Ultrasound Appearance of the Endometrium Post-Radiofrequency Ablation.

OBJECTIVE: To describe the ultrasonographic appearance of the post-ablative endometrium to improve knowledge of its sonographic findings. METHODS: This was an Institutional Review Board approved prospective study of patients who underwent second-generation endometrial ablation from 2016 to 2019 at a single health system. Patients had postoperative transvaginal ultrasounds at 2, 6, and 12 months. Ultrasound reports were analyzed for endometrial thickness, description of the endometrium and myometrium, presence of uterine fibroids, and uterine size. Statistical tests for repeated measures were utilized. RESULTS: There were 68 patients with the average age of 42 (SD 6) years and a BMI of 33 (SD 8). Preoperatively the average endometrial thickness was 10 mm, uterine length was 9.7 cm, and 38.2% had leiomyoma. The average endometrial thickness decreased at each ultrasound: 8.4 mm (SD 3.4), 7.2 mm (SD 3.0), and 5.8 mm (SD 2.5) at 2, 6, and 12 months, respectively. When comparing endometrial thickness postoperatively there was a significant difference at 2 and 12 months (P = .041), and 6 and 12 months (P = .031). There was no change during the postoperative period in the presence of leiomyoma, hyperechoic endometrium, hypoechoic endometrium, heterogeneous endometrium, and cystic endometrium on the ultrasounds. CONCLUSION: After ablation with a second-generation device, the endometrial thickness on ultrasound decreases with time following surgery. Additional studies correlating these findings to clinical outcomes would be useful.

Indications for Maternal Echocardiography in Detecting Disease and the Impact on Pregnancy Management.

OBJECTIVE: Few obstetric-specific guidelines detail the indications for screening echocardiography in pregnancy. The objective of the study is to examine the association of common indications for maternal echocardiography with the likelihood of abnormality identification, pregnancy management alteration, and conformity with current American College of Cardiology Foundation (ACCF) guidelines. STUDY DESIGN: This retrospective cohort analysis categorized all echocardiograms performed within pregnancy and the first month postpartum within a tertiary health system to correlate indications with abnormal findings. RESULTS: Data from 226 echocardiograms were analyzed from 205 women. The most common indication for initial echocardiography was cardiac symptoms (34.6%). History of cardiac disease was the only indication demonstrating a significant association with an abnormal finding on initial echocardiography (odds ratio [OR]: 2.6; p = 0.006). Postpartum status (OR: 4.9; p < 0.001), multiparity (p < 0.001), and tobacco use (OR: 2.2; p = 0.011) were demographic characteristics associated with the identification of abnormal findings on initial echocardiography. Abnormal echocardiographic findings were associated with changes in clinical management but did not correlate with adverse obstetric or neonatal outcomes, which may support the impact of a multidisciplinary programmatic approach. ACCF appropriateness criteria correlated well with identification of abnormal echocardiographic results (p = 0.034). CONCLUSION: Although the presence of cardiac symptoms or history of diabetes failed to demonstrate association with abnormal echocardiographic findings, a history of prior cardiac disease, tobacco use, multiparity, and postpartum status were factors associated with identification of abnormal findings on initial maternal echocardiography. The ACCF appropriateness criteria for obtaining echocardiography can be applied to pregnant women with consideration for these additional risk factors. KEY POINTS: · The ACCF criteria are applicable in pregnancy for appropriateness of echocardiography indications.. · Several clinical factors often prompt performance of echocardiography in pregnancy without merit.. · Consideration for multiparty, tobacco abuse, and postpartum state should coincide with ACCF criteria..

The effect of combined spinal epidural versus epidural analgesia on fetal heart rate in laboring patients at risk for uteroplacental insufficiency.

BACKGROUND: The effects of neuraxial analgesia on fetal heart tracings have been studied in "healthy" pregnancies. Our objective was to compare the impact of intrapartum epidural analgesia (EA) versus combined spinal epidural analgesia (CSE) on fetal heart rate changes in pregnancies at risk for uteroplacental insufficiency (UPI). METHODS: Singleton pregnancies diagnosed with chronic hypertension, gestational hypertension and/or preeclampsia, and/or fetal growth restriction (FGR) and receiving neuraxial analgesia intrapartum from 2012 to 2015 were studied retrospectively. The primary outcome was change in fetal heart rate (FHR) category following neuraxial analgesia. Manual review of all FHR tracings was performed and classified by the National Institute of Child Health and Human Development (NICHD) categories. Data collection included maternal demographics, blood pressure, uterine tachysystole, uterine hypertonus, mode of delivery, interventions for FHR abnormalities and neonatal outcomes. RESULTS: Of laboring patients at risk for UPI, 110 patients received EA and 127 patients received CSE. The rate and change in FHR categories and abnormalities following neuraxial analgesia were the same in both groups. Both EA and CSE resulted in a significant increase in NICHD FHR category II, from 27.3 to 65.5% for EA and 20.9 to 64.3% for CSE. The occurrence of maternal hypotension, uterine tachysystole, interventions for FHR abnormalities, and uterine hypertonus following neuraxial analgesia was not found to be significantly different between the two groups. When compared to the EA group, CSE had a higher rate of NICU admission (29.5 versus 16.4%, p = .021). CONCLUSIONS: FHR category increased following both CSE and EA. The side effects of maternal hypotension and need for fetal interventions was not different between CSE and EA.

The Maternal Impact, Health Burden, and Postpartum Sequela in Triplet Pregnancies: A Retrospective Cohort.

OBJECTIVE: The aim of the study is to describe the maternal health burden and perinatal outcomes in triplet pregnancies, and identify the maternal and pregnancy indicators associated with increased perinatal morbidity and mortality. STUDY DESIGN: This is a retrospective cohort study of triplet pregnancies from 2007 to 2014. Maternal data were manually collected and assessed until 6 weeks postpartum, and neonatal data were assessed until hospital discharge or death. RESULTS: Eighty-two triplet pregnancies were identified with 246 babies born. Mean gestational age at delivery was 32.3 (standard deviation [SD] ± 3.6) weeks and average birth weight was 1,726 g (SD ± 500). There were 12 perinatal deaths and 25 (10.2%) infants diagnosed with a congenital anomaly. Prior preterm birth and nulliparity had a negative impact on gestational age at delivery (p = 0.016) as compared with prior full-term births. Pregnancy complications (preeclampsia or hypertensive disorders [46.3%], gestational diabetes [28%], postpartum hemorrhage [9.8%], and blood transfusions [8.5%]) also impacted gestational age at delivery (33.0 vs. 34.0 weeks, p = 0.031). Spontaneous conception, chorionicity, and maternal medical problems did not have an impact on median gestational age. CONCLUSION: Nulliparity and presence of pregnancy complications are pertinent to triplet outcomes. This study provides valuable information for anticipatory guidance and preconception counseling to patients considering artificial reproductive technology.

Cannabis Use Based on Urine Drug Screens in Pregnancy and Its Association With Infant Birth Weight.

OBJECTIVES: This study aims to clarify any association between infant birth weight and cannabis use in pregnancy based on urine drug screens. METHODS: A retrospective medical record review of singleton births from August 2013 through December 2014 with available urine drug screens (UDS) at initiation of prenatal care and delivery was conducted at a large tertiary academic referral center. Patients who used drugs other than cannabis were excluded. RESULTS: The prevalence of cannabis use in pregnancies not complicated by use of other drugs as evidenced by tetrahydrocannabinol in the urine of 2173 patients was 22.6%. Infants born to mothers who tested positive for only tetrahydrocannabinol in urine at both presentation for prenatal care and delivery were of lower median birth weight compared with those who tested negative [2925 g (IQR 2522-3265) vs 3235 g (IQR 2900-3591), P = <0.001]. There was no clinically relevant difference in gestational age at birth [39.0 weeks (IQR 37.1-40.0) vs 39.3 weeks (IQR 38.3-40.0), P = 0.012] between those positive for tetrahydrocannabinol (THC) and those who tested negative. Concomitant tobacco use during pregnancy was not noted to impact infant birth weight using the analysis of covariance. Higher perinatal mortality was observed among those who used cannabis with an adjusted odds ratio of 4.2 (95% CI, 1.53-11.49). CONCLUSIONS: Cannabis use is negatively correlated with fetal birth weight (up to 450 g less) in patients who tested positive for THC when compared with those who did not as documented in the urine drug screens. On the basis of these findings, additional patient education and cessation interventions should be explored with regard to cannabis use in pregnancy.

Randomized controlled trial of intravenous acetaminophen for postcesarean delivery pain control.

BACKGROUND: Cesarean delivery is a common surgery in the United States, with 1.3 million performed during 2009.1 Obstetricians must balance the growing concern with opioid abuse, dependence, and side effects with optimal postoperative pain control. Intravenous acetaminophen may represent an additional method to decrease the reliance on opioid medications and improve postoperative pain following cesarean delivery. OBJECTIVE: The objective of the study was to determine whether the administration of intravenous acetaminophen following routine scheduled cesarean delivery would decrease the need for narcotic medications to control postoperative pain. STUDY DESIGN: This was an institutional review board-approved, double-blind, placebo-controlled, randomized trial, registered on clinicaltrials.gov (number 02046382). Women scheduled to undergo cesarean delivery with regional anesthesia at term were recruited. All perioperative and postpartum care was standardized via study order sets. Study patients were given all medications in a standardized manner receiving either acetaminophen 1000 mg intravenously or 100 mL saline (placebo) every 8 hours for 48 hours for a total of 6 doses. The pharmacy prepared intravenous acetaminophen and saline in identical administration bags labeled study drug to ensure blinding. The initial dose of study drug was given within 60 minutes of skin incision. Quantity of breakthrough and scheduled analgesic medications and self-reported pain levels on the Faces Pain Scale (0-10) before and after study drug administration were collected. Patient demographics were extracted from the chart. Power calculation determined that 45 patients per arm were required to detect a 30% reduction in postcesarean narcotic requirement with 80% power and a significance level of P = .05. RESULTS: A total of 133 patients were consented for the study. Twenty-nine were excluded and 104 patients completed the study: 57 received intravenous acetaminophen and 47 received placebo. There were no differences in baseline demographic characteristics including patient age, body mass index, gravidity, parity, race, comorbidities, or number of prior cesarean deliveries. There were no differences between groups in estimated blood loss or length of stay. The total amount of oral narcotic medications consumed by patients receiving intravenous acetaminophen was significantly reduced when compared with the placebo group (47 mg vs 65 mg of oxycodone; P = .034). The total amount of ibuprofen used between groups was not different. There was no difference in pain scores between groups before and after study dose administration. There was no significant difference in narcotic side effects (nausea/emesis, respiratory depression, constipation) in either study arm. CONCLUSION: Intravenous acetaminophen in the postoperative period following cesarean delivery resulted in a significant decrease in oral narcotic consumption for pain control.