Larish, Alyssa

Abstract Introduction Fetal growth restriction (FGR) is associated with an increased risk of neonatal morbidity and mortality. Current diagnostic criteria for FGR do not discriminate between constitutionally small and pathologically restricted fetuses. Following FGR diagnosis, umbilical artery (UA) Doppler is utilized to monitor fetal well‐being, but its limitations have increased interest in investigating growth velocity as an adjunctive tool. The objective of this study is to compare the predictive ability of UA Doppler studies and growth velocity for adverse neonatal outcomes in growth‐restricted fetuses. Methods This is a secondary analysis of a cohort of pregnancies delivered in a single healthcare network from August 2017 to December 2022, diagnosed antenatally with FGR. The cohort was restricted to those with baseline estimated fetal weight (EFW) between the 3rd and 50th percentiles. All subjects had growth velocity measured (defined as EFW percentile change per week between baseline and subsequent ultrasound). The primary outcome was a composite of neonatal morbidity (neonatal intensive care unit [NICU] admission, low 5‐min Appearance, Pulse, Grimace, Activity, Respiration score [<7], intraventricular hemorrhage, necrotizing enterocolitis, or metabolic acidosis) and severe adverse perinatal events (stillbirth or neonatal death, hypoxic ischemic encephalopathy, mechanical ventilation, or severe metabolic acidosis [pH < 7.0]). Neonatal morbidity and severe adverse perinatal events were analyzed separately as secondary outcomes. Independence between growth velocity and S/D ratio was evaluated. Univariate logistic regression models were then performed, with each outcome of interest as the dependent variable and S/D ratio and growth velocity as independent variables. Receiver operating characteristic (ROC) curves were generated to compare the performance of both tests. Results A total of 172 patients were included in the analysis. UA Doppler data were available for 165 patients, 15.3% of whom had S/D ratio >95th percentile; none demonstrated absent or reversed end‐diastolic flow. There was no correlation observed between S/D ratio percentile and growth velocity, suggesting independence. ROC analysis demonstrated that the discriminatory ability of growth velocity was higher across outcomes with areas under the curve (AUC) ranging from 0.65 to 0.69 while AUC for S/D ratio percentiles ranged from 0.51 to 0.53, approximating the performance of chance. Higher growth velocity was significantly associated with reduced odds of the composite outcome (odds ratio [OR], 0.79; 95% confidence interval [CI], 0.69–0.90), and neonatal morbidity (OR, 0.84; 95% CI, 0.73–0.95). S/D ratio percentile was not associated with these outcomes. Conclusion In pregnancies complicated by growth restriction with forward UA flow, growth velocity outperformed S/D ratio percentile in predicting adverse outcomes. The two tests were independent, indicating that growth velocity may reflect a component of fetal development not captured by UA Doppler. These results suggest that growth velocity could be used in addition to UA Doppler studies for fetal risk assessment, especially in fetuses with forward arterial flow.

Introduction Out‐of‐hospital community births account for 1.6% to 2% of births in the United States and are associated with fewer obstetric interventions but increased neonatal risk. Little is known about how maternity care providers’ characteristics, values, and prior exposure to community birth influence attitudes toward community birth. Methods We conducted an observational cross‐sectional survey using a 40 to 43 item Research Electronic Data Capture questionnaire distributed October 2 to 30, 2024. Eligible participants (“providers”) included in‐hospital physicians, midwives, community birth providers, and registered nurses. The survey assessed demographics, practice characteristics, provider values, prior community birth experience, and attitudes toward community birth. Descriptive statistics were used to summarize characteristics. Group comparisons between in‐hospital and community birth providers were conducted using analysis of variance and χ 2 or Fisher exact tests. Associations between attitudes and provider values were evaluated using linear models with Bonferroni correction. Results Sixty‐seven providers completed the survey (51 in hospital, 16 community based). Most respondents were female (89.6%) and White (77.6%), with a median of 7 years in practice (IQR, 3‐14.5). Attitudes significantly differed by role ( P = .007) and credentials ( P = .002). In‐hospital providers reported safety concerns about community birth and perceived antenatal counseling to be inadequate. Perceived patient distrust during transfer was common among both in‐hospital and community‐based providers (69% and 81%, respectively). After adjustment for provider role and multiple comparisons, no significant differences in personal values were noted by attitude group; however, providers with positive attitudes toward community birth were more likely to believe that patients value compassion (β = 2.3, P = .004). Discussion Provider attitudes toward community birth appear to be shaped more by professional role and clinical experience than by differences in underlying value systems. High levels of perceived patient distrust during transfer highlight the need for interventions that strengthen compassion across maternity care settings.

Background: Pregnancies complicated by fetal growth restriction are at increased risk of fetal demise and adverse neonatal outcomes. Distinguishing growth-restricted fetuses from constitutionally small ones remains challenging. Given the variability in current diagnostic criteria and the importance of identifying at-risk fetuses, fetal growth velocity has emerged as a predictor of adverse neonatal outcomes. Objective: To evaluate whether percentile-based fetal growth velocity, defined as change in estimated fetal weight percentile per week, predicts adverse neonatal outcomes in pregnancies affected by fetal growth restriction or small-for-gestational-age neonates. The primary aim was to determine the relationship between growth velocity and a composite of adverse neonatal outcomes. Study Design: This was a retrospective cohort study of pregnant patients 18 - 45 years old who delivered between August 2017 to December 2022 in a single healthcare system. Patients were excluded who had fewer than 2 ultrasounds after 16 weeks gestation, genetic or anatomic abnormalities, or a multiple gestation. Results: 300 patients met all inclusion criteria, and most patients (n=199) delivered at the tertiary care center. Three had an intrauterine fetal demise at a mean gestational age of 35w3d. 74 neonates were admitted to the NICU with a mean length of stay of 8.5 days; 29 required respiratory support. No neonatal deaths occurred. In fetuses with initial estimated fetal weight <3rd percentile (n=33), the probability of composite outcome was increased (50%, 95% CI 44.8-55.2) compared to those >50th percentile (5%, 95% CI 3.7-6.6). In the 3-10th and 10 - 50th percentile subgroups with decelerated growth, composite outcome rates were also increased (56.2% and 44.1%) compared to those with neutral or increased growth velocity. Conclusion: Percentile-based fetal growth velocity is a simple calculation that correlates with adverse neonatal outcomes regardless of initial estimated fetal weight. As fetal growth velocity decreased, our cohort saw increased rates of adverse outcomes. Change in EFW percentile normalizes for gestational age and allows ease of clinical interpretation. Decelerated growth identified fetuses at highest risk, suggesting growth velocity as a useful metric in routine surveillance.

INTRODUCTION: Perinatal mental illness imparts a significant health burden. A multitude of factors are hypothesized to increase the incidence of perinatal mood and anxiety disorders (PMADs) in the fetal surgical population, including uncertain fetal prognosis and the inherent risks of surgery and preterm delivery. We sought to determine the disease course of PMADs in the fetal surgery population. METHODS: A retrospective chart review was conducted of fetal surgery patients from 2017 to 2021 at a tertiary care center. Demographics, surgical, obstetric, and psychiatric diagnoses were recorded. Standard descriptive analyses were performed. RESULTS: One hundred nineteen eligible patients were identified. Fetal surgery was performed at a median gestational age of 23.0 (range 16.0–34.0) weeks. Laser ablation of placental anastomoses (n=51) and in utero myelomeningocele repair (n=22) were the most common procedures. 26.8% (32/119) had preexisting mood disorders, with 59.3% (19/32) and 53.1% (17/32) on a baseline medication for depression or anxiety, respectively, prior to surgery. 26.4% (23/87) of patients without a history of anxiety or depression had a new diagnosis of PMAD. Two patients experienced suicidal ideation. 6.7% (8/119) and 10.1% (12/119) initiated a new psychiatric medication during or post-pregnancy, respectively. 19.8% (21/113) received a therapy referral. Among patients with baseline anxiety or depression, 62.5% (20/32) experienced an exacerbation postpartum with 25.0% (8/32) referred for therapy, and 34.3% (11/32) changing dose or medication for anxiety and 37.5% (12/32) for depression. CONCLUSION: Among patients undergoing fetal surgery, a high incidence of PMAD was identified. Most patients with prepregnancy anxiety or depression experienced an exacerbation postpartum. Further research into effective supportive interventions is warranted.

INTRODUCTION: While focal-occult placenta accreta spectrum (PAS) is known to lead to adverse outcomes, little is known of the morbidity in comparison to previa-associated PAS. METHODS: After IRB approval, retrospective review was conducted of pathologically confirmed (decidual layer absence or basal-plate myometrial fibers) PAS from 2018 to 2021 at a tertiary care center. Baseline characteristics and surgical, obstetric, and subsequent pregnancy outcomes were recorded. Focal-occult PAS was compared with previa-associated PAS using Kruskal-Wallis/Chi-square tests; P<.05 was considered significant. RESULTS: A total of 56 cases were identified: 22 previa-associated and 34 focal-occult PAS. All patients with previa-associated and 26.5% of those with focal-occult PAS underwent hysterectomy. Of the previa-associated PAS patients, 20 of 22 were diagnosed antenatally, as was 1 of 34 focal-occult PAS patients. Mean maternal age (32.5 vs. 33.1 year), number of previous dilation and curettage procedures (0.4 vs. 0.3), and in vitro fertilization rates (4.5% vs. 23.5%) were not significantly different between groups. Mean parity (3.7 vs. 1.4), gestational age at delivery (34.3 vs. 35.7 weeks), any previous cesarean delivery (95.5% vs. 29.4%), mean number of previous cesareans (2.5 vs. 0.5), and placental locations were significantly different between groups. All measures of morbidity, including postpartum hemorrhage rates (81.0% vs. 75.8%), median qualitative blood loss (1,500cc, range: 500–9,516cc vs. 1,660cc, range: 350–12,220cc), mean units of red blood cells transfused (1.8 vs. 1.9), massive transfusion (9.1% vs. 20.6%), ICU admission (9.1% vs. 14.7%), and reoperation rates (9.1% vs. 32.4%) were similar between groups. Six focal-occult PAS patients had a subsequent pregnancy, and two had recurrent PAS. CONCLUSION: Despite representing lower grade PAS, focal-occult PAS has similar measures of morbidity when compared to previa-associated PAS, potentially attributable to lack of antenatal detection.

We sought to determine the incidence and location of human papillomavirus (HPV)–associated anogenital disease in women with HPV‐positive oropharyngeal squamous cell carcinoma (OPSCC) via a retrospective cohort study with prospective contact to update history at Mayo Clinic in Rochester, Minnesota. Females undergoing treatment for nonmetastatic HPV‐positive OPSCC from 2011 to 2019 were identified. Clinical history and outcomes were abstracted from medical records. Patients without documented anogenital history were contacted, consented, and administered a survey, and external records were requested and reviewed. Seventeen of 46 patients (37.0%) had a history of anogenital HPV‐associated disease, and 16 of 17 (94.1%) required procedures to diagnose or treat HPV lesions. The cervix was the most common site (16/17, 94.1%). Procedures included colposcopy (n = 6), cervical excision (n = 3), cryotherapy (n = 4), and hysterectomy (n = 3). One case of fatal cervical carcinoma was noted, diagnosed 1 year following OPSCC. Three of 17 (17.6%) had HPV‐related vulvovaginal disease, and 1 of 17 had anal disease. Patients with a history of HPV‐positive OPSCC may be at elevated risk for HPV‐associated anogenital disease.

INTRODUCTION: Retained products of conception (POC) following uterine evacuation can lead to adverse sequelae, including hemorrhage, endometritis, intrauterine adhesions, and reoperation. Incidence of retained POC range from 1.5–3.7%. Use of procedural transvaginal sonography (TVUS) in the operating room has been proposed to help decrease this. METHODS: A retrospective review of first trimester uterine evacuation procedures from 1/2015–2/2017 was performed, noting use of transabdominal ultrasonography (TAUS), retained products of conception (sonographic findings requiring surgical or medical intervention), and complications. A practice change was implemented in May 2018, in which intra-procedural TVUS was routinely performed. A second retrospective chart review was conducted to assess for post-implementation incidence of retained POC, reoperation, and associated complications. Fisher's exact test was performed. RESULTS: Prior to implementation, 130 eligible procedures were performed during the specified timeframe, with 9/130 (6.9%) incidence of retained products of conception. TAUS was performed in 59/130 (45.4%) of procedures, and 4/9 (44.4%) of those with retained products. There were eight re-operative procedures in seven patients, and two patients were treated with misoprostol. Complications included hemorrhage, Asherman's and endometritis. Following implementation, 94 first trimester procedures were performed with transvaginal sonography, with 0 (0%) cases of retained POC (P=.01), no incidences of re-operation (P=.02), and one case of Asherman's. TVUS led to additional focused curettage in 20/94 (21.3%) of procedures. The endometrium was measured in 64 procedures, with a mean thickness of 5.5 mm (1–12 mm). CONCLUSION: Implementation of routine TVUS during uterine evacuation appears to reduce the incidence of retained POC and associated reoperation rates.