Expectant management of viable cesarean scar pregnancies: a systematic review.

OBJECTIVE: Cesarean scar pregnancy (CSP) is a potentially life-threatening disease that has been steadily increasing in prevalence. Pregnancy termination is usually recommended given the risk of life-threatening complications. In some cases, patients refuse to terminate viable CSPs, even after counseling. Recent studies report that, even with a high burden of possible complications and maternal morbidity, many CSPs progress to live, close to term births. The aim of this study is to further demonstrate the natural history of viable cesarean scar pregnancies. METHODS: We conducted a systematic review of original studies reporting cases of expectant management of CSPs with positive fetal heartbeats. RESULTS: After selection, 28 studies were included in the review, with a total of 398 cases of CSP, 136 managed expectantly and 117 with positive fetal heartbeat managed expectantly. This study confirmed that the majority of patients experience live births, as 78% of patients selected for expectant management experienced live births at or close to term, with 79% developing morbidly adherent placenta, 55% requiring hysterectomy, and 40% having severe bleeding. DISCUSSION: The optimal management protocol for CSP is still to be defined and more studies are needed to further elucidate this rare but rising disease. Our study provides information on the natural history of untreated CSPs and suggests that termination may not be the only option offered to the patient.

Manejo expectante en preeclampsia severa remota del término (24-33,6 semanas): experiencia en centro de alta complejidad / Expectant management in severe preeclampsia remote from term (24-33.6 weeks): experience in a high complexity center

Resumen Introducción: la preeclampsia severa antes de 34 semanas de gestación tiene alto riesgo de complicaciones maternas y fetales. El manejo expectante, pudiera reducir el riesgo de complicaciones de un parto prematuro. Objetivo: evaluar la efectividad comparativa del manejo expectante en la prevención de desenlaces adversos maternos y perinatales de las pacientes con preeclampsia severa remota del término. Metodología: estudio de cohorte retrospectivo en gestantes con preeclampsia severa entre la 24 a 33,6 semanas, admitidas en un centro de alta complejidad colombiano entre 2011 y 2019. Se compararon medidas descriptivas según el manejo expectante o intervencionistas como grupo de referencia y, de asociación con los desenlaces compuestos maternos y neonatales, además se ajustó por edad gestacional menor a 28 semanas al parto. Resultados: se analizaron 134 pacientes, 110 con manejo expectante y 24 con intervencionista. El manejo expectante tuvo menor probabilidad de cesárea (RR 0,79 IC95% 0,69-0,91) y de resultado compuesto materno (RR 0,67 IC95% 0,57-0,79), que no persistió luego del ajuste. El manejo expectante presentó menor probabilidad de APGAR <7 al minuto (21,6% vs. 40%, RR 0,53 IC95% 0,29-0,97) y de resultado neonatal compuesto (60% vs. 83,3%, RR 0,72 IC95% 0.57-0.90). Al realizar ajuste con edad menor a 28 semanas al parto, el manejo expectante mostró menor probabilidad de APGAR menor a 7 al minuto (RR 0,43 IC95% 0,24-0,75), resultado perinatal adverso compuesto (RR 0,62 IC95% 0,48-0,81), muerte neonatal (RR 0,26 IC95% 0,29-0,71), síndrome de dificultad respiratoria (RR 0,65 IC95% 0,48-0,88), hemorragia intraventricular (RR 0,31 IC95% 0,11-0,89) e ingreso a unidad de cuidados intensivos neonatales (RR 0,80 IC95% 0,70-0,92). Conclusión: la preeclampsia severa remota del término es una patología grave y compleja que enfrenta los intereses maternos y los fetales. Debido al controversial enfoque, su manejo debe realizarse en centros de alta complejidad, con participación interdisciplinaria y anteponiendo la individualidad de cada binomio; nuestros hallazgos sugieren que el manejo expectante es razonable cuando las condiciones maternas y fetales lo permiten, especialmente para gestaciones menores a 28 semanas en favor de mejorar los desenlaces fetales sin detrimento de los desenlaces maternos.

Abstract Introduction: severe preeclampsia before 34 weeks of gestational age has a high risk of maternal and fetal complications. Expectant management could decrease the risk of complications associated with premature birth. Objective: to evaluate the efficacy of expectant management in the prevention of maternal and perinatal adverse events of patients with severe preeclampsia remote from term. Methodology: a retrospective cohort study in pregnant women diagnosed with severe preeclampsia between 24 and 33.6 weeks of gestational age who were admitted in a Colombian high complexity medical center between 2011 and 2019 was carried out. Descriptive measurements of the expectant management and the interventionist management were compared and the association with maternal and neonatal composite outcomes. Results were adjusted by gestational age under 28 weeks of delivery. Results: 134 patients were analyzed; 110 patients with expectant management and 24 interventionist management. Expectant management had a lower probability of cesarean section (RR 0.79 CI95% 0.69-0.91) and maternal composite result (RR 0.67 CI95% 0.57-0.79) that did not persist after the adjustment. Expectant management had a lower probability of APGAR <7 the first minute (21.6% vs. 40%, RR 0.53 CI95% 0.29-0.97) and neonatal composite result (60% vs. 83.3%, RR 0.72 CI95% 0.57-0.90). When adjusting the age under 28 weeks of delivery, the expectant management showed a lower probability of APGAR under 7 at minute one (RR 0.43 CI95% 0.24-0.75), composite outcome of perinatal adverse events (RR 0.62 CI95% 0.48-0.81), neonatal death (RR 0.26 CI95% 0.29-0.71), respiratory distress syndrome (RR 0.65 CI95% 0.48-0.88), intraventricular hemorrhage (RR 0.31 CI95% 0.11-0.89) and admission to the neonatal intensive care unit (RR 0.80 CI95% 0.70-0.92). Conclusion: severe preeclampsia remote from term is a severe and complex disease which faces maternal and neonatal interests. Due to approach controversies, management should be performed in high complexity centers with a multidisciplinary approach individualizing each binomial; our findings suggest expectant management is reasonable when both maternal and fetal conditions allow it, especially in pregnancies under 28 weeks of gestational age to improve fetal outcomes without risking maternal outcomes.

Retrospective evaluation of patients treated for ectopic pregnancy: Experience of a tertiary center

Abstract Objective In recent years, there has been an increase in the incidence of ectopic pregnancies; therefore, it is important for tertiary centers to report their approaches and outcomes to expand and improve treatment modalities. The aim of the present study was to evaluate the general characteristics, treatment and outcomes of cases diagnosed with ectopic pregnancy. Methods In total, 432 patients treated for ectopic pregnancy between February 2016 and June 2019 were retrospectively evaluated. Results Overall, 370 patients had tubal pregnancy, 32 had cesarean scar pregnancy, 18 had pregnancy of unknown location, 6 had cervical pregnancy, and 6 had interstitial pregnancy. The most important risk factors were advanced age (> 35 years; prevalence: 31.2%) and smoking (prevalence: 27.1%). Thirty patients who did not have any symptoms of rupture and whose human chorionic gonadotropin (β-hCG) levels were ≤ 200 mIU/ml were followed-up with expectant management, while 316 patients whose β-hCG levels were between 1,500 mIU/ml and 5,000 mIU/ml did not have an intrauterine gestational sac on the transvaginal or abdominal ultrasound, did not demonstrate findings of rupture, and were treated with a systemic multi-dose methotrexate treatment protocol. In total, 24 patients who did not respond to the medical treatment, 20 patients whose β-hCG levels were > 5,000 mIU/ml, 16 patients who had shown symptoms of rupture at the initial presentation, and 6 patients diagnosed with interstitial pregnancy underwent surgery. Patients with cervical and scar pregnancies underwent ultrasound-guided curettage, and no additional treatment was needed. Conclusion The fertility status of the patients, the clinical and laboratory findings, and the levels of β-hCG are the factors that must be considered in planning the appropriate treatment.

Long-Term Results of Expectant Management of First Episode of Primary Spontaneous Pneumothorax: Is it a Safe Therapeutic Option?

Introduction: Expectant treatment in clinically stable patients with small primary spontaneous pneumothorax (PSP) remains in discussion, partly due to the described increased recurrence rate compared to patients treated with pleural drainage. Objective: To present the experience in the management of grade I PSP, comparing long- and short-term results of patients treated with pleural drainage with those treated expectantly. Methods: We present a retrospective study of patients diagnosed with small asymptomatic or mildly symptomatic PSP. Results: 34 out of 69 patients were treated with pleural drainage and 35 underwent expectant treatment with outpatient management. Both groups were comparable regarding sex, side, size of pneumothorax and history of tobacco smoking. As for the short-term results, there weren't any differences between groups in success therapy, but there were significant differences related to hospital stay, where patients treated with pleural drainage presented longer length of stay. Regarding long-term results, there weren't significant differences in terms of recurrence between both groups. Conclusion: The expectant management of clinically stable patients with small primary spontaneous pneumothorax with strict ambulatory control follow-up and those who comply with treatment recommendations and can obtain prompt emergency medical care presents acceptable long- and short-term results and should be the first choice of treatment.

Type II and III selective fetal growth restriction: perinatal outcomes of expectant management and laser ablation of placental vessels

OBJECTIVES: To describe the perinatal outcomes of type II and III selective fetal growth restriction (sFGR) in monochorionic-diamniotic (MCDA) twin pregnancies treated with expectant management or laser ablation of placental vessels (LAPV). METHODS: Retrospective analysis of cases of sFGR that received expectant management (type II, n=6; type III, n=22) or LAPV (type II, n=30; type III, n=9). The main outcomes were gestational age at delivery and survival rate. RESULTS: The smaller fetus presented an absent/reversed "a" wave in the ductus venosus (arAWDV) in all LAPV cases, while none of the expectant management cases presented arAWDV. The median gestational age at delivery was within the 32nd week for expectant management (type II and III) and for type II LAPV, and the 30th week for type III LAPV. The rate of at least one twin alive at hospital discharge was 83.3% and 90.9% for expectant management type II and III, respectively, and 90% and 77.8% for LAPV type II and III, respectively. CONCLUSION: LAPV in type II and III sFGR twins with arAWDV in the smaller fetus seems to yield outcomes similar to those of less severe cases that received expectant management.

Impact of Latency Duration on the Prognosis of Preterm Infants after Preterm Premature Rupture of Membranes at 24 to 32 Weeks' Gestation: A National Population-Based Cohort Study.

OBJECTIVE: To assess the impact of latency duration on survival, survival without severe morbidity, and early-onset sepsis in infants born after preterm premature rupture of membranes (PPROM) at 24-32 weeks' gestation. STUDY DESIGN: This study was based on the prospective national population-based Etude Épidémiologique sur les Petits Ȃges Gestationnels 2 cohort of preterm births and included 702 singletons delivered in France after PPROM at 24-32 weeks' gestation. Latency duration was defined as the time from spontaneous rupture of membranes to delivery, divided into 4 periods (12 hours to 2 days [reference], 3-7 days, 8-14 days, and >14 days). Multivariable logistic regression was used to assess the relationship between latency duration and survival, survival without severe morbidity at discharge, or early-onset sepsis. RESULTS: Latency duration ranged from 12 hours to 2 days (18%), 3-7 days (38%), 8-14 days (24%), and >14 days (20%). Rates of survival, survival without severe morbidity, and early-onset sepsis were 93.5% (95% CI 91.8-94.8), 85.4% (82.4-87.9), and 3.4% (2.0-5.7), respectively. A crude association found between prolonged latency duration and improved survival disappeared on adjusting for gestational age at birth (aOR 1.0 [reference], 1.6 [95% CI 0.8-3.2], 1.2 [0.5-2.9], and 1.0 [0.3-3.2] for latency durations from 12 hours to 2 days, 3-7 days, 8-14 days, and >14 days, respectively). Prolonged latency duration was not associated with survival without severe morbidity or early-onset sepsis. CONCLUSION: For a given gestational age at birth, prolonged latency duration after PPROM does not worsen neonatal prognosis.

Manejo de la preeclampsia con elementos de severidad antes de las 34 semanas de gestación: nuevos conceptos

La preeclampsia es una de las principales causas de mortalidad materna en el Perú y en el mundo. El manejo de la preeclampsia con elementos de severidad en pacientes con menos de 34 semanas de gestación es un tema polémico. En este artículo presentamos una revisión de la literatura y la evidencia y últimas recomendaciones para el manejo de preeclampsia con elementos de severidad en países de América Latina.

Preeclampsia is one of the main causes of maternal mortality in Peru and the world. Management of preeclampsia with severity elements in patients less than 34 weeks of gestation is controversial. In this article review of the literature and evidence and current recommendations for management of preeclampsia with components of severity in Latin American countries is presented.

Manejo expectante o conservador de preeclampsia grave lejos del término

La preeclampsia grave que se desarrolla antes de las 34 semanas de gestación se asocia con altas probabilidades de mortalidad y morbilidad perinatal. El manejo con la interrupción inmediata puede llevar a altas morbilidades y mortalidad perinatal, y mucho tiempo de hospitalización en unidades intensivas neonatales. Por otro lado, la prolongación del embarazo puede llevar a muertes y asfixia en útero e incrementar la morbilidad materna. El manejo conservador versus agresivo o interrupción inmediata ha sido estudiado en tres estudios clínicos aleatorios, en los que se ha evaluado cerca de 400 pacientes. Estos estudios muestran disminución del síndrome de dificultad respiratoria, pero igual tiempo en unidades de cuidados intensivos y similar mortalidad perinatal. Además, a pesar de prolongar el embarazo por 1 a 2 semanas y no encontrar otros beneficios, se presentaron más pequeños para la edad gestacional y más desprendimiento de placenta. Por lo tanto, en embarazos con menos de 34 semanas se debe administrar corticoides por un periodo de 48 a 72 horas y luego interrumpir. Si el embarazo tiene entre 24 y 28 semanas, además del corticoide se puede considerar el manejo conservador, con posible interrupción ante eventos maternos o fetales.

Severe preeclampsia that develops at <34 weeks of gestation is associated with high perinatal mortality and morbidity rates. Management with immediate delivery leads to high neonatal mortality and morbidity rates and prolonged hospitalization in the neonatal intensive care unit because of prematurity. Conversely, attempts to prolong pregnancy with expectant management may result in fetal death or asphyxia damage in utero and increased maternal morbidity. Expectant care has been compared with interventionist care in three randomized controlled trials (RCTs) that enrolled 400 women. Interventionist care was associated with more respiratory distress syndrome but similar neonatal intensive care unit (NICU) admission and neonatal mortality. Expectant care was associated with a mean pregnancy prolongation of 1-2 weeks, but more small for gestational age (SGA) infants and abruptio placentae. Women with severe preeclampsia before 34 weeks may benefit from stabilization on a 48-72 hour period, to enable maximal effect of antenatal corticosteroids and delivery. Women with severe preeclampsia between 24-28 weeks may benefit from effect of antenatal corticosteroids and observation with possible expectant management and delivery due to maternal o fetal conditions.

Rotura prematura de membranas al termino: manejo expectante por 24 horas e inducción con oxitocina / Premature rupture of membranes at term: expectant management for 24 hours and induction with oxytocin

La conducta más difundida en pacientes con rotura prematura de membranas (RPM) al término es la inducción inmediata por el riesgo de infecciones maternas y neonatales. Para reducir estas complicaciones y mantener una adecuada tasa de parto vaginal se comunican diversos métodos de inducción del parto y profilaxis antibiótica. Este estudio retrospectivo muestra los resultados de una conducta expectante por 24 horas en 115 pacientes consecutivas con embarazos de término entre enero y abril de 2001 con el diagnóstico de RPM; sin signos clínicos de infección, sufrimiento fetal o trabajo de parto al momento de consultar. Una vez cumplidas las 24 horas, las pacientes que no iniciaron trabajo de parto fueron inducidas con oxitocina. Los resultados muestran una tasa de parto vaginal de 84% y un 9,5% de infección ovular clínica en trabajo de parto. La incidencia de infección neonatal fue de 6,9%, sin mortalidad ni secuelas a mediano plazo.

Prelabor rupture of membranes at term is a condition that most obstetricians manage with inmediate labor induction in order to reduce maternal and neonatal infection. Different methods for labor induction and prophylaxis antibiotic treatments are proposed in the medical literature to prevent neonatal sepsis and to lower the cesarean section rate. This retrospective observational study reports the results of a policy of expectant management of 24 hours in 115 consecutive cases between January and April, 2001, in the presence of prelabour rupture of membranes at term. Patients were excluded if clinical chorioamnionitis, fetal distress or labor were present at admission. Patients who did not begin spontaneous labor after 24 hours received intravenous oxytocin for labor induction. The incidence of cesarean section was 16%, with 9.5% of patients with corioamnionitis during labor. There was a 6.9% of neonatal infection without mortality or long term sequelae were present.