Imaging findings in association with altered maternal alpha-fetoprotein levels during pregnancy.

Maternal serum alpha-fetoprotein is a valuable laboratory test used in pregnant women as an indicator to detect certain clinical abnormalities. These can be grouped into four main categories: fetal factors, pregnancy complications, placental abnormalities, and maternal factors. Imaging is an invaluable tool to investigate the various etiologies leading to altered maternal serum alpha-fetoprotein. By reading this article, the radiologist, sonologist, or other health care practitioner should be able to define the probable pathology leading to the laboratory detected abnormal maternal serum levels, thus helping the clinician to appropriately manage the pregnancy and counsel the patient.

Is Foley Catheter Use during a Trial of Labor after Cesarean Associated with Uterine Rupture?

OBJECTIVE: We sought to assess the safety of transcervical Foley catheter (TCF) placement for cervical ripening in women undergoing induction of labor (IOL) after prior cesarean by evaluating the risk of uterine rupture. STUDY DESIGN: We performed a secondary analysis of the Maternal-Fetal Medicine Unit's Cesarean Section Registry, a prospective observational cohort study. We included women with a history of ≤2 low-transverse cesarean deliveries who underwent IOL at ≥24 weeks of gestational age with a live singleton fetus without major anomalies. We excluded those who received prostaglandins or laminaria. We performed multinomial logistic regression to calculate adjusted odds ratios (aORs) for uterine rupture and dehiscence. Relevant confounders included prior vaginal delivery, pregnancy-induced hypertension, chorioamnionitis, and cervical effacement and dilation on admission. RESULTS: A total of 2,564 women were eligible. Unadjusted analysis demonstrated no increased risk of uterine rupture with TCF (1.9 vs. 0.9%; p = 0.10) but an increased risk of uterine dehiscence (1.9 vs. 0.6%; p = 0.02). After adjustment, TCF was not associated with an increased risk of uterine rupture (aOR: 2.02; 95% confidence interval [CI]: 0.71-5.78) or uterine scar dehiscence (aOR: 1.32; 95% CI: 0.37-4.72). CONCLUSION: Foley catheter is a safe tool for mechanical dilation in women undergoing IOL after prior cesarean.

Successful pregnancy in patients with exstrophy-epispadias complex: A University of Washington experience.

INTRODUCTION: With advances in genitourinary reconstructive surgery, women with exstrophy-epispadias complex (EEC) have improved health and quality of life, and may reach reproductive age and consider pregnancy. Despite literature suggesting impaired fertility and higher risk with pregnancy, childbirth is possible. Medical comorbidities, including müllerian anomalies, contribute to increased risk of obstetric and urologic complications during pregnancy. OBJECTIVES: We reviewed our experience with EEC patients who achieved pregnancy to investigate (1) urological characteristics of women who achieved pregnancy; (2) pregnancy management, complications, and delivery; and (3) neonatal outcomes. We developed recommendations for managing pregnancy in women with EEC. STUDY DESIGN/RESULTS: This was a retrospective chart review of 36 female patients with EEC seen at our institution between 1996 and 2013. Female patients less than 18 years, and patients who did not have documented pregnancy were excluded. This resulted in a total of 12 patients with 22 pregnancies. All women with successful pregnancy had bladder exstrophy. The majority had undergone prior bladder augmentation (75%) and were on self-catheterization programs (92%). Thirty-six percent had symptomatic urinary tract infections (UTIs) during pregnancy. Five women had more than one pregnancy. There were four terminations of pregnancy. Of 18 desired pregnancies, there were four spontaneous abortions (SABs) (22%) and 16 live births (78%). The cesarean delivery (CD) rate was 100% (14/14), of which the majority were vertical (classical) uterine incisions with a paramedian skin incision. With the exception of one patient, there were no CD surgical complications. The mean gestational age at delivery was 36 weeks (Range 25 4/7 to 39 4/7 weeks) among eight pregnancies with known gestational age. There were no stillbirths, one neonatal death and no birth defects. DISCUSSION: Women with EEC can have successful pregnancies, though at increased risk for preterm delivery and SABs. In our cohort, the rate of SAB is similar to that described in prior studies. Symptomatic UTIs likely due to self-catheterization were common. Cesarean delivery using a paramedian skin incision and classical uterine incision were not associated with major complications in this cohort. Limitations include reliance on retrospective data and small sample size. The strength of this study is the longitudinal detailed management of pregnancies in EEC women by a single team over time. A multidisciplinary approach to providing a continuum of care from pediatrics through adolescence to adulthood optimizes successful transitions, reproductive health, and successful pregnancies. Based on our experience, an algorithm providing guidance for pregnancy management was developed.

1,5-Anhydroglucitol: a new predictor of neonatal birth weight in diabetic pregnancies.

OBJECTIVE: To determine whether 1,5-anhydroglucitol is predictive of neonatal birth weight. STUDY DESIGN: A retrospective cohort study including 85 pregnancies complicated by diabetes (Type 1=37, Type 2=24, gestational=24). Women had simultaneous hemoglobin A1c and 1,5-anhydroglucitol measurements every 4-8 weeks throughout pregnancy until delivery. Neonatal birth weight was evaluated by standardized z-scores. Linear regression analysis was performed to determine an association of 1,5-anhydroglucitol with neonatal birth weight z-score. RESULTS: Type 1 diabetic patients had the lowest mean 1,5-anhydroglucitol of 3.5mcg/mL (SD=1.6mcg/mL) and highest mean hemoglobin A1c of 6.5% (SD=0.74%) compared to gestational diabetic patients who had the highest mean 1,5-anhydroglucitol of 6.7mcg/mL (SD=3.8mcg/mL) and lowest mean hemoglobin A1c of 6.0% (SD=0.94%). Mean 1,5-anhydroglucitol values were significantly different between diabetes types (p<0.01). Mean neonatal birth weight was above population averages for all diabetes classifications, although mean birth weight z-scores did not differ significantly between diabetic types (p=0.38). Multivariate linear regression showed a negative association between log-transformed 1,5-anhydroglucitol and birth weight (coefficient -0.82, 95% CI -1.19, -0.46). CONCLUSION: In pregnancies complicated by diabetes, low 1,5-anhydroglucitol was associated with increased neonatal birth weight. 1,5-Anhydroglucitol may be useful in the assessment of glycemic control in pregnancy in addition to A1c.

The role of embryonic origin in preeclampsia: a comparison of autologous in vitro fertilization and ovum donor pregnancies.

OBJECTIVE: To compare the risk of gestational hypertension and preeclampsia in pregnancies conceived through standard in vitro fertilization (IVF) using autologous oocytes with pregnancies conceived using donated oocytes. METHODS: We conducted a retrospective, matched cohort study of women undergoing IVF using autologous compared with donor oocytes between 1998 and 2005. Women with live births resulting from oocyte donor pregnancies were matched for age and plurality (singleton or twin) with women undergoing autologous IVF. Primary outcomes were the incidence of preeclampsia or gestational hypertension (with and without proteinuria) in the third trimester. Data on preterm delivery, low birth weight, and embryo cryopreservation were also recorded. RESULTS: Outcome data were available for 158 pregnancies, including 77 ovum-donor recipient pregnancies and 81 pregnancies using autologous oocytes. There were no differences in age, parity, and gestational type between the two cohorts. The incidence of gestational hypertension and preeclampsia was significantly higher in ovum-donor recipients compared with women undergoing autologous IVF (24.7% compared with 7.4%, P<.01, and 16.9% compared with 4.9%, P=.02, respectively). Ovum-donor recipients were more likely than women undergoing autologous IVF to deliver prematurely (34% compared with 19%). This association remained after controlling for multiple gestation (odds ratio 2.6, 95% confidence interval 1.04-6.3). Sixteen pregnancies from cryopreserved embryos were more likely to have hypertensive disorders of pregnancy (odds ratio 5.0, 95% confidence interval 1.2-20.5). CONCLUSION: Pregnancies derived from donor oocytes and cryopreserved-thawed embryos may be at a higher risk for hypertensive disorders of pregnancy. These findings inform future research and help counsel women using assisted reproductive technology.

The association between the length of first stage of labor, mode of delivery, and perinatal outcomes in women undergoing induction of labor.

OBJECTIVE: To estimate the association between the lengths of the first stage of labor, mode of delivery, and perinatal outcomes in women undergoing labor induction. STUDY DESIGN: Retrospective cohort study of singleton, term pregnancies with labor induction and delivered during the second stage. The length of the first stage was examined by 6-hour intervals as predictors of mode of delivery and perinatal morbidity using chi(2) test and multivariable logistic regression analysis. RESULTS: There were 3620 women who met study criteria. Compared with women with a first stage between 0-12 hours, women with longer first stages had a higher risk of cesarean delivery during the second stage, up to an adjusted odds ratio of 7.44 in those with a first stage > or =24 hours (95% confidence interval [CI], 3.43-16.1). Women with a first stage > or =24 hours also had higher odds of postpartum hemorrhage (adjusted odds ratio [aOR], 3.16; 95% CI, 1.73-5.79), chorioamnionitis (aOR, 2.83; 95% CI, 1.19-6.69), and neonatal admission to the intensive care nursery (aOR, 2.03; 95% CI, 1.10-3.74). CONCLUSION: In women who underwent induction of labor, even when a second stage of labor was reached, the risk for cesarean delivery and maternal morbidity remained increased when the length of the first stage was longer than 24 hours. However, in this clinical scenario, the frequency of cesarean delivery remains less than 50%. The decision for surgical intervention thus should not be based on the elapse of time alone.