfusion. We have established a model of impaired spiral artery remodeling (SAR) by elevating estradiol levels in the first trimester of baboon pregnancy. In the present study, B-flow/spatiotemporal image correlation (STIC) M-mode ultrasonography, a non-Doppler technology for sharp rendering of vessel dimensions, was used to determine whether spiral artery distensibility was altered in SAR-suppressed baboons. Contrast-enhanced ultrasound/microbubble imaging was also performed to determine whether it detected changes in placenta intervillous space perfusion in SAR-suppressed baboons. METHODS The two imaging procedures were performed in the first trimester in baboons not treated or treated with estradiol to suppress SAR. RESULTS Spiral artery distensibility, that is, luminal diameter at systole minus diameter at diastole, and volume flow as quantified by B-flow/STIC M-mode were 26% (p = 0.03) and 55% (p = 0.059) lower, respectively, in SAR-suppressed baboons. However, placental intervillous space flow rate and video intensity plateau levels reflecting blood perfusion, quantified by contrast-enhanced ultrasound/microbubble imaging, were unaltered in SAR-suppressed baboons. CONCLUSION The results indicate that B-flow/STIC M-mode ultrasonography provides a non-invasive method to detect reduced distensibility and, thus, function of spiral arteries across the cardiac cycle in the first trimester in a primate model of impaired SAR. This study represents a first step in determining whether B-flow/STIC M-mode detects a similar defect in SAR early in adverse human pregnancy. This would provide an avenue to develop therapeutic modalities to prevent the devastating consequences of impaired SAR.
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Affiliation(s)
- Ozhan M Turan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffery S Babischkin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Graham W Aberdeen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sifa Turan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gerald J Pepe
- Department of Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Eugene D Albrecht
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA.
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Kolosky T, Uddin O, Panchal B, Forbes HE, Levin MR, Engelmann A, Turan S, Turan OM, Alexander JL. Multimodal prenatal and postnatal imaging of microphthalmia with cyst. J AAPOS 2023; 27:369-372. [PMID: 37777051 DOI: 10.1016/j.jaapos.2023.08.007] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/27/2023] [Accepted: 08/08/2023] [Indexed: 10/02/2023]
Abstract
Congenital ocular anomalies may be detected on prenatal imaging using fetal ultrasound and magnetic resonance imaging (MRI), although standard prenatal ultrasound for fetal physical development does not currently include ocular and orbital evaluation. We present the case of a male infant born at 39 weeks' gestation with microphthalmia with cyst that was characterized using serial multimodal imaging, including fetal ultrasound and MRI, B-scan ultrasonography, ultrasound biomicroscopy, and postnatal MRI. Multiple prenatal and postnatal imaging modalities yielded comparable evaluations of the ocular and orbital pathology, validating the prenatal assessments.
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Affiliation(s)
- Taylor Kolosky
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Olivia Uddin
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bhakti Panchal
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - He Eun Forbes
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Moran R Levin
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Alexander Engelmann
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sifa Turan
- Department of Obstetrics, Gynecology, and Reproductive Services, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology, and Reproductive Services, University of Maryland School of Medicine, Baltimore, Maryland
| | - Janet L Alexander
- Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, Baltimore, Maryland.
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Abi Habib P, Goetzinger K, Turan OM. Placenta accreta spectrum conservative management and coagulopathy: case series and systematic review. Ultrasound Obstet Gynecol 2023. [PMID: 38030960 DOI: 10.1002/uog.27547] [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: 10/04/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Management of placenta accreta spectrum (PAS) with the placenta kept in situ aims to preserve fertility and minimize blood loss. However, this method is associated with a risk of coagulopathy and subsequent bleeding. The aim of this study was to evaluate the occurrence and pathophysiology of coagulopathy in cases of PAS managed conservatively. METHODS We reviewed our database for cases of PAS in which the placenta was kept in situ. In addition, we performed a systematic review of articles on PAS in which the placenta was left in situ and was complicated by coagulopathy. PubMed was searched for publications between 1980 and 2023. Our eligibility criteria included studies in which no additional interventions were performed other than keeping the placenta entirely in situ, and in which coagulopathy was reported. RESULTS After screening and selection of full-text articles, 10 studies were included in the review. A review of our databases yielded a case series of PAS managed conservatively with the placenta kept in situ. When adding our case series to the results of our systematic review, a total of 87 cases were found to have been managed conservatively, with 28 cases of coagulopathy. Of these, the time at which coagulopathy developed was known in 11 cases. The median time at development of coagulopathy was 58 (interquartile range, 50-67) days postpartum. CONCLUSIONS Our findings highlight that conservative management of PAS with the placenta in situ poses a risk of coagulopathy. Keeping the placenta in situ after delivery prolongs the risk factors that are integral to PAS. The pathophysiology behind coagulopathy is comparable with that of concealed placental abruption, due to the disrupted uteroplacental interface and the collection of blood in the placenta. Therefore, the presence of large placental lakes could be an indicator of developing coagulopathy. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- P Abi Habib
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - K Goetzinger
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - O M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Cojocaru L, Noe M, Pahlavan A, Werzen A, Seung H, Yoo YCJ, Tyson P, Narayanan S, Turan S, Turan OM, Chua JV. Increased risk of severe COVID-19 in pregnancy in a multicenter propensity score-matched study. J Perinat Med 2023; 51:1171-1178. [PMID: 37596826 DOI: 10.1515/jpm-2023-0068] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/08/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVES To explore the association between COVID-19 severity and pregnancy using measures such as COVID-19 ordinal scale severity score, hospitalization, intensive care unit (ICU) admission, oxygen supplementation, invasive mechanical ventilation, and death. METHODS We conducted a retrospective, multicenter cohort study to understand the association between COVID-19 severity and pregnancy. We reviewed consecutive charts of adult females, ages 18-45, with laboratory testing for SARS-CoV-2 infection between March 1, 2020, and August 31, 2020. Cases were patients diagnosed with COVID-19 during pregnancy, whereas controls were not pregnant at the time of COVID-19 diagnosis. Primary endpoints were the COVID-19 severity score at presentation (within four hours) and the nadir of the clinical course. The secondary endpoints were the proportion of patients requiring hospitalization, ICU admission, oxygen supplementation, invasive mechanical ventilation, and death. RESULTS A higher proportion of pregnant women had moderate to severe COVID-19 disease at the nadir of the clinical course than non-pregnant women (25 vs. 16.1 %, p=0.04, respectively). There was a higher rate of hospitalization (25.6 vs. 17.2 %), ICU admission (8.9 vs. 4.4 %), need for vasoactive substances (5.0 vs. 2.8 %), and invasive mechanical ventilation (5.6 vs. 2.8 %) in the pregnant cohort. These differences were not significant after applying propensity score matching.We found a high rate of pregnancy complications in our population (40.7 %). The most worrisome is the rate of hypertensive disorders of pregnancy (20.1 %). CONCLUSIONS In our propensity score-matched study, COVID-19 in pregnancy is associated with an increased risk of disease severity and pregnancy complications.
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Affiliation(s)
- Liviu Cojocaru
- Division of Anesthesia Critical Care, Department of Anesthesiology, Perioperative Care, and Pain Medicine, New York University Grossman School of Medicine, New York, NY, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Myint Noe
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Autusa Pahlavan
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
| | - Alissa Werzen
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Hyunuk Seung
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Young Chae Jessica Yoo
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Patricia Tyson
- Department of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shivakumar Narayanan
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shifa Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joel V Chua
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
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Esteves KM, Tugarinov N, Lechmann G, Abi Habib P, Cagliyan E, Goetzinger KR, Turan OM, Turan S. The value of detailed first-trimester ultrasound in the era of noninvasive prenatal testing. Am J Obstet Gynecol 2023; 229:326.e1-326.e6. [PMID: 37271433 DOI: 10.1016/j.ajog.2023.05.031] [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: 03/07/2023] [Revised: 05/26/2023] [Accepted: 05/27/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND In 2020, the American College of Obstetricians and Gynecologists recommended noninvasive prenatal testing be offered to all patients. However, current societal guidelines in the United States do not universally recommend a detailed first-trimester ultrasound. OBJECTIVE This study aimed to determine the additional findings identified through first-trimester ultrasound that would have otherwise been missed if noninvasive prenatal testing was used alone as a first-trimester screening method. STUDY DESIGN This was a retrospective cohort study involving 2158 pregnant patients and 2216 fetuses that were seen at a single medical center between January 1, 2020, and December 31, 2022. All those included underwent both noninvasive prenatal testing and detailed first-trimester ultrasound between 11.0 and 13.6 weeks of gestation. Noninvasive prenatal testing results were categorized as low risk or high risk, and first-trimester ultrasound results were categorized as normal or abnormal. Abnormal first-trimester ultrasounds were further classified as first-trimester screening markers (increased nuchal translucency, absent nasal bone, tricuspid regurgitation, and ductus venosus reverse a-wave) or structural defects (the cranium, neck, heart, thorax, abdominal wall, stomach, kidneys, bladder, spine, and extremities). Descriptive statistics were used to report our findings. RESULTS Of 2216 fetuses, 65 (3.0%) had a high-risk noninvasive prenatal testing result, whereas 2151 (97.0%) had a low-risk noninvasive prenatal testing result. Of those with a low-risk noninvasive prenatal testing result, 2035 (94.6%) had a normal first-trimester ultrasound, whereas 116 (5.4%) had at least 1 abnormal finding on first-trimester ultrasound. The most common screening marker detected within the low-risk noninvasive prenatal testing group was absent nasal bone (52/2151 [2.4%]), followed by reversed a-wave of the ductus venosus (30/2151 [1.4%]). The most common structural defect in this group was cardiac abnormality (15/2151 [0.7%]). Overall, 181 fetuses were identified as having "abnormal screening" through either a high-risk noninvasive prenatal testing result (n=65) or through a low-risk noninvasive prenatal testing result but abnormal first-trimester ultrasound (n=116). In summary, the incorporation of first-trimester ultrasound screening identified 116 additional fetuses (5.4%) that required further follow-up and surveillance than noninvasive prenatal testing alone would have identified. CONCLUSION Detailed first-trimester ultrasound identified more fetuses with a potential abnormality than noninvasive prenatal testing alone. Therefore, first-trimester ultrasound remains a valuable screening method that should be used in combination with noninvasive prenatal testing.
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Affiliation(s)
- Kristyn M Esteves
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland Medical Center - Center for Advanced Fetal Care, Baltimore, MD
| | - Nicol Tugarinov
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland Medical Center - Center for Advanced Fetal Care, Baltimore, MD
| | - Grace Lechmann
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland Medical Center - Center for Advanced Fetal Care, Baltimore, MD
| | - Paola Abi Habib
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland Medical Center - Center for Advanced Fetal Care, Baltimore, MD
| | - Erkan Cagliyan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland Medical Center - Center for Advanced Fetal Care, Baltimore, MD
| | - Katherine R Goetzinger
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland Medical Center - Center for Advanced Fetal Care, Baltimore, MD
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland Medical Center - Center for Advanced Fetal Care, Baltimore, MD
| | - Sifa Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland Medical Center - Center for Advanced Fetal Care, Baltimore, MD.
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Kegel S, Abi Habib P, Seger L, Turan OM, Turan S. The impact of early diagnosis of fetal single-ventricle cardiac defects on reproductive choices. Am J Obstet Gynecol MFM 2023; 5:101093. [PMID: 37451368 DOI: 10.1016/j.ajogmf.2023.101093] [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: 04/25/2023] [Revised: 07/10/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Congenital heart defects are the most common fetal anomaly. Congenital heart defects with single-ventricle cardiac defects have high mortality rates, and in pregnancies diagnosed with this condition, patients are often offered termination of pregnancy as an option. OBJECTIVE This study aimed to investigate the relationship between gestational age at diagnosis and reproductive choices in fetuses diagnosed with single-ventricle cardiac defects. STUDY DESIGN This was a retrospective single-center cohort study in which 158 patients with a fetal diagnosis of single-ventricle cardiac defects were reviewed. Cases were categorized as isolated or complex. Complex cases included fetuses with single-ventricle cardiac defects in addition to other fetal extracardiac anomalies or chromosomal abnormalities. RESULTS A total of 158 patients were diagnosed with single-ventricle cardiac defects during the study period. Of those patients, 37 (23.4%) underwent termination of pregnancy, 113 (71.5%) delivered, and 8 (5.1%) had an intrauterine fetal demise. Gestational age at diagnosis and race were significant predictors of the termination decision. The median gestational age at diagnosis was earlier in the termination of pregnancy group (20.4 vs 23.6 weeks; P<.001). Pregnancies complicated by single-ventricle cardiac defects diagnosed in early gestation (11 0/7 to 14 5/7 weeks of gestation) were more likely to be terminated than pregnancies complicated by single-ventricle cardiac defects diagnosed in middle gestation (15 0/7 to 27 5/7 weeks of gestation) and late gestation (≥28 weeks of gestation) (54.2% vs 23.2% and 2.9%; P<.001). Earlier gestational age at diagnosis was correlated with earlier gestational age at termination (r=0.92; P<.001). CONCLUSION Termination of pregnancy was more common when the single-ventricle cardiac defect was diagnosed earlier in pregnancy. This could be explained by the fact that early diagnoses allow parents to make deliberate and informed decisions.
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Affiliation(s)
- Samantha Kegel
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Paola Abi Habib
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Lindsey Seger
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Sifa Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD.
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Cojocaru L, Salvatori C, Sharon A, Seung H, Nyman K, Kodali BS, Turan OM. General versus Regional Anesthesia and Neonatal Data: A Propensity-Score-Matched Study. Am J Perinatol 2023; 40:227-234. [PMID: 36181759 DOI: 10.1055/s-0042-1757861] [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: 02/01/2023]
Abstract
OBJECTIVE This study aimed to evaluate whether there is a difference in neonatal outcomes with general anesthesia (GA) versus regional anesthesia (RA) when induction of anesthesia to delivery time (IADT) is prolonged (≥10 minutes). STUDY DESIGN This is a retrospective case-control study that included cases from July 2014 until August 2020. We reviewed all singleton pregnancies delivered between 24 and 42 weeks of gestation with IADT ≥ 10 minutes. Urgent deliveries, those who received RA for labor pain management or started cesarean delivery under RA and converted to GA, as well as cases with fetal anomalies, were excluded. The propensity score (PS) matching method was performed using age, ethnicity/race, body mass index, gestational age at delivery, preexisting maternal comorbidities, and pregnancy complications. Analyses were performed with SAS software version 9.4. RESULTS During the study period, we identified 258 cases meeting inclusion criteria. After the PS matching was applied, the study sample was reduced to 60 cases in each group. The median IADT and uterine incision to delivery time were similar between groups (41.5 [30.5, 52] vs. 46 minutes [38, 53.5], p = 0.2 and 1.5 [1, 3] vs. 2 minutes [1, 3], respectively). There was no significant difference between groups with respect to arterial or venous cord pH (7.24 [7.21, 7.26] vs. 7.23 [7.2, 7.27], p = 0.7 and 7.29 [7.26, 7.33] vs. 7.3 [7.26, 7.33], p = 0.4, respectively). Nor were there any associations between maternal characteristics and Apgar's score at 5 minutes, except for Apgar's score at 1 minute (p < 0.001). No significant difference was identified in the rate of admission to the neonatal intensive care unit (NICU; 11 [52.4%] vs. 10 [47.6%], p = 0.8) or NICU length of stay between GA and RA (4 [3, 14] vs. 4.5 [3, 11], p = 0.9). CONCLUSION Our data indicate that even with prolonged IADT, favorable neonatal outcomes are seen with both GA and RA, in contrast with previous studies performed decades ago. KEY POINTS · Improving cesarean delivery safety, including the safety of anesthesia, is of paramount importance.. · Reappraisal of historical outcomes is warranted as advances in the medical field unfold.. · Favorable neonatal outcomes are seen with both general and regional anesthesia..
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Affiliation(s)
- Liviu Cojocaru
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Cristiana Salvatori
- Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Amir Sharon
- Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Hyunuk Seung
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Katherine Nyman
- Division of Neonatology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bhavani S Kodali
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
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Flanagan MF, Vollgraff Heidweiller-Schreurs CA, Li W, Ganzevoort W, de Boer MA, Vazquez-Sarandeses A, Turan OM, Bossuyt PM, Mol BWJ, Rolnik DL. Added prognostic value of Doppler ultrasound for adverse perinatal outcomes: A pooled analysis of three cohort studies. Aust N Z J Obstet Gynaecol 2023; 63:19-26. [PMID: 35678065 DOI: 10.1111/ajo.13547] [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: 12/09/2021] [Accepted: 05/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fetal growth restriction (FGR) is an obstetric complication associated with adverse perinatal outcomes. Doppler ultrasound can improve perinatal outcomes through monitoring at-risk fetuses and helping time delivery. AIM To investigate the prognostic value of different Doppler ultrasound measurements for adverse perinatal outcomes. MATERIALS Individual participant data. METHODS We performed a pooled analysis on individual participant data. We compared six prognostic models using multilevel logistic regression, where each subsequent model added a new variable to a base model that included maternal characteristics. Estimated fetal weight (EFW) and four Doppler ultrasound measurements were added in turn: umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI), cerebroplacental ratio (CPR), and mean uterine artery pulsatility index (mUtA PI). The primary outcome was a composite adverse perinatal outcome, defined as perinatal mortality, emergency caesarean delivery for fetal distress, or neonatal admission. Discriminative ability was quantified with area under the curve (AUC). RESULTS Three data sets (N = 3284) were included. Overall, the model that included EFW and UA PI improved AUC from 0.650 (95% CI 0.624-0.676) to 0.673 (95% CI 0.646-0.700). Adding more ultrasound measurements did not improve further the discriminative ability. In subgroup analysis, the addition of EFW and UA PI improved AUC in both preterm (AUC from 0.711 to 0.795) and small for gestational age pregnancies (AUC from 0.729 to 0.770), but they did not improve the models in term delivery or normal growth subgroups. CONCLUSIONS Umbilical artery pulsatility index added prognostic value for adverse perinatal outcomes to the already available information, but the combination of other Doppler ultrasound measurements (MCA PI, CPR or UtA PI) did not improve further prognostic performance.
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Affiliation(s)
- Madeline F Flanagan
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | | | - Wentao Li
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - Wessel Ganzevoort
- Department of Obstetrics & Gynaecology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Marjon A de Boer
- Department of Obstetrics & Gynaecology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Alicia Vazquez-Sarandeses
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Ozhan M Turan
- Departments of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Patrick M Bossuyt
- Department of Obstetrics & Gynaecology, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Ben W J Mol
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
| | - Daniel L Rolnik
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia
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12
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Esteves K, Tugarinov N, Lechmann G, Stockett A, Cagliyan E, Turan OM, Turan S. The value of detailed first trimester ultrasound in the era of non-invasive prenatal testing. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.879] [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: 01/09/2023]
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13
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Seif KE, Goetzinger KR, Turan OM. The Optimal Cesarean Skin Incision in Patients with Super Obesity. Am J Perinatol 2023; 40:15-21. [PMID: 35752170 DOI: 10.1055/a-1885-1799] [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: 11/01/2022]
Abstract
OBJECTIVE This study aimed to evaluate if supraumbilical midline vertical incision performed in patients with a hanging pannus (umbilicus at the level of the pubic bone) is a reasonable alternative to the Pfannenstiel in patients with body mass index (BMI) ≥ 50 kg/m2 undergoing cesarean delivery. STUDY DESIGN Retrospective cohort study in patients with BMI ≥ 50 kg/m2 undergoing cesarean delivery at a single center from 2016 to 2020. Study groups were Pfannenstiel's versus supraumbilical vertical skin incision. If patients had a hanging pannus (umbilicus at the level of the pubic bone), vertical incisions were performed. Otherwise, Pfannenstiel's incision was performed. Decision for the incision was made prospectively. Primary outcome was a composite of need for blood transfusion, presence of immediate surgical complications, and presence of delayed surgical complications. Secondary outcomes included the individual components of the primary outcome, the median surgical blood loss, total operative time, time from skin incision to delivery of neonate, hysterotomy type, and neonatal outcomes. MedCalc 19.5.1 was used for analysis. RESULTS A total of 103 patients with BMI ≥50 kg/m2 were included. Of those, 68 (66%) had Pfannenstiel's and 35 (34%) had supraumbilical vertical incisions. There was no statistically significant difference in the incidence of the primary outcome (12 vs. 11%, p = 0.96). There was neither significant difference in immediate or delayed postoperative complications nor in neonatal outcomes. However, patients in the vertical midline incision group were more likely to have a classical hysterotomy (52%) compared with the Pfannenstiel group (6%; p < 0.05), increased overall median surgical blood loss (1,000 vs. 835 mL, p < 0.05), and increased total surgical time by a median of 30 minutes (p < 0.05). CONCLUSION In patients with super obesity and hanging pannus, performing a supraumbilical vertical midline incision offers a reasonable alternative to Pfannenstiel's incision, but patients should be counseled about the increased risk for classical hysterotomy and implications in future pregnancies. KEY POINTS · Patients with BMI >50 kg/m2 were allocated to different incision types based on subcutaneous fat distribution pattern. If umbilicus was at level of pubic bone, supraumbilical vertical skin incision was made. · There were no significant differences between Pfannenstiel's and supraumbilical vertical incisions in terms of the composite outcome and immediate or delayed postoperative complications and neonatal outcomes.. · In patients with a hanging pannus, performing a supraumbilical vertical midline incision offers a reasonable alternative to Pfannenstiel's incision, but patients should be counseled about the increased risk for classical hysterotomy and subsequent implications in future pregnancies..
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Affiliation(s)
- Karl E Seif
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Katherine R Goetzinger
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
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Kegel S, Tadbiri H, Cagliyan E, Mech J, Seger L, Turan OM, Turan S. Effect of gestational age at diagnosis of single ventricle defects on reproductive choices. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.409] [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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15
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Cojocaru L, Pahlavan A, Tadbiri H, Seung H, Reddy R, Mangione ME, Uribe K, Ufua M, Stockett AM, Jones-Beatty K, Burd I, Turan OM, Turan S. Temporal Trend of COVID-19 Clinical Severity and the Ethnic/Racial Disparity: A Report from the Maryland Study Group. Am J Perinatol 2023; 40:115-121. [PMID: 36108638 DOI: 10.1055/s-0042-1757391] [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: 01/04/2023]
Abstract
OBJECTIVES This study aimed to evaluate the temporal trend of novel coronavirus disease 2019 (COVID-19) symptoms and severity of clinical outcomes among pregnant women over a calendar year in the State of Maryland and compare clinical outcomes between different ethnic and racial groups. STUDY DESIGN We conducted a retrospective, multicenter observational study of the temporal trend of COVID-19 clinical presentation during pregnancy in the State of Maryland. We reviewed consecutive charts of adult pregnant females, aged 18 to 55 years, with laboratory-confirmed severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection between March 1, 2020, and February 28, 2021, and managed within the University of Maryland Medical System and Johns Hopkins Medicine. We excluded cases with insufficient data for assessing the COVID-19 diagnosis, pregnancy status, or clinical outcomes. We evaluated the evolution of COVID-19 symptoms at the time of presentation. Also, we compared COVID-19 infection rate, hospitalization rate, oxygen use, and intensive care unit (ICU) admission rates between different ethnic and racial groups. RESULTS We included 595 pregnant women with laboratory-confirmed COVID-19 over the study period. The prevalence of respiratory and systemic symptoms decreased over time with incidence rate ratios (IRRs) of 0.91 per month (95% confidence interval [CI]: 0.88-0.95) and 0.87 per month (95% CI: 0.83-0.95), respectively. The prevalence of hospitalization, O2 requirement, and ICU admission decreased over time with IRRs of 0.86 per month (95% CI: 0.82-0.91), 0.91 per month (95% CI: 0.84-0.98), and 0.70 per month (95% CI: 0.57-0.85), respectively. The Hispanic and Black populations had a higher COVID-19 infection rate and hospitalization rate than the non-Hispanic White population (p = 0.004, < 0.001, and < 0.001, respectively). CONCLUSION Understanding the concepts of viral evolution could potentially help the fight against pandemics like COVID-19. Moreover, this might improve the knowledge of how pandemics affect disadvantaged populations and help close the gap in health care inequities. KEY POINTS · A trade-off between virulence and transmissibility is determined by the natural selection of viruses.. · Understanding the concepts of viral evolution can help the fight against pandemics like COVID-19.. · Evolution of SARS-CoV-2 over time resulted in decreased virulence and increased infectivity..
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Affiliation(s)
- Liviu Cojocaru
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Autusa Pahlavan
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Hooman Tadbiri
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Hyunuk Seung
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Ramya Reddy
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Mary E Mangione
- Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Katelyn Uribe
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Michelle Ufua
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Arica M Stockett
- Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland.,Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kimberly Jones-Beatty
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Irina Burd
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
| | - Sifa Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, Maryland
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Esteves K, Elsamadicy E, Seif KE, Goetzinger K, Turan OM. Loop diuretic use in postpartum preeclampsia: A systematic review and meta-analysis. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.320] [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: 01/09/2023]
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17
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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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Crimmins S, Martin L, Solaru O, Desai A, Esteves K, Elsamadicy E, Kopelman JN, Turan OM. Third Trimester Ultrasound Stratifies Risk of Peripartum Complications in Pregnancies Complicated by Impaired Glucose Tolerance. Am J Perinatol 2022. [PMID: 36368651 DOI: 10.1055/s-0042-1758486] [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: 11/13/2022]
Abstract
OBJECTIVE The objective of our study was to investigate the effect of impaired glucose metabolism (IGM) and ultrasound (US) findings consistent with hyperglycemia on maternal and neonatal outcomes. STUDY DESIGN This was a retrospective case-control study of singleton, nonanomalous pregnancies with an elevated 1-hour glucose screening test (GST) completed after 23 weeks of gestation. IGM was defined as a 1-hour GST of >130, but less than two abnormal values on 3-hour glucose tolerance test (GTT). Gestational diabetes was defined as two or more abnormal values on 3-hour GTT. Ultrasound evidence of hyperglycemia was defined as abdominal circumference >95th centile and/or polyhydramnios. Individuals with IGM were divided into those with ultrasound evidence of hyperglycemia (impaired glucose metabolism consistent with ultrasound findings [IGM-US]) and those without IGM. Maternal demographics, delivery outcomes (gestational age at delivery, delivery mode, shoulder dystocia, lacerations), postpartum hemorrhage, and neonatal outcome (birth weight centile [BW%], neonatal intensive care unit admission, hypoglycemia, and glucose) were recorded. Composite morbidity was tabulated. Delivery and neonatal outcome variables were compared in individuals with IGM-US, IGM, and gestational diabetes mellitus (GDM). Odds ratios were calculated and adjusted for maternal age, BMI, and gestational weight gain. RESULTS A total of 637 individuals with an abnormal 1-hour GST were included (122 with IGM-US, 280 with IGM, and 235 with GDM). When compared to the IGM group, IGM-US had higher rates of cesarean delivery and BW% > 90th centile at delivery (adjusted odds ratio [aOR]: 1.7 [1.1-2.8] and aOR: 5.9 [2.7-13.0], respectively). Individuals with GDM also demonstrated similar rates with BW% > 90% but not cesarean section(aOR: 3.9 [1.8-8.5] and aOR: 1.4 [0.9-2.1], respectively). The remaining maternal and fetal outcomes were similar. CONCLUSION Women with impaired glucose tolerance should have a third-trimester ultrasound to identify an increased risk of perinatal complications. KEY POINTS · Women with elevated blood glucose screening should be evaluated with third-trimester ultrasound to identify risks for perinatal morbidity.. · The third-trimester ultrasound identifies individuals at risk for cesarean section.. · Counseling should be completed with individuals with polyhydramnios or accelerated growth..
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Affiliation(s)
- Sarah Crimmins
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lucille Martin
- University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Andrea Desai
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kristyn Esteves
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Emad Elsamadicy
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Jerome N Kopelman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
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Mustafa HJ, Goetzinger K, Turan OM. Single fetal demise following fetoscopic ablation for twin-to-twin transfusion syndrome-cohort study, systematic review, and meta-analysis: a response. Am J Obstet Gynecol 2022; 227:550-551. [PMID: 35427538 DOI: 10.1016/j.ajog.2022.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/11/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, 22 South Greene St., Baltimore, MD 21201
| | - Katherine Goetzinger
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, 22 South Greene St., Baltimore, MD 21201
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Maryland School of Medicine, 22 South Greene St., Baltimore, MD 21201.
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Mustafa HJ, Javinani A, Krispin E, Tadbiri H, Shamshirsaz AA, Espinoza J, Nassr AA, Donepudi R, Belfort MA, Sanz Cortes M, Harman C, Turan OM. Perinatal outcomes of fetoscopic laser surgery for twin-twin transfusion syndrome in triplet pregnancy: cohort study, systematic review and meta-analysis. Ultrasound Obstet Gynecol 2022; 60:42-51. [PMID: 35229918 DOI: 10.1002/uog.24887] [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: 10/04/2021] [Revised: 02/09/2022] [Accepted: 02/14/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The aims of this study were to investigate the perinatal outcome of dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplet pregnancies complicated by twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation (FLP) in two academic fetal centers, and to conduct a systematic review of previously published data to investigate perinatal survival in this targeted population. METHODS The first part of the study was a retrospective cohort study of prospectively collected data of consecutive triplet pregnancies with TTTS that underwent FLP at two fetal treatment centers between 2012 and 2020. Demographic, preoperative and operative variables and postoperative outcome were collected. Perinatal outcomes were investigated. The second part of the study was a systematic review and meta-analysis of studies evaluating the outcome of DCTA and/or MCTA triplet pregnancies, including our cohort study. PubMed, Web of Science and Scopus were searched from inception to September 2020. Primary outcomes were fetal survival (survival to birth), neonatal survival (survival to 28 days of age) and gestational age (GA) at birth. RESULTS A total of 31 sets of triplets with TTTS managed with FLP were included in the cohort study. Of these, 24 were DCTA and seven were MCTA. There were no significant differences in preoperative and operative variables between the two groups. There were also no significant differences between groups in GA at delivery or perinatal survival rate, including fetal and neonatal survival of at least one triplet, at least two triplets and all three triplets. Nine studies, including our cohort study, were included in the systematic review (156 DCTA and 37 MCTA triplet pregnancies treated with FLP). The overall fetal and neonatal survival was 79% (95% CI, 75-83%) and 75% (95% CI, 71-79%), respectively, in DCTA cases and 74% (95% CI, 52-92%) and 71% (95% CI, 49-89%), respectively, in MCTA cases. The rate of preterm birth before 28 weeks and before 32 weeks' gestation was 14% (95% CI, 4-29%) and 61% (95% CI, 50-72%), respectively, in DCTA triplets and 21% (95% CI, 3-45%) and 82% (95% CI, 62-96%), respectively, in MCTA triplets. CONCLUSIONS Triplet pregnancies with TTTS are at high risk of adverse perinatal outcome and preterm birth, regardless of chorionicity. The rate of survival after FLP in MCTA triplets was higher in our study than that reported in previous studies and is currently comparable with survival in DCTA triplets, which could be due to improved surgical skills. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- H J Mustafa
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A Javinani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - E Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - H Tadbiri
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - C Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - O M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Mustafa HJ, Cermak R, Pedersen N, Harman C, Turan OM. Perinatal outcomes of pregnancies with twin-anemia polycythemia sequence complicating twin-to-twin transfusion syndrome using different twin-anemia polycythemia sequence diagnostic criteria. Prenat Diagn 2022; 42:985-993. [PMID: 35686505 DOI: 10.1002/pd.6195] [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: 02/14/2022] [Revised: 06/01/2022] [Accepted: 06/04/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To investigate whether the presence of twin-anemia polycythemia sequence (TAPS) with twin-to-twin transfusion syndrome (TTTS) or post-laser TAPS would change outcomes using different TAPS diagnostic criteria. METHODS TTTS cases undergoing laser surgery between 2012 and 2020 were included. Groups included pre-laser TTTS-only compared to TTTS + TAPS, and no post-laser TAPS compared to post-laser TAPS. Three prenatal TAPS diagnostic criteria were used: group A: middle cerebral artery-peak systolic velocity (MCA-PSV) > 1.5 MoM in one twin and <1 MoM in the other twin, group B: inter-twin MCA-PSV difference >1 MoM, and group C: inter-twin MCA-PSV difference >0.5 MoM. Perinatal outcomes including survival and severe cerebral injury were investigated. RESULTS 174 laser procedures were included. TTTS + TAPS cases were 16 in group A, 17 in group B, and 29 in group C. Post-laser TAPS cases were 11 in group A, 6 in group B, and 12 in group C. There were no differences in preoperative, operative variables and outcomes including survival and severe cerebral injury between groups using all three TAPS diagnostic criteria. The incidence of TTTS + TAPS was highest in group C (16.7%), then group B (9.8%), followed by group A (9.2%). The incidence of post-laser TAPS was highest in group C (9%), then group A (8.3%), followed by group B (4.5%). CONCLUSION Presence of TAPS complicating TTTS and presence of post-laser TAPS do not seem to be associated with worse perinatal outcomes including postnatal-ultrasound detected cerebral injury using three different TAPS criteria. Collaborative studies are needed to investigate the validity and the performance of different TAPS criteria.
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Affiliation(s)
- Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Rachel Cermak
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nicole Pedersen
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher Harman
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Mustafa HJ, Tadbiri H, Pedersen N, Harman C, Turan OM. Proximate Cord Insertion in Twin-to-Twin Transfusion Syndrome: Case Series and PRISMA compliant Systematic Review and Meta-analysis. Fetal Diagn Ther 2022; 49:180-189. [PMID: 35378537 DOI: 10.1159/000524162] [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: 09/07/2021] [Accepted: 03/17/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We aimed to investigate the prevalence and clinical outcomes of twin-to-twin transfusion syndrome (TTTS) with proximate cord insertions. METHODS Retrospective cohort study of TTTS cases managed at single fetal center between 2012 and 2020. Presence of proximate cord insertions defined as a distance of equal or less than four centimeters between placental cord insertions that was recorded based on sonographic and fetoscopic examinations. Clinical outcomes were investigated compared to unmatched cohort and to 1:2 matched controls using pre-operative variables including: Quintero staging, selective fetal growth restriction (sFGR), anterior placenta, pre-operative cervical length (CL), and gestational age (GA) at fetal intervention. Systematic review and meta-analysis were conducted following PRSMA guidelines through searching PubMed, Scopus, CINAHL, and Medline databases from inception until January 2021. RESULTS The prevalence of proximate cord insertions in monochorionic placentas with TTTS was 2% (5/246). All five cases were managed by fetoscopic laser surgery (FLS). Procedure time was significantly longer (mean: 61.4 minutes in proximate cord vs 37.5 minutes in non-proximate cord, p<0.001), and amnioinfusion was significantly more common (100% in proximate cord vs 43% in non-proximate cord, p=0.01). Perinatal survival, and neonatal outcomes were not different between groups. Similar findings were seen following 1:2 control matching. Systematic review yielded total of 19 case reports of which different management options were applied including FLS (n=13), amniodrainage (n=3), and selective reduction (n=3). Clinical outcomes results were mixed and inconsistent. FLS was described as technically challenging and residual anastomosis were common. Overall fetal and neonatal survival following FLS was 85% and 80% respectively. CONCLUSION Presence of proximate cords in TTTS cases pose serious technical challenges even for highly experienced surgeons. Feasibility should be only determined by fetoscopic examination. .
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Affiliation(s)
- Hiba J Mustafa
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA,
| | - Hooman Tadbiri
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nicole Pedersen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Christopher Harman
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Mustafa HJ, Pedersen N, Harman C, Turan OM. Atypical Stage III Twin-to-Twin Transfusion Syndrome, Characteristics and Outcomes. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.847] [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: 11/01/2022]
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Krispin E, Nassr AA, Donepudi RV, Cortes MS, Espinoza J, Mustafa HJ, Harman C, Turan OM, Mostafaee S, Sun RC, Belfort MA, Shamshirsaz AA. Predicting dual survival for twin-twin transfusion syndrome following fetoscopic laser photocoagulation. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.779] [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: 11/16/2022]
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Mustafa HJ, Makar E, Pedersen N, Harman C, Turan OM. Neurological outcomes in Spontaneous and Post Laser Twin Anemia Polycythemia Using Traditional and Delphi Criteria. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.1074] [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: 11/01/2022]
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Tadbiri H, Turan S, Aberdeen G, Kelley B, Stockett A, Harman C, Turan OM. Spiral artery function in different placental locations. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.292] [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: 11/01/2022]
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Mustafa HJ, Goetzinger K, Javinani A, Aghajani F, Harman C, Shamshirsaz AA, Cortes MS, Donepudi RV, Krispin E, Nassr AA, Espinoza J, Belfort MA, Turan OM. Spontaneous preterm birth and PPROM After Fetoscopic laser Surgery for TTTS- Systematic review and Meta-analysis. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.304] [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: 12/01/2022]
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Ahmed A, Seger L, Makar E, Turan OM, Turan S. Bimodal Ultrasound Simulator Training in Obstetrics. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.1097] [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: 11/24/2022]
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Mustafa HJ, Pedersen N, Harman C, Turan OM. Cerebral Injury in Neonates of Pregnancies Complicated with Twin-to-Twin transfusion syndrome Treated with Laser Ablation. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.483] [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: 11/28/2022]
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Mustafa HJ, Javinani A, Harman C, Krispin E, Shamshirsaz AA, Espinoza J, Cortes MS, Donepudi RV, Belfort MA, Nassr AA, Turan OM. Preoperative and Operative Predictors of Single Fetal Demise After Laser Ablation for Twin-to-Twin Transfusion Syndrome. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.112] [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: 12/01/2022]
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Perreand E, Mangione M, Patel M, Miyamoto M, Cojocaru L, Seung H, Chua J, Turan OM, Turan S. Gestational Diabetes Mellitus: a Risk Factor for COVID-19. Am J Obstet Gynecol 2022. [PMCID: PMC8696627 DOI: 10.1016/j.ajog.2021.11.1234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Sun RC, Taylor L, Johnson R, MendezMartinez Y, Krispin E, Shamshirsaz AA, Cortes MS, Donepudi RV, Nassr AA, Lombaard H, Belfort MA, Espinoza A, Hiba M, Turan OM, Harman C, Espinoza J. Intertwin differences of cerebroplacental ratio are associated with increased neonatal survival in TTTS. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.558] [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: 11/01/2022]
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Cojocaru L, Turan OM, Levine A, Sollecito L, Williams S, Elsamadicy E, Crimmins S, Turan S. Proning modus operandi in pregnancies complicated by acute respiratory distress syndrome secondary to COVID-19. J Matern Fetal Neonatal Med 2021; 35:9043-9052. [PMID: 34915799 DOI: 10.1080/14767058.2021.2013464] [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: 10/19/2022]
Abstract
INTRODUCTION Prone positioning has been widely utilized in ARDS management before and during the COVID-19 pandemic due to its demonstrated mortality benefits. In pregnancy, proning requires careful attention to often overlooked physiologic changes in pregnancy and additional technical challenges accompanying a gravid abdomen. The purpose of this manuscript is to demonstrate a proning technique that was successfully used at our institution to avoid premature delivery of the fetus while improving maternal outcomes. All technical challenges are addressed in the instructional videos using a pregnant model with twin gestation at 32 weeks. METHODS We reviewed all the patients' charts with positive SARS-CoV-2 from March 2020 until July 2020 and identified those who developed ARDS. Subsequently, we identified four patients that were proned during the antepartum period. We described their clinical course, including the change in ventilatory parameters in relationship with proning timing. Stepwise instructions for self-proning and proning in mechanically ventilated patients are illustrated in video format. RESULTS During the study period, we identified 100 pregnant patients with SARS-CoV-2 infection. Mechanical ventilation was required in 8 of these patients. In four cases, proning was performed during the antepartum period. We were able to improve the P/F ratio while decreasing FiO2 and avoiding iatrogenic preterm delivery. Except for one case, where the patient self-extubated and required emergent delivery, all patients were successfully extubated, followed for prenatal care, and delivered for usual obstetric indications. CONCLUSION Proning remains a well-proven intervention in ARDS and should be considered in pregnant women when indicated. We recognize that proning might not be effective in all cases. However, proning positioning is an option to improve oxygenation in patients with severe hypoxemia when the next consideration is delivery of a premature infant or maternal cannulation for extracorporeal membrane oxygenation.
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Affiliation(s)
- Liviu Cojocaru
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrea Levine
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Linda Sollecito
- Medical Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD, USA
| | - Susan Williams
- Medical Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD, USA
| | - Emad Elsamadicy
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Crimmins
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sifa Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
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Mustafa HJ, Krispin E, Tadbiri H, Espinoza J, Shamshirsaz AA, Nassr AA, Donepudi R, Belfort MA, Cortes MS, Pederson N, Harman C, Turan OM. Efficacy of long-term indomethacin therapy in prolonging pregnancy after fetoscopic laser surgery for twin-to-twin transfusion syndrome: a collaborative cohort study. BJOG 2021; 129:597-606. [PMID: 34780110 DOI: 10.1111/1471-0528.17017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate the efficacy of long-term indomethacin therapy (LIT) in prolonging pregnancy and reducing spontaneous preterm birth (PTB) in patients undergoing fetoscopic laser surgery (FLS) for the management of twin-to-twin transfusion syndrome (TTTS). DESIGN Retrospective cohort study of prospectively collected data. SETTING Collaborative multicentre study. POPULATION Five hundred and fifty-seven consecutive TTTS cases that underwent FLS. METHODS Long-term indomethacin therapy was defined as indomethacin use for at least 48 hours. Log-binomial regression was used to estimate the relative risk of PTB in the LIT group compared with a non-LIT group. Cox regression was used to evaluate the association between LIT use and FLS-to-delivery survival. MAIN OUTCOME MEASURES Gestational age (GA) at delivery. RESULTS Among the 411 pregnancies included, a total of 180 patients (43.8%) received LIT after FLS and 231 patients (56.2%) did not. Median GA at fetal intervention did not differ between groups (20.4 weeks). Median GA at delivery was significantly higher in the LIT group (33.6 weeks) compared with the non-LIT group (31.1 weeks; P < 0.001). FLS-to-delivery interval was significantly longer in the LIT group (P < 0.001). The risks of PTB before 34, 32, 28 and 26 weeks of gestation were all significantly lower in the LIT group compared with the non-LIT group (relative risks 0.69, 0.51, 0.37 and 0.18, respectively). The number needed to treat with LIT to prevent one PTB before 32 weeks of gestation was four, and to prevent one PTB before 34 weeks was five. CONCLUSION Long-term indomethacin after FLS for TTTS was found to be associated with prolongation of pregnancy and reduced risk for PTB. TWEETABLE ABSTRACT Long-term indomethacin used after fetoscopic laser surgery for twin-to-twin transfusion syndrome is effective in prolonging pregnancy and reducing the risk for preterm birth; especially extreme preterm birth.
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Affiliation(s)
- H J Mustafa
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - E Krispin
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - H Tadbiri
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - J Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - R Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - M S Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - N Pederson
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - C Harman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - O M Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Blue NR, Hoffman M, Allshouse AA, Grobman WA, Simhan HN, Turan OM, Parry S, Chung JH, Reddy U, Haas DM, Myers S, Mercer B, Saade GR, Silver RM. Antenatal Fetal Adrenal Measurements at 22 to 30 Weeks' Gestation, Fetal Growth Restriction, and Perinatal Morbidity. Am J Perinatol 2021; 38:676-682. [PMID: 31756754 PMCID: PMC7708295 DOI: 10.1055/s-0039-3400308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Our objective was to test the association of fetal adrenal size with perinatal morbidity among fetuses with fetal growth restriction (FGR; estimated fetal weight [EFW] < 10th percentile). STUDY DESIGN This was a secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) adrenal study, which measured fetal adrenal gland size at 22 to 30 weeks' gestation. We analyzed the transverse adrenal area (TAA) and fetal zone area (absolute measurements and corrected for fetal size) and the ratio of the fetal zone area to the total transverse area using a composite perinatal outcome of stillbirth, neonatal intensive care unit admission, respiratory distress syndrome, necrotizing enterocolitis, retinopathy of prematurity, sepsis, mechanical ventilation, seizure, or death. Among fetuses with FGR, adrenal measurements were compared between those that did and did not experience the composite perinatal outcome. RESULTS There were 1,709 eligible neonates. Seven percent (n = 120) were diagnosed with FGR at the time of adrenal measurement, and 14.7% (n = 251) experienced perinatal morbidity. EFW-corrected and absolute adrenal measurements were similar among fetuses with and without FGR as well as among those who did and did not experience morbidity. The area under the curve for corrected TAA was 0.52 (95% confidence interval 0.38-0.67). CONCLUSION In our cohort, adrenal size was not associated with risk of morbidity among fetuses with FGR.
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Affiliation(s)
- Nathan R Blue
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Matthew Hoffman
- Department of Obstetrics and Gynecology, Christiana Care Health System, Wilmington, Delaware
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Hyagriv N Simhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, Pennsylvania
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, Maryland
| | - Samuel Parry
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Judith H Chung
- Department of Obstetrics and Gynecology, University of California, Irvine, Orange, California
| | - Uma Reddy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephen Myers
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, Kansas
| | - Brian Mercer
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio
| | - George R Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, Texas
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
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Lankford AS, Chow JH, Jackson AM, Wallis M, Galvagno SM, Malinow AM, Turan OM, Menaker JA, Crimmins SD, Rector R, Kaczorowski D, Griffith B, Kon Z, Herr D, Mazzeffi MA. Clinical Outcomes of Pregnant and Postpartum Extracorporeal Membrane Oxygenation Patients. Anesth Analg 2021; 132:777-787. [PMID: 33591093 DOI: 10.1213/ane.0000000000005266] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24-31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.
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Affiliation(s)
| | - Jonathan H Chow
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Amanda M Jackson
- Walter Reed National Military Medical Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Bethesda, Maryland
| | - Marianne Wallis
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrew M Malinow
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Jay A Menaker
- University of Maryland School of Medicine, Department of Surgery, Baltimore, Maryland
| | | | - Raymond Rector
- University of Maryland Medical Center, Department of Surgery, Baltimore, Maryland
| | - David Kaczorowski
- University of Maryland School of Medicine, Department of Surgery, Baltimore, Maryland
| | - Bartley Griffith
- University of Maryland School of Medicine, Department of Surgery, Baltimore, Maryland
| | - Zachary Kon
- New York University School of Medicine, Department of Surgery, New York, New York
| | - Daniel Herr
- University of Maryland School of Medicine, Department of Surgery, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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Cojocaru L, Lankford A, Galey J, Bharadwaj S, Kodali BS, Kennedy K, Goetzinger K, Turan OM. Surgical advances in the management of placenta accreta spectrum: establishing new expectations for operative blood loss. J Matern Fetal Neonatal Med 2020; 35:4496-4505. [PMID: 33272057 DOI: 10.1080/14767058.2020.1852213] [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: 10/22/2022]
Abstract
OBJECTIVE To evaluate whether the implementation of our surgical approach, referred to in the text as Linear Cutter Vessel Sealing System (LCVSS) technique, will improve perioperative outcomes in patients with placenta accreta spectrum (PAS), specifically by reducing blood loss and blood transfusion rates at the time of cesarean hysterectomy (C-HYST). The LCVSS technique integrates the following: (1) hysterotomy performed using the Linear Cutter, (2) no placental manipulation, (3) cauterization of anatomically prominent vascular anastomosis using the handheld vessel sealing system, and (4) completion of bladder dissection until the cervico-vaginal junction before ligation and division of uterine arteries. MATERIALS AND METHODS This is a retrospective cohort study that analyzed perioperative outcomes in patients undergoing C-HYST for PAS at a tertiary care center from 1 July 2014 to 1 December 2019. Comparisons were performed between cases managed with the use of the LCVSS technique (designated as LCVSS cohort) and those managed without the use of the LCVSS technique (designated as no technique cohort). The primary outcomes were cumulative blood loss (CBL) and total perioperative blood transfusion of ≥4 and ≥6 units of PRBCs. The secondary outcomes were intra- and postoperative complications. Continuous and categorical variables were compared according to the sample size and distribution. Binary logistic regression analysis was performed to predict confounders for blood transfusion of ≥4 units of PRBCs. RESULTS A total of 69 prenatally diagnosed PAS cases underwent C-HYST at the time of delivery. Forty-four cases that were performed using the LCVSS technique comprised the LCVSS cohort. The remaining 25 were marked as no technique cohort. CBL was significantly lower in the LCVSS cohort (1124 ml [300-4100] vs 3500 ml [650-10600]; p < .001). The rate of urinary tract injuries was similar (16%). The rate of postoperative complications and reoperation for intra-abdominal bleeding were lower but not significantly different in LCVSS cohort (9 vs 20% and 0 vs 8%, p = .26 and p = .12, respectively). There were no differences in neonatal outcomes. CONCLUSION Implementation of this advanced surgical approach for PAS management resulted in reduced blood loss and blood transfusion rates in comparison with no technique cohort.
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Affiliation(s)
- Liviu Cojocaru
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Allison Lankford
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jessica Galey
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shobana Bharadwaj
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bhavani S Kodali
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kelly Kennedy
- Department of Obstetrics, Gynecology and Reproductive Science, Center for Advanced Fetal Care, University of Maryland Medical Center, Baltimore, MD, USA
| | - Katherine Goetzinger
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
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Cojocaru L, Crimmins S, Sundararajan S, Goetzinger K, Elsamadicy E, Lankford A, Turan OM, Turan S. An initiative to evaluate the safety of maternal bonding in patients with SARS-CoV-2 infection. J Matern Fetal Neonatal Med 2020; 35:3540-3546. [PMID: 32998572 DOI: 10.1080/14767058.2020.1828335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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
BACKGROUND In the last two decades, the world faced three epidemics caused by novel coronaviruses, namely, SARS-CoV in 2002, MERS-CoV in 2012, and the ongoing SARS-CoV-2 that started in late 2019. Despite a growing understanding of SARS-CoV-2 virology, epidemiology, and clinical management strategies, other aspects, such as mode of delivery, vertical transmission, and maternal bonding, remain controversial. The question we faced upon the decision to separate the neonates of SARS-CoV-2 positive mother is whether we follow the principle of "do no harm"? METHODS This is a quality improvement project that analyzed all cases of SARS-CoV-2 positive pregnancies that delivered at a major health care system from March 1, 2020 to June, 1 2020. The article was prepared following Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. Data were prospectively collected and entered into the Research Electronic Data Capture (REDCap). Maternal bonding was defined by events such as rooming-in, skin to skin contact (STSC), and breastfeeding. Descriptive analysis was performed using the same software platform. INTERVENTION We compared neonatal transmission rates between those neonates who experienced bonding versus those who were separated. RESULTS A total of 1989 women were screened for SARS-CoV-2, from which 86 tested positive. Out of 31 analyzed pregnancies, five women (16%) were admitted to ICU and required mechanical ventilation. From the remaining 26 (84%), 17 (65%) opted for rooming-in, 12 (46%) for STSC, and 16 (61%) fed the infants with breastmilk (11 direct breastfeedings and five pumped the breast milk). All neonatal tests for SARS-CoV-2 returned negative. CONCLUSION Our results have illustrated that maternal bonding appears safe in neonates born to mothers that are SARS-CoV-2 positive.
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Affiliation(s)
- Liviu Cojocaru
- Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Crimmins
- Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sripriya Sundararajan
- Department of Pediatrics. Division of Neonatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine Goetzinger
- Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emad Elsamadicy
- Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Allison Lankford
- Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sifa Turan
- Division of Maternal-Fetal Medicine. Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
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Abstract
Objective: The objectives of this study were (1) to estimate the association between marginal placental cord insertion (PCI) and small for gestational age (SGA) and other adverse perinatal outcomes and (2) to determine if pregnancy-associated plasma protein A (PAPP-A) levels was altered in these patients.Methods: It was a retrospective cohort study of singleton pregnancies undergoing ultrasound between 2016 and 2018. Marginal PCI was defined as a distance of ≤2 cm from placental edge to PCI site, visualized in both sagittal and transverse planes, and diagnosed between 16 and 32 weeks. Velamentous PCI were excluded. The primary outcome was SGA, defined as birthweight below 10th percentile for gestational age. Pregnancies with marginal PCI were compared to those with normal PCI with respect to maternal characteristics, PAPP-A levels and adverse perinatal and delivery outcomes.Results: The incidence of marginal PCI was 4.2% (76/1819). Compared to those with a normal PCI, patients with a marginal PCI were more likely to be nulliparous and less likely to be African American or morbidly obese (p < .05). SGA rate was similar between the groups (17.6% vs. 18.1%). There was a trend toward an increased incidence of oligohydramnios, polyhydramnios and breech presentation in patients with marginal PCI; however, these did not reach statistical significance. The incidence of low PAPP-A level was comparable between the groups (18.4% vs. 14.3%, p > .05).Conclusion: Our study did not demonstrate any increase in adverse pregnancy outcomes in the presence of marginal PCI. These findings may provide reassurance for counseling patients with this sonographic finding.
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Affiliation(s)
- Mehmet R Asoglu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Crimmins
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jerome N Kopelman
- 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
| | - Katherine R Goetzinger
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Asoglu MR, Cutting EM, Ozdemir H, Higgs AS, Siegel GB, Turan OM, Turan S. The rate of undetectable genetic causes by Cell-free DNA test in congenital heart defects. J Matern Fetal Neonatal Med 2020; 35:1484-1490. [PMID: 32338089 DOI: 10.1080/14767058.2020.1757643] [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: 10/24/2022]
Abstract
Objective: The study aimed to estimate the rate of genetic causes that were undetectable by Cell-free DNA (cfDNA) test in prenatally diagnosed congenital heart defect (CHD) cases based on an assumption that cfDNA would accurately detect common aneuploidies including trisomy 21/18/13/45X, and del22q11.2.Methods: This study included prenatally diagnosed CHD cases with diagnostic genetic results. The possibility of false-positive/negative results from cfDNA testing was discarded. Thus, cfDNA results would be positive in common aneuploidies or del22q11.2 and negative in normal diagnostic genetic testing results or other genetic conditions. The rate of genetic causes that were undetectable by cfDNA test was estimated for all cases as well as for CHD subgroups.Results: Of 302 cases, 98 (34.8%) had a type of genetic abnormalities, with 67 having common aneuploidies or del22q11.2 and 31 having other genetic conditions. The rate of genetic causes that were undetectable by cfDNA test in CHD cases was 13.2% among those with assumingly negative cfDNA screen results and 10.3% among the entire study population. These rates were similar between CHD subgroups (p > .05). The rate of genetic causes that were undetectable by cfDNA test was higher in the non-isolated cases than in the isolated ones among those with assumingly negative-screen results (20.5% and 9.9%, respectively, p = .025).Conclusion: In prenatally diagnosed CDH cases, a significant number of chromosomal abnormalities are still identified after diagnostic testing even if cfDNA screen is negative, and thus it is important to extensively counsel patients with negative cfDNA screen carrying a CHD-affected fetus.
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Affiliation(s)
- Mehmet Resit Asoglu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth M Cutting
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Halis Ozdemir
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amanda S Higgs
- 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
| | - Sifa Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Asoglu MR, Turan OM, Seger L, Kochan M, Turan S. Middle cerebral artery pulsatility index as possible predictive marker for neonatal death in fetuses with tricuspid valve malformation. Ultrasound Obstet Gynecol 2020; 55:552-554. [PMID: 31483895 DOI: 10.1002/uog.20862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/21/2019] [Accepted: 08/23/2019] [Indexed: 06/10/2023]
Affiliation(s)
- M R Asoglu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - O M Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - L Seger
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - M Kochan
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - S Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Turan OM, Shannon A, Asoglu MR, Goetzinger KR. A novel approach to reduce blood loss in patients with placenta accreta spectrum disorder. J Matern Fetal Neonatal Med 2019; 34:2061-2070. [PMID: 31455134 DOI: 10.1080/14767058.2019.1656194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 10/26/2022]
Abstract
OBJECTIVE Cesarean hysterectomy for the treatment of placenta accreta spectrum (PAS) disorders has the potential to be associated with significant blood loss, massive transfusion, and operative morbidity. Two major contributors to blood loss are the hysterotomy and the bladder dissection. We introduce a new surgical technique and hypothesize that developing the hysterotomy with a linear cutter and mobilization of the bladder using a vessel sealing system (VSS) before clamping uterine arteries will lead to a total reduction in blood loss and transfusion rates. MATERIALS AND METHODS This was a case series, which presents clinical outcomes according to our described surgical technique. The following surgical outcomes were collected: operation time (minutes), estimated blood loss (EBL), intraoperative complications, need for reoperation before discharge, and transfusion rates. Our surgical technique utilizes a linear cutter to create a bloodless hysterotomy and a VSS to dissect the vesicouterine tissue. The VSS cauterizes and transects the small vesicouterine and placental-vesical vascular anastomoses that are prone to bleeding. Once the bladder is mobilized below the level of the cervix, the uterine arteries are ligated to complete the key components of the hysterectomy. RESULTS Of the 23 cases, the median EBL was 1500 cubic centimeters and patients received a median of 1 unit of packed red blood cells. Eleven of the 23 cases did not require any blood transfusion and no patients required massive transfusion. The EBL did not differ between procedures that were performed emergently versus scheduled and it also did not differ between patients that had placenta increta versus placenta percreta, as diagnosed by histopathology. CONCLUSION Use of a linear cutter and closure of the lower anastomosis with VSS prior to clamping uterine artery during cesarean hysterectomy can significantly reduce blood loss and transfusion rates. This technique is applicable in emergent and nonemergent settings as well as for the most challenging procedures complicated by placenta percreta.
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Affiliation(s)
- Ozhan M Turan
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Allison Shannon
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Mehmet R Asoglu
- University of Maryland School of Medicine, Baltimore, MD, USA
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Turan OM, Driscoll C, Cetinkaya-Demir B, Gabbay-Benziv R, Turan S, Kopelman JN, Harman C. Prolonged early antenatal indomethacin exposure is safe for fetus and neonate . J Matern Fetal Neonatal Med 2019; 34:167-176. [PMID: 30905227 DOI: 10.1080/14767058.2019.1599351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 10/27/2022]
Abstract
Objective: To evaluate fetal and neonatal safety of early-onset long-term antenatal indomethacin treatment (LIT) for short cervix.Methods: In this cohort study, women started LIT for short cervix (<25 mm) before completing 25 weeks. They followed a standardized regiment of oral indomethacin: 100 mg loading, 50 mg qid for 48 h, 25 mg qid until delivery or at 32 weeks gestational age (GA), whichever comes first. Weekly monitoring for oligohydramnios and ductus arteriosus (DA) constriction included confirmation of compliance with treatment/dose. This approach is established in our clinical practice. To identify LIT complications separate from prematurity, each neonate exposed to LIT were matched to two unexposed neonatal controls within ±3 days of GA of delivery and birth weight of ±10%. Odds ratios for neonatal variables included pulmonary hemorrhage, patent DA (PDA) requiring medical or surgical correction, necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), intraventricular hemorrhage (IVH) grade III-IV, other intracranial hemorrhage (ICH), neonatal mortality, calculated individually, and for total composite morbidity. Statistical determinants of neonatal morbidity were assessed using binary logistic regression. Exposure to LIT, maternal age, parity, BMI, GA at delivery, birth-weight (BW), neonatal gender, cord artery pH, and 5-min Apgar score were independent variables.Results: 166 LIT cases were matched with 332 controls. LIT median duration was 49 (3-108) days. Mean delivery GA was 34 weeks. LIT was stopped for 5 patients (2.9%) with oligohydramnios and 1 (0.6%) with DA constriction, without consequent morbidity. 71 cases (43%) completed LIT, stopping at 32 weeks. 95 stopped early for preterm premature ruptures of membranes (PPROM) (20%), active labor (11%) or patient choice (22%). Odds of any individual complication did not differ between treated cases and controls. LIT was not a statistical determinant of composite morbidity or any individual neonatal problem.Conclusion: Continuous early-onset indomethacin exposure, up to 15 weeks antenatally, did not increase fetal or neonatal complications. This level of safety is permissive to a randomized trial of indomethacin for the treatment of short cervix.
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Affiliation(s)
- Ozhan M Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Colleen Driscoll
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bilge Cetinkaya-Demir
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rinat Gabbay-Benziv
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sifa Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jerome N Kopelman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chris Harman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Cutting E, Turan OM, Higgs A, Harman C, Turan S. 889: Utility of Noninvasive Prenatal Testing (NIPT) in evaluation of Congenital Heart Defects (CHD). Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.913] [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: 11/15/2022]
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Crimmins SD, Solaru O, Fahey J, Kopelman JN, Turan OM, Harman C. 411: Does personalized smartphone glucose monitoring improve management of gestational diabetes? Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.432] [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: 10/27/2022]
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Turan S, Turan OM, Song H, Seger L, Sidh P, Christopher H, Thompson LP. 236: Micro RNA expression profile in pregnant women complicated fetuses with muscular ventricular septal defects. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.257] [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: 11/25/2022]
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Turan S, Turan OM, Song H, Seger L, Sidh P, Harman C, Thompson LP. 235: Serum microRNA levels from women at risk of congenital heart defects (CHD) with normal fetuses. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.256] [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: 11/28/2022]
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Abstract
The ductus venosus is a fetal vessel that functions importantly in the transfer of oxygen-and nutrient-rich blood from the umbilical vein to vital organs. Its control under active regulation and its anatomy result in a flow-velocity profile that is typically forward throughout the cardiac cycle. This forward cardiac function reflects afterload, cardiac contractility, compliance, and vascular volume changes. Ductus venosus assessment gives valuable information under different fetal conditions. For example, during first trimester screening, an abnormal ductus venosus measurement changes the screening result. Assessment of ductus venosus in twin-to-twin transfusion syndrome is an essential element of staging. In fetal growth restriction, an abnormal waveform mandates imminent delivery. In this review, we will discuss the role of ductus venosus assessment and its role in antenatal management and outcome prediction in certain fetal conditions throughout pregnancy.
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Affiliation(s)
- Sifa Turan
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, Baltimore, USA
| | - Ozhan M Turan
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, Baltimore, USA
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Yao R, Contag SA, Goetzinger KR, Crimmins SD, Kopelman JN, Turan S, Turan OM. The role of fetal growth restriction in the association between Down syndrome and perinatal mortality. J Matern Fetal Neonatal Med 2018; 33:952-960. [PMID: 30196734 DOI: 10.1080/14767058.2018.1511695] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 10/28/2022]
Abstract
Objective: Down syndrome (DS) is associated with significant risk of perinatal mortality. We hypothesize that this association is primarily mediated through the effects of fetal growth restriction (FGR).Methods: This was a retrospective cohort analysis using the US Natality Database from 2011 to 2013. Analysis was limited to singleton nonanomalous pregnancies or confirmed DS pregnancies without severe structural anomalies between 24 and 42 w in gestation. The risk of stillbirth (SB) associated with DS was estimated using both Cox proportional Hazard (HR) regression and accelerated failure time (AFT) methods. The risk of neonatal mortality was estimated using logistic regression analyses. Mediation analysis was then performed to estimate the effect of small for gestational age (SGA), defined as birthweight ≤10th percentile for gestational age, on perinatal mortality associated with DS. All regression models were selected using backward stepwise elimination method. The final regression models included adjustment for maternal age, hypertension, and diabetes.Results: The final cohort included 2446 DS cases among 9,804,718 births. The overall SB rate was 223.6/1000 births in DS group and 4.7/1000 births without DS (p < .001, adjusted hazard ratio (aHR): 58.25; 95% CI [53.44,63.49]). Based on the AFT model, DS survival-to-delivery rate is 4.3 times lower (TR: 0.23; 95% CI [0.22,0.24]). Thirty-five percentage of the effect of DS on stillbirth was mediated through SGA (% mediation:35.1%; 95% CI [33.7,36.4]). The rate of neonatal mortality among DS was 69.0/1000 births compared with 2.8/1000 births without DS (p < .001, adjusted odds ratio (aOR): 27.16; 95% CI: [22.63,32.60]). Only 11.6% of the effect of DS on neonatal deaths was mediated through SGA (%mediation:11.6%; 95% CI [8.4,10.6]).Conclusion: Over one-third of overall stillbirths were mediated through SGA. Routine surveillance of fetal growth and standard SGA surveillance protocols may reduce the risk of perinatal mortality in DS pregnancies. Conversely, it is important to point out that these surveillance strategies may not be effective two-third of the cases not affected by growth restriction.
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Affiliation(s)
- Ruofan Yao
- Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Stephen A Contag
- Department of Obstetrics and Gynecology, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Katherine R Goetzinger
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah D Crimmins
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jerome N Kopelman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sifa Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
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Asoglu MR, Bears B, Turan S, Harman C, Turan OM. The factors associated with mode of delivery in fetuses with congenital heart defects. J Matern Fetal Neonatal Med 2018; 33:816-824. [PMID: 30153755 DOI: 10.1080/14767058.2018.1505855] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 10/28/2022]
Abstract
Objective: It is not evident whether the mode of delivery (MOD) should be modified in pregnancies complicated by fetal congenital heart defects (CHDs). The question as to whether MOD of CHD infants has a significant impact on neonatal outcome remains elusive. The aim of this study was to evaluate factors associated with MOD and its impact on immediate neonatal outcomes in a cohort of late preterm or term fetuses with CHDs born in a tertiary center.Methods: This retrospective study comprised of singleton pregnancies with known fetal CHDs who delivered after 34 0/7 weeks of gestation over a 7-year period. Fetuses with chromosomal abnormality or stillbirths were excluded. Obstetric risk factors were classified as maternal medical, maternal surgical or fetal comorbidities. MOD was classified as elective cesarean delivery (CD) or attempted vaginal delivery (VD). The latter was further categorized as successful VD or intrapartum CD. The study population was stratified into four categories based on the severity of cardiac abnormalities diagnosed by fetal echocardiography. Immediate neonatal outcomes included Apgar scores and umbilical cord artery pH.Results: Of a total of 222 patients, 79.8% underwent attempted VD and 20.2% had elective CD. Of the attempted VD group, 80.2% had successful VD and 19.8% had intrapartum CD. The frequencies of maternal medical, maternal surgical and fetal comorbidities were higher in the elective CD group than in the attempted VD group and also were higher in the intrapartum CD group than in the successful VD group (p < .05 for all). Multivariate logistic regression models revealed that maternal surgical or fetal comorbidities increased the chance of elective CD and maternal medical or fetal comorbidities decreased the chance of successful VD. The severity of CHDs was not an independent factor that affected MOD. Elective or intrapartum CD did not improve immediate neonatal outcomes.Conclusion: Our results demonstrated that preexisting obstetric comorbidities were significant variables that affected the MOD in fetuses with CHD. Vaginal delivery should be attempted unless obstetric and medical contraindications accompany index pregnancy.
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Affiliation(s)
- Mehmet Resit Asoglu
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Breanne Bears
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sifa Turan
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, 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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