Codsi, Elisabeth

Importance Monochorionic (MC) twins are hemodynamically connected by vascular anastomoses within the single shared placenta. The transfer of fluid or blood from one fetus to the other may result in development of pathologic complications, such as twin-twin transfusion syndrome, twin anemia polycythemia sequence, selective intrauterine growth restriction, and twin reversed arterial perfusion sequence. Monoamniotic gestations, which comprise a small fraction of MC pregnancies, can also present with unique challenges, particularly antepartum umbilical cord entanglement. All these complications carry a high risk of fetal morbidity and mortality if not recognized and managed in a timely fashion. Objective The purpose of this article is to review evidence-based management of complicated MC twin gestations and propose a standardized approach to surveillance. Evidence Acquisition Monochorionic gestations account for the majority of complications that occur in twin pregnancies; however, there is unclear evidence on the appropriate surveillance for and management of specific complications associated with these pregnancies. Results This article summarizes management for each specific type of MC complication in a structured and clear manner. Conclusions Early pregnancy ultrasound, ideally between 10 and 13 weeks' gestation, is critical for the diagnosis and characterization of twin pregnancies. To improve outcomes for MC twins, appropriate fetal surveillance should be initiated at 16 weeks' gestation and continued until delivery. Relevance Improve perinatal outcomes in MC twin pregnancies. Target Audience Obstetricians and gynecologists, family physicians Learning Objectives After completing this activity, the learner should be better able to describe the sonographic findings used to establish the diagnosis of MC twin pregnancies; identify complications unique to MC twins pregnancies, including twin-twin transfusion syndrome, twin reversed arterial perfusion sequence, twin anemia polycythemia syndrome, co-twin demise, cord entanglement, and conjoined twins; and explain the management of complications associated with MC twin pregnancies.

ObjectivesWe evaluated the current state of ultrasound training in obstetrics and gynecology (OB‐GYN) residency programs across the United States.MethodsAn electronic survey was sent to OB‐GYN residency program directors and OB‐GYN residents. Responses were obtained in September 2016. Program directors and residents were asked to reflect on their current ultrasound curriculum.ResultsA total of 93 program directors and 437 residents responded. Respondents were mostly from university programs located in tertiary centers. Ultrasound curricula varied: 11% of program directors and 23% of residents did not have any ultrasound‐related didactics; of those who did, 27% of program directors and 40% of residents had it yearly or less. Three‐quarters had mandatory ultrasound rotations, and few offered ultrasound electives (program directors, 52%; residents, 28%). Most residents were required to perform ultrasound examinations daily or weekly (98%). Most stated that the main focus of the rotation was OB only. Skill was evaluated mainly subjectively by direct observation. Although most program directors stated that residents were satisfactory/excellent in ultrasound, 22% would not treat patients on the basis of ultrasound examinations performed by their senior residents. Similarly, of all postgraduate year 4 respondents (n = 86), 76% stated that they will require additional training to be able to perform or read ultrasound examinations independently, and 43% would not treat a patient on the basis of their own ultrasound examinations without further confirmation. Residents believed that the biggest obstacle in ultrasound training is lack of dedicated faculty time (41%).ConclusionsRecognizing the lack of clearly defined milestones in ultrasound training in OB‐GYN residency, this study confirms the substantial heterogeneity in curricula between programs, highlighting a need for a standardized ultrasound curriculum.

INTRODUCTION: Malpresentation is a common problem early in pregnancy. The rate of spontaneous version (SV) by gestational age has been studied, but is poorly understood after preterm premature rupture of membranes (PPROM), which complicates 3% of pregnancies in the United States. The objective of our study was to report the rate of SV following PPROM. METHODS: We conducted a retrospective cohort study on women age 18 or above with singleton intrauterine pregnancies who experienced PPROM between 22-34 weeks gestation and were delivered at the Mayo Clinic from 01/2010-12/2015. Demographic characteristics, obstetric history, and prenatal care details were abstracted through chart review. Aneuploidy, major fetal anomalies, maternal Müllerian anomalies, and delivery less than 24 hours after PPROM were excluded. RESULTS: Among 120 patients included in the study, 29 were nulliparous. Mean maternal age at PPROM diagnosis was 29.3 years. The median gestational age at PPROM diagnosis and at delivery was 31 1/7 weeks and 32 5/7 weeks, respectively. Intrauterine growth restriction was diagnosed in 10 women following PPROM. Sixty-nine (57.5%) patients delivered vaginally and 51 (42.5%) underwent cesarean section. Twenty-three (19.2%) women experienced SV following PPROM. Of the 21 breech presentations at PPROM diagnosis, 4 (19%) converted to cephalic presentation at delivery. CONCLUSION: We determined that approximately 1 out of 5 women experience SV in the setting of PPROM. Data about SV following PPROM is important in order to counsel patients about expectations for the remainder of their pregnancy. This new evidence can better prepare patients and providers for safe delivery.

INTRODUCTION: Criteria for gestational hypertension (GH) include only 2 systolic blood pressures (BP) equal or greater than 140 or diastolic BP equal or greater than 90 at least 4 hours apart after 20 weeks gestation. We sought to determine the frequency of previously-normotensive patients meeting criteria for GH when presenting for delivery, and its association with adverse maternal/fetal outcomes. METHODS: We performed a retrospective cohort study of consecutive term deliveries without a diagnosis of hypertensive disorder of pregnancy (HDP) prior to admission. Characteristics of BP elevations, evaluations for and diagnosis of HDP; and associations with adverse composite maternal (seizure, pulmonary edema, unplanned ICU admission, emergent treatment of HTN, stroke, death) or fetal adverse events (5 minute Apgar more than 7, death or unplanned NICU admission) were determined. RESULTS: Of 185 patients, 140 (76%) had at least 1 BP elevation and 55 (30%) met formal criteria for HDP. Most elevated BPs occurred from admission to 1 hour postpartum (73%). Of those meeting GH criteria, only 18 (10%) underwent evaluation and 16 (9%) were formally diagnosed with HDP. A higher rate of fetal composite outcomes (7% vs 1%) was found in patients meeting criteria for HDP. CONCLUSION: BP elevations during admission for delivery were common, and though 30% met the strict definition for GH, only 9% were formally diagnosed reflecting low clinical suspicion. BP elevations through 1 hour postpartum appear to be most often a normal physiologic response to stress rather than a manifestation of HDP, yet GH is associated with risk for poor fetal outcomes.

Glomerular damage is common in preeclampsia (PE), but the extent and etiology of tubular injury are not well understood. The aim of this study was to evaluate tubular injury in patients with PE and to assess whether it predates clinical disease. We performed a prospective cohort study of 315 pregnant women who provided urine samples at the end of the second trimester and at delivery. This analysis included women who developed PE ( n = 15), gestational hypertension (GH; n = 14), and normotensive controls (NC; n = 44). Urinary markers of tubular injury, α1-microglobulin (A1M), retinol-binding protein (RBP), kidney-injury molecule-1 (KIM1), complement C5b-9, tissue inhibitor metalloproteinase-2 (TIMP-2), and insulin-like growth factor binding protein-7 (IGFBP-7) were measured by enzyme-linked immunosorbent assay (ELISA) and reported in relation to urine creatinine concentration. Second-trimester concentrations of all markers were similar among groups. At delivery, A1M concentrations were higher in the PE group than in the GH and NC groups as an A1M/creatinine ratio >13 (66.7, 8.3, and 35%, respectively, P = 0.01). Concentrations of C5b-9 were higher in the PE group than in the GH and NC groups (medians 9.85, 0.05, and 0.28 ng/mg, respectively, P = 0.003). KIM1, RBP, TIMP-2, and IGFBP-7 concentrations did not differ among groups at delivery. In conclusion, proximal tubular dysfunction, as assessed by A1M and C5b-9, developed during the interval between the end of the second trimester and delivery in patients with PE. However, this was not matched by abnormalities in markers previously associated with tubular cell injury (KIM-1, IGFBP-7, and TIMP-2).

Multiple anomalies including micromelia, poor mineralization of the vertebrae, and a persistent notochord were identified on second trimester ultrasound in a fetus with aCOL2A1mutation. To our knowledge, this represents the first case of a persistent notochord associated with aCOL2A1mutation in humans. In this case report, we describe ultrasound and postmortem findings and review the pathogenesis associated with a persistent notochord.