Multidisciplinary approach to the surgical management of interstitial ectopic pregnancy.

OBJECTIVE: To present a multidisciplinary approach to localize and resect suspected interstitial ectopic pregnancies. Interstitial ectopic pregnancies are distinct from eccentric intracavitary pregnancies and are defined by ultrasound-based criteria, including an empty uterine cavity, gestational sac located >1 cm from the cavity, thin overlying myometrium <5 mm, and the interstitial line sign. DESIGN: Case report. SETTING: Academic medical center. PATIENT(S): Here, we present the case of a 28-year-old patient at 6 weeks of gestation by last menstrual period who presented to the emergency department with spotting. Initial pelvic ultrasound findings demonstrated a gestational sac and yolk sac that were believed to be located eccentrically within the uterine cavity. Follow-up imaging was performed 2 weeks later that revealed the pregnancy was located at the uterotubal junction and distinct from the endometrial cavity, consistent with an interstitial ectopic. The patient had ongoing light spotting with mild cramping, a benign clinical exam, and normal laboratory findings. Accurate assessment of pregnancy location is critical given that the mortality rate from interstitial pregnancies is twice that of other ectopics. In contrast, live birth rates for eccentric intracavitary pregnancies may be up to 69%, and some clinicians consider expectant management of asymptomatic patients in the first trimester. INTERVENTION: The patient was recommended for inpatient admission with expedited surgical management of interstitial ectopic pregnancy. On laparoscopic entry, the pregnancy was not well-visualized because it did not deform the uterine serosa. MAIN OUTCOME MEASURES: We present a surgical approach to suspected interstitial ectopic pregnancy that is not well-visualized at the time of laparoscopy. RESULTS: The following principles are explored: the use of multiple minimally invasive modalities (laparoscopy and hysteroscopy) to perform a thorough evaluation of the pregnancy location; incorporation of intraoperative ultrasound; temporary vessel ligation and injection of intramyometrial vasopressin; complete enucleation of the products of conception; and closure of the myometrial defect. CONCLUSION: We emphasize the benefits of a multidisciplinary approach for the localization and resection of interstitial ectopic pregnancy. This patient was discharged home in good condition with no complications.

Effects of delayed cord clamping on neonatal hyperbilirubinemia in pre-gestational diabetes at term.

OBJECTIVE: To evaluate the effects of delayed cord clamping on neonatal hyperbilirubinemia in infants born to patients diagnosed with pre-gestational diabetes (type I or type II). METHODS: In January 2016, our institution implemented an organization-wide thirty-second delayed cord clamping protocol. This retrospective cross-sectional study represents infants of mothers diagnosed with pre-gestational diabetes who delivered before and after protocol implementation. The study period was from October 2014 to August 2017. The primary outcome was peak neonatal transcutaneous bilirubin (mg/dL) level during neonatal hospital stay. The secondary outcomes included neonatal serum bilirubin (mg/dL), jaundice requiring phototherapy, hypoglycemia, polycythemia, respiratory distress, and neonatal intensive care unit (NICU) admission. A subgroup analysis for outcomes stratified by type of pre-gestational diabetes was also performed. RESULTS: 145 patients were included in the final analysis. The mean peak neonatal transcutaneous bilirubin level was 10.1 mg/dL ± 3.4 mg/dL for immediate cord clamping and 9.5 mg/dL ± 3.4 mg/dL for delayed cord clamping (p = .25). There were no significant differences between groups for neonatal jaundice requiring phototherapy, hypoglycemia, polycythemia, respiratory distress, or NICU admission. No differences were observed in neonatal outcome by subgroup analysis of pre-gestational diabetes type. CONCLUSION: In our study, there was no significant increase in peak neonatal transcutaneous bilirubin in term (≥37 week) infants of mothers with pre-gestational diabetes after undergoing thirty-seconds of delayed cord clamping. In the absence of contraindications, we advocate for continued use of delayed cord clamping for these infants.

Pregnancy-Associated Myocardial Infarction: A Review of Current Practices and Guidelines.

PURPOSE OF REVIEW: Pregnancy-associated myocardial infarction is a principal cause of cardiovascular disease with a steadily rising incidence of 4.98 AMI events/100,000 deliveries over the last four decades in the USA. It is also linked with significant maternal and fetal morbidity and mortality, with maternal case fatality rate ranging from 5.1 to 37%. The management of acute myocardial infarction can be challenging in pregnant patients since treatment modalities and medication use are limited by their safety during pregnancy. RECENT FINDINGS: Limited guidelines exist regarding the management of pregnancy-associated myocardial infarction. Routinely used medications in myocardial infarction including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and statin therapy are contraindicated during pregnancy. Aspirin use is considered safe in pregnant women, but dual antiplatelet therapy and therapeutic anticoagulation can be associated with increased risk of maternal and fetal complications, and should only be used after a comprehensive benefit-to-risk assessment. The standard approach to revascularization requires additional caution in pregnant women. Percutaneous coronary intervention is generally considered safe but can be associated with high failure rates and poor outcomes depending on the etiology. Fibrinolytic therapy may have significant sequelae in pregnant patients, and hemodynamic management during surgery is complex and adds risk during pregnancy. Understanding the risks and benefits of the different treatment modalities available and their utility depending on the underlying etiology, encompassed with a multidisciplinary team approach, is vital to improve outcomes and minimize maternal and fetal complications.

Affordable Care Act Medicaid Expansion and Racial and Ethnic Disparities in Access to Primary Care.

The Affordable Care Act's (ACA) Medicaid expansions improved access to care for low-income populations, yet evidence is limited on how these gains differed by race/ethnicity. We examined how Medicaid expansions affected access to primary care, and how race/ethnicity moderated these effects. Using 2011-2016 Behavior Risk Factor Surveillance System data, we found that low-income adults in Medicaid expansion states were 13.9 percentage points more likely to have insurance, 5.6 percentage points more likely to have a usual source of care, and 5.0 percentage points less likely to delay care due to cost post-expansion versus in non-expansion states. Insurance gains were 6.4 percentage points lower for Hispanic adults than White adults in expansion states post-expansion; otherwise, gains were similar by race/ethnicity. Baseline access disparities between White and minority adults persisted post-expansion, especially between White and Hispanic adults. Access may decline comparably for White and minority adults if ACA Medicaid expansions are repealed.

Antenatal ultrasound compared to MRI evaluation of fetal myelomeningocele: a prenatal and postnatal evaluation.

Background Spina bifida affects 0.5-1 in 1000 pregnancies in the United States and is often diagnosed in the mid-second trimester. The objective of the study was to directly compare ultrasounds (US) and magnetic resonance imaging (MRI) obtained in the antenatal period in the diagnosis and localization of fetal myelomeningocele (MMC) and compare these with the postnatal outcomes of these infants Methods A retrospective analysis of patients referred to the Fetal Care Center at the Cleveland Clinic from 2005 to 2017. US and MRIs were obtained from the Cleveland Clinic electronic medical record. Infants were followed-up at an interdisciplinary myelomeningocele pediatrics clinic. Results MRI and US varied in correlation with physical exam at the time of birth and surgery. While no differences were detected in demographics, pregnancy outcomes or pediatric outcomes, it was noted that the majority of patients developed neurogenic bladders irrespective of the lesion level. Conclusion MRI is not superior to US in the diagnosis of MMC. Pregnancies complicated by MMC do not vary in morbidity, and pediatric outcomes remain similar regardless of the lesion level. This data provides additional information for the counseling of patients when faced with this antenatal diagnosis.

Second Trimester Cervical Ectopic Pregnancy and Hemorrhage: A Case Report and Review of the Literature.

Cervical ectopic pregnancies are a rare occurrence in the United States. Here we present the interdisciplinary and conservative management approach to a cervical ectopic at an advanced gestational age. In addition, we review the surgical management of hemorrhage from cervical ectopic pregnancies, which is often catastrophic and life-threatening.

Antibiotics after preterm premature rupture of the membranes.

Preterm premature rupture of the membranes remains a common cause of preterm deliveries and neonatal morbidities. The goal of this study is to review the evidence with regard to the antibiotic treatment after preterm premature rupture of the membranes, long-term outcomes related to antibiotic treatment, and possible complications with treatment. Future research goals are also discussed.

Pregravid obesity associates with increased maternal endotoxemia and metabolic inflammation.

Obese pregnant women develop severe insulin resistance and enhanced systemic and placental inflammation, suggesting associated modifications of endocrine and immune functions. Activation of innate immunity by endotoxins/lipopolysaccharides (LPS) has been proposed as a mechanism for enhancing metabolic alterations in disorders with insulin resistance. The aim of this study was to characterize the immune responses developed by the adipose tissue (AT) and their potential links to maternal endotoxemia in pregnancy with obesity. Blood and subcutaneous abdominal AT were obtained from 120 lean and obese women (term pregnancy) recruited at delivery. Gene expression was assessed in AT and stromal vascular cells isolated from a subset of 24 subjects from the same cohort. Doubling of plasma endotoxin concentrations indicated subclinical endotoxemia in obese compared with lean women. This was associated with significant increase in systemic C-reactive protein and interleukin-6 (IL-6) but not tumor necrosis factor-α (TNF-α) concentrations. AT inflammation was characterized by accumulation of CD68(+) macrophages with a threefold increased gene expression of the macrophage markers CD68, EMR1, and CD14. Gene expression for cytokines IL-6, TNF-α, IL-8, and monocyte chemotactic protein-1 (MCP1) and for LPS-sensing CD14, toll-like receptor 4 (TLR4), translocating chain-associated membrane protein 2 was 2.5-5-fold higher in stromal cells of obese compared to lean. LPS-treated cultured stromal cells of obese women expressed a 5-16-fold stimulation of the same cytokines upregulated in vivo. Our data demonstrate that subclinical endotoxemia is associated with systemic and AT inflammation in obese pregnant women. Recognition of bacterial pathogens may contribute to the combined dysfunction of innate immunity and the metabolic systems in AT.

Birth weight and body composition of neonates born to Caucasian compared with African-American mothers.

OBJECTIVE: To estimate whether neonates of African-American women have lower birth weights because of either decreased lean body mass or fat mass. METHODS: A secondary analysis of a cohort of 104 African-American and 274 Caucasian term, singleton, healthy pregnancies. Women with existing or gestational diabetes were excluded. Neonatal body composition was estimated using anthropometric measurements. RESULTS: There were significant differences in maternal age (29.5 compared with 25.8, P<.001), prepregnancy body mass index (26.2 compared with 30.9 kg/m, P<.001), and weight gain during pregnancy (15.2 compared with 13.4 kg, P=.03) in Caucasian compared with African-American women, respectively. After adjusting for these factors, African-American women's neonates had significantly lower birth weights (3.20 compared with 3.36 kg, P=.003), less lean body mass (2.80 compared with 2.94 kg, P=.002), but no difference in fat mass (392 compared with 417 g, P=.078). CONCLUSION: Decreased birth weight in African-American neonates is due to lower lean body mass and not a difference in adiposity.