Management of abnormal serum markers in the absence of aneuploidy or neural tube defects.

OBJECTIVE: Few guidelines address the management of pregnancies complicated by abnormal maternal serum analytes (MSAs) in the absence of aneuploidy or neural tube defects (NTDs). Our objective was to gather preliminary data regarding current opinions and management strategies among perinatologists in the US. METHODS: This survey of Maternal Fetal Medicine (MFM) physicians and fellows used a secure electronic web-based data capture tool. RESULTS: A total of 545 potential participants were contacted, and 136 (25%) responded. The majority were experienced academic physicians with robust practices. Nearly all (97.7%) respondents reported a belief in an association between abnormal MSAs and adverse pregnancy outcomes other than aneuploidy or NTDs. Plasma protein A (PAPP-A) and α-fetoprotein (AFP) were most often chosen as markers demonstrating a strong association with adverse outcomes. Most (86.9%) respondents acknowledged that abnormal MSAs influenced their counseling approach, and the majority (80.1%) offered additional ultrasound examinations. Nearly half started at 28 weeks and almost one-third at 32 weeks. Respondents acknowledging a relevant protocol in their hospital or practice were more likely to offer additional antenatal testing (p = 0.01). CONCLUSIONS: Although most perinatologists were in agreement regarding the association of MSAs with adverse pregnancy outcomes, a lack of consensus exists regarding management strategies.

A modified fetal heart rate tracing interpretation system for prediction of cesarean section.

OBJECTIVE: To investigate whether a modified version of the 2008 National Institute of Child Health and Human Development (NICHD) interpretation system upon admission decreases cesarean delivery risk. METHODS: This retrospective cohort study ascribed a modified category to the first 30 min of fetal heart rate (FHR) tracings in labor. Category I was divided into two subsets (Ia and Ib) by the presence of accelerations. Category II was divided into four subsets (IIa-IId) based on baseline FHR, variability, response to stimulation and decelerations. Log-binomial regression was used to calculate risk ratios (RR) and 95% confidence intervals (CI). RESULTS: A category was ascribed to 910 women. Most FHR tracings were Category Ia (65.8%), Ib (7.7%), IIb (11.8%) and IId (14.0%). Category Ib tracings (fewer than two accelerations) were 2.26 (95% CI: 1.13-4.52) times more likely to result in cesarean delivery for abnormal FHR tracing than Category Ia tracings. A similar increase in risk was seen when comparing Category IIb and Category IId with Category Ia. CONCLUSION: Application of a modified version of the 2008 NICHD FHR interpretation system to the initial 30 min of labor can identify women at increased risk of cesarean delivery for abnormal FHR tracing.

Vaginal cuff dehiscence after different modes of hysterectomy.

OBJECTIVE: To update the incidence of vaginal cuff dehiscence after different modes of hysterectomy and to describe surgical and patient characteristics of dehiscence complications. METHODS: This was an observational cohort study at a large academic hospital. All women who underwent hysterectomy and dehiscence repair between January 2006 and December 2009 were identified. Data from this study period were analyzed separately and in combination with our preliminary study (January 2000 to December 2005) for a 10-year analysis (January 2000 to December 2009). The primary outcome was incidence of vaginal cuff dehiscence after total laparoscopic hysterectomy compared with abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy (LAVH). RESULTS: Between 2006 and 2009, the overall incidence of dehiscence was 0.39% (95% confidence interval [CI] 0.21-0.56). The incidence after total laparoscopic hysterectomy was 0.75% (95% CI 0.09-1.4), which was the highest among all modes of hysterectomy (LAVH was 0.46% [95% CI 0.0-1.10]; total abdominal hysterectomy was 0.38% [95% CI 0.16-0.61]; and total vaginal hysterectomy was 0.11%, [95% CI 0.0-0.32]). This incidence was appreciably lower than previously reported (4.93% in 2007 publication, 2.76% readjusted calculation). The 10-year cumulative incidence of dehiscence after all modes of hysterectomy was 0.24% (95% CI 0.15-0.33) and 1.35% (95% CI 0.72-2.3) among total laparoscopic hysterectomies. During the 10-year study period, total laparoscopic hysterectomy-related dehiscence was significantly increased compared with other modes of hysterectomy, with a risk ratio of dehiscence after total laparoscopic hysterectomy of 9.1 (95% CI 4.1-20.3) compared with total abdominal hysterectomy, risk ratio of 17.2 (95% CI 3.9-75.9) compared with total vaginal hysterectomy, and risk ratio of 4.9 (95% CI 1.1-21.5) compared with LAVH. CONCLUSION: Our updated 1.35% incidence of dehiscence after total laparoscopic hysterectomy is much lower than previously reported. LEVEL OF EVIDENCE: II.