Patient-Prosthesis Mismatch in Pregnancy: A Multidisciplinary Approach.

A 24-year-old gravida 3 para 1 woman with history of bioprosthetic aortic valve replacement complicated by patient-prosthesis mismatch presented for prenatal care. Her pregnancy was managed by a multidisciplinary cardio-obstetrics team, resulting in an uncomplicated repeat cesarean section at term.

Two pregnancies in a patient following pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension.

Pregnancies complicated by pulmonary hypertension are associated with a high rate of maternal morbidity and mortality. Pulmonary endarterectomy is a curative treatment for pulmonary hypertension in select patients with chronic thromboembolic pulmonary hypertension. Limited data exist regarding the maternal and perinatal outcomes following pulmonary endarterectomy.We present the case of a patient in her 20s with antiphospholipid antibody syndrome and chronic thromboembolic pulmonary hypertension who underwent pulmonary endarterectomy and subsequently carried two pregnancies. Her cardiopulmonary status remained stable throughout both pregnancies. Her first pregnancy was complicated by HELLP syndrome requiring induction of labour at 30 weeks, and her second child was born at term. In summary, this patient's course provides cautious optimism that a curative pulmonary endarterectomy may allow a patient to avoid complications of pulmonary hypertension during pregnancy.

Report of a novel variant in the FAM111A gene in a fetus with multiple anomalies including gracile bones, hypoplastic spleen, and hypomineralized skull.

Kenny-Caffey syndrome type 2 (KCS2) and osteocraniostenosis (OCS) are allelic disorders caused by heterozygous pathogenic variants in the FAM111A gene. Both conditions are characterized by gracile bones, characteristic facial features, hypomineralized skull with delayed closure of fontanelles and hypoparathyroidism. OCS and KCS2 are often referred to as FAM111A-related syndromes as a group; although OCS presents with a more severe, perinatal lethal phenotype. We report a novel FAM111A mutation in a fetus with poorly ossified skull, proportionate long extremities with thin diaphysis, and hypoplastic spleen consistent with FAM111A-related syndromes. Trio whole exome sequencing identified a p.Y562S de novo missense variant in the FAM111A gene. The variant shows significant similarity to other reported pathogenic mutations fitting proposed pathophysiologic mechanism which provide sufficient evidence for classification as likely pathogenic. Our report contributed a novel variant to the handful of OCS and KCS2 cases reported with pathogenic variants.

A Pilot Study of a Sleep Intervention Delivered through Group Prenatal Care to Overweight and Obese Women.

OBJECTIVES: We sought to investigate the feasibility of a behavioral sleep intervention for insomnia, delivered through group prenatal care and the relationship of this intervention to improvements in insomnia symptoms and sleep quality. PARTICIPANTS: Women receiving prenatal care and reporting a pre-pregnancy BMI of ≥25 kg/m2 and sleep duration of <6.5 h per night. METHODS: Participants were randomized to group prenatal care or group prenatal care with a behavioral sleep intervention, adapted from cognitive behavioral therapy for insomnia (CBT-I) online program Go! to Sleep®. In the second trimester (T1), late third trimester (T2) and 6-8 weeks postpartum (T3) study assessments were completed including the Insomnia Severity Index, Pittsburgh Sleep Quality Index, fasting glucose and insulin and weight and height. Data were analyzed using independent samples t-tests, chi-square tests, correlations, and two-way repeated measures ANOVA where appropriate. P < .05 was set as the level of significance. RESULTS: From May 2014 to April 2015, 311 women were evaluated for inclusion and 53 women were randomized to participate (27 intervention; 26 control), 15% were lost to follow up. The intervention group had lower third trimester and postpartum levels of moderate to severe insomnia (T2 50.0% vs 85.0% (p = .018) and T3 13.6% vs 52.4% (p-.008)) and mean insomnia severity scores (T2 (14.7 (±6.6) vs 19.3 (± 6.0) p = .02) and T3 (9.7 (±5.4) vs 15.1(±7.2) p = .01)) when compared to the control group. CONCLUSION: A randomized controlled trial of a behavioral sleep intervention for insomnia delivered through group prenatal care led to improvements in insomnia symptoms.

Excessive Gestational Weight Gain.

Excessive gestational weight gain (GWG) is associated with an increasing incidence of maternal and neonatal complications, including hypertensive disorders of pregnancy, fetal macrosomia, and increased cesarean birth rates. In the United States, it is recommended that health care providers use an individualized approach to counsel a woman about pregnancy weight gain goals that is based on the woman's initial body mass index (BMI) and to track GWG throughout the pregnancy by evaluating maternal weight at each visit. Studies have shown that women entering pregnancy with a higher BMI are at increased risk for excessive GWG and postpartum weight retention. Research also demonstrates an increased risk of childhood obesity in children born to women with excessive GWG. Specific counseling about exercise and diet, as well as technology and motivational interviewing, are some tools prenatal care providers can use that have been shown to be effective in reducing excessive GWG. This article reviews the current research regarding maternal and neonatal risks associated with excessive GWG, as well as the interventions that have demonstrated promise for addressing this problem.

Pregnancy as a window to future health: maternal placental syndromes and short-term cardiovascular outcomes.

BACKGROUND: Cardiovascular disease is the leading cause of death among women. Identifying risk factors for future cardiovascular disease may lead to earlier lifestyle modifications and disease prevention. Additionally, interpregnancy development of cardiovascular disease can lead to increased perinatal morbidity in subsequent pregnancies. Identification and implementation of interventions in the short term (within 5 years of first pregnancy) may decrease morbidity in subsequent pregnancies. OBJECTIVE: We identified the short-term risk (within 5 years of first pregnancy) of cardiovascular disease among women who experienced a maternal placental syndrome, as well as preterm birth and/or delivered a small-for-gestational-age infant. STUDY DESIGN: We conducted a retrospective cohort study using a population-based, clinically enhanced database of women in the state of Florida. Nulliparous women and girls aged 15-49 years experiencing their first delivery during the study time period with no prepregnancy history of diabetes mellitus, hypertension, or heart or renal disease were included in the study. The risk of subsequent cardiovascular disease was compared among women who did and did not experience a placental syndrome during their first pregnancy. Risk was then reassessed among women with placental syndrome and preterm birth or delivering a small-for-gestational-age infant vs those without these adverse pregnancy outcomes. RESULTS: The final study population was 302,686 women and girls. Median follow-up time for each patient was 4.9 years. The unadjusted rate of subsequent cardiovascular disease among women and girls with any placental syndrome (11.8 per 1000 women) was 39% higher than the rate among women and girls without a placental syndrome (8.5 per 1000 women). Even after adjusting for sociodemographic factors, preexisting conditions, and clinical and behavioral conditions associated with the current pregnancy, women and girls with any placental syndrome experienced a 19% increased risk of cardiovascular disease (hazard ratio, 1.19; 95% confidence interval, 1.07-1.32). Women and girls with >1 placental syndrome had the highest cardiovascular disease risk (hazard ratio, 1.43; 95% confidence interval, 1.20-1.70), followed by those with eclampsia/preeclampsia alone (hazard ratio, 1.42; 95% confidence interval, 1.14-1.76). When placental syndrome was combined with preterm birth and/or small for gestational age, the adjusted risk of cardiovascular disease increased 45% (95% confidence interval, 1.24-1.71). Women and girls with placental syndrome who then developed cardiovascular disease experienced a 5-fold increase in health care-related costs during follow-up, compared to those who did not develop cardiovascular disease. CONCLUSION: Women and girls experiencing placental syndromes and preterm birth or small-for-gestational-age infant are at increased risk of subsequent cardiovascular disease in short-term follow-up. Strategies to identify and improve cardiovascular disease risk in the postpartum period may improve future heart disease outcomes.

Sleep Disordered Breathing and Adverse Pregnancy Outcomes.

Sleep disordered breathing (SDB) occurs in 0.6% to 15% of reproductive-aged women. Because of an overlap in symptoms of SDB and normal pregnancy findings, the diagnosis of SDB in pregnancy is challenging. The repetitive arousals, sleep fragmentation, and hypoxias experienced by patients with SDB lead to an increase in oxidative stress and inflammation. In the nonpregnant population SDB is associated with an increased risk of diabetes mellitus, heart disease, and stroke. Increasing evidence identifies an association between SDB in pregnancy and gestational diabetes, preeclampsia, and fetal growth abnormalities.

Does Laparoscopic Hysterectomy Increase the Risk of Vaginal Cuff Dehiscence? An Analysis of Outcomes from Multiple Academic Centers and a Review of the Literature.

Vaginal cuff dehiscence represents a serious, but infrequent complication after hysterectomy, with a reported increased incidence following a laparoscopic approach. Various risk factors have been proposed including laparoscopically placed suture, surgical experience, use of electrosurgery, surgical indication, and obesity. Technical aspects of the procedure itself have also been questioned such as the variable use of monopolar electrosurgery during colpotomy and the suture type or number of layers chosen to reapproximate the vaginal cuff. Nothwithstanding the tendency for cuff dehiscence to occur following laparoscopic approach, there remains a paucity of high-quality data that supports or refutes this finding or clearly defines the mechanism(s) by which this event occurs allowing for the proposal of objective guidelines for reducing risk. Various techniques have been proposed to decrease the risk of vaginal cuff dehiscence during endoscopic hysterectomy, including use of monopolar current on cutting mode, achievement of cuff hemostasis with sutures rather than electrocoagulation, use of a two-layer cuff closure with polydioxanone suture, and use of bidirectional barbed suture for cuff closure. The authors experience at three university-based minimally invasive gynecologic surgery programs showed a low rate of vaginal cuff dehiscence in their own practices. Large randomized controlled trials are needed to truly determine whether there is a difference in vaginal cuff dehiscence between surgical modalities for hysterectomy as well as to determine the true risk factors.

Gallstone and Severe Hypertriglyceride-Induced Pancreatitis in Pregnancy.

IMPORTANCE: Patients with biliary disease or underlying dyslipidemias are at risk for pancreatitis in pregnancy. Appropriate treatment can decrease the risk of recurrence and perinatal complications. Prevention of severe lipid elevations can prevent the development of pancreatitis in pregnancy. OBJECTIVE: To review the pathophysiology, diagnosis and treatment of gallstone and severe hypertriglyceride-induced pancreatitis in pregnancy. EVIDENCE ACQUISITION: We performed a literature search regarding pancreatitis, gallstones, hyperlipidemia, and the treatment of both severe hypertriglyceride-induced pancreatitis and gallstone pancreatitis in pregnancy. RESULTS: In the setting of acute pancreatitis, removal of the offending agent, either gallstones or serum lipids, can lead to improved status and decrease recurrence risk. CONCLUSIONS AND RELEVANCE: Patients with acute pancreatitis should be treated with analgesia and fluid resuscitation and maintain a nothing-per-os status. In cases of gallstone pancreatitis, removal of the offending stone through endoscopic retrograde cholangiopancreatography or cholecystectomy can decrease recurrence risk. Severe hypertriglyceride-induced pancreatitis includes similar management. Lipopheresis may be considered in refractory cases. Patients with severe hypercholesterolemia should maintain a low-fat diet and can continue lipid-lowering agents outside the statin class of medications. Preventing severe dyslipidemia in gestation can decrease the risk of pancreatitis and improve maternal and neonatal outcomes.

Sleep-disordered breathing and future cardiovascular disease risk.

Sleep-disordered breathing occurs in 0.6-15% of reproductive age women. This condition is associated with an increased lifetime risk of cardiovascular disease, cardiovascular mortality, and all-cause mortality. A substantial body of evidence demonstrated increased perinatal morbidity among pregnancies affected by SDB including gestational diabetes, gestational hypertension, and preeclampsia. These same conditions are predictive of later cardiovascular disease. Treatment of SDB has been demonstrated to decrease future cardiovascular events and mortality. Screening at-risk individuals in the perinatal period can identify women with SDB, who can benefit from treatment. Continuous positive airway pressure and lifestyle interventions can decrease subsequent adverse cardiovascular health outcomes.

Maternal opioid drug use during pregnancy and its impact on perinatal morbidity, mortality, and the costs of medical care in the United States.

OBJECTIVE: To identify factors associated with opioid use during pregnancy and to compare perinatal morbidity, mortality, and healthcare costs between opioid users and nonusers. METHODS: We conducted a cross-sectional analysis of pregnancy-related discharges from 1998 to 2009 using the largest publicly available all-payer inpatient database in the United States. We scanned ICD-9-CM codes for opioid use and perinatal outcomes. Costs of care were estimated from hospital charges. Survey logistic regression was used to assess the association between maternal opioid use and each outcome; generalized linear modeling was used to compare hospitalization costs by opioid use status. RESULTS: Women who used opioids during pregnancy experienced higher rates of depression, anxiety, and chronic medical conditions. After adjusting for confounders, opioid use was associated with increased odds of threatened preterm labor, early onset delivery, poor fetal growth, and stillbirth. Users were four times as likely to have a prolonged hospital stay and were almost four times more likely to die before discharge. The mean per-hospitalization cost of a woman who used opioids during pregnancy was $5,616 (95% CI: $5,166-$6,067), compared to $4,084 (95% CI: $4,002-$4,166) for nonusers. CONCLUSION: Opioid use during pregnancy is associated with adverse perinatal outcomes and increased healthcare costs.

Perinatal outcomes and hospital costs in gastroschisis based on gestational age at delivery.

OBJECTIVE: To investigate the association between gestational age at delivery and perinatal outcomes among gastroschisis-affected pregnancies that result in live birth. METHODS: We conducted a retrospective cohort study using a linked maternal-infant database for more than 2.3 million liveborn neonates in Florida from 1998 to 2009. Cases were identified using a combination of International Classification of Diseases, 9th Edition, Clinical Modification, diagnosis and procedure codes indicative of gastroschisis. We restricted our analyses to singleton cases without another major birth defect or medical conditions that would justify early elective delivery. We categorized cases based on gestational age in weeks and compared perinatal outcomes. RESULTS: Among 1,005 neonates with gastroschisis, 324 (32.3%) were isolated, singleton cases without an additional indication for early delivery. We observed decreased rates of adverse pregnancy outcomes among those neonates delivered in the early term period (37-38 weeks of gestation) compared with preterm (less than 34 weeks of gestation); specifically, jaundice (18.5% compared with 42.3%, P=.01) and respiratory distress syndrome (5.9% compared with 23.1%, P≤.01). As the gestational age at birth increased, we observed fewer mean number of days spent in the hospital (less than 34 weeks of gestation: 55.9, P<.01; 34-36 weeks of gestation: 51.9, P=.02; 37-38 weeks of gestation: 36.9 [reference]) and lower direct inpatient medical costs (in thousands, U.S. dollars; less than 34 weeks of gestation: 79, P=.01; 34-36 weeks of gestation: 71, P=.04; 37-38 weeks of gestation: 51 [reference]) per infant in the first year of life. CONCLUSION: In pregnancies complicated by gastroschisis, and with no other known major indications, birth at early term or later term gestation, when compared with delivery before 37 weeks of gestation, is associated with improved perinatal outcomes and lower medical costs. LEVEL OF EVIDENCE: II.

Positive interferon-γ release assay leading to a diagnosis of Mycobacterium tuberculosis pericarditis in pregnancy.

BACKGROUND: Tuberculosis during pregnancy is associated with increased complications. The wide range of presentations among patients with extrapulmonary tuberculosis can make diagnosis and treatment difficult. CASE: We present the case of a patient with Mycobacterium tuberculosis pericarditis presenting in pregnancy with recurrent pericardial effusions. The diagnosis of active tuberculosis was made and treatment initiated after a positive interferon-gamma release assay and granulomatous pericardial pathology despite negative tuberculin skin testing. Culture of pericardial tissue obtained by pericardectomy confirmed the diagnosis 1 month after initiation of treatment. CONCLUSION: This case report demonstrates the use of interferon-gamma release assay in diagnosing tuberculosis among high-risk pregnant patients. Although limited by expense and minimal experience in pregnancy, these assays may be useful to screen for tuberculosis in high-risk pregnant populations.

Postmortem ultrasonography of the macerated fetus complements autopsy following in utero fetal demise.

Postmortem evaluation following an in utero fetal demise is essential for determining cause of death and counseling regarding future pregnancies. Severe maceration and fetal size along with patient desires may limit the physician's ability to perform a complete autopsy. In the cases presented, we demonstrate the utility of postmortem ultrasonography as an adjunct to traditional autopsy following fetal demise.