Is a pregnancy following a second trimester uterine evacuation associated with increased adverse maternal and neonatal outcomes?

OBJECTIVE

To evaluate maternal and neonatal outcomes of pregnancies following a uterine evacuation in the second trimester, in comparison to a first trimester spontaneous pregnancy loss.

STUDY DESIGN

A retrospective analysis of data of women who conceived ≤6 months following a uterine evacuation due to a spontaneous pregnancy loss and subsequently delivered in a single tertiary medical center between 2016 and 2021. Maternal and neonatal outcomes were compared between women with second trimester (14-23 weeks) and first trimester (<14 weeks) pregnancy loss. The primary outcome of this study was the preterm delivery (<37 weeks) rate. Secondary outcomes were adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95 % confidence intervals (CIs) were calculated.

RESULTS

During the study period, 1365 women met the inclusion criteria. Of those, 272 (19.9 %) women gave birth following a second trimester uterine evacuation and 1093 (80.1 %) women following a first trimester uterine evacuation. There were no demographic differences between the two groups. No difference was found in the preterm delivery rate in the subsequent pregnancy (5.1 % vs. 5.3 %, p = 0.91), further confirmed in the multivariate analysis [aOR 1.02 (0.53-1.94), p = 0.96]. No differences were identified with respect to other maternal and neonatal parameters examined, including hypertension disorders of pregnancy, third stage placental complications, mode of delivery and neonatal birth weight.

CONCLUSION

Pregnancy conceived shortly after second trimester uterine evacuation as compared to first trimester, confers no additional risk for preterm delivery or other adverse perinatal outcomes. Further studies to strengthen these findings are needed.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Multidisciplinary Management of Morbidly Adherent Placenta

BACKGROUND

Morbidly adherent placentation (MAP) increases the risk for obstetric hemorrhage. Cesarean hysterectomy is the prevalent perioperative approach. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive and relatively simple endovascular procedure to temporarily occlude the aorta and control below diaphragm bleeding in trauma. It has been effectively used to reduce obstetric hemorrhage.

OBJECTIVES

To evaluate whether REBOA during cesarean delivery (CD) in women with morbidly adherent placentation is a safe and effective treatment modality.

METHODS

We introduced REBOA for CD with antepartum diagnosis of MAP in 2019 and compared these patients (RG) to a standard approach group (SAG) treated in our center over the preceding year, as a control. All relevant data were collected from patient electronic files.

RESULTS

Estimated blood loss and transfusion rates were significantly higher in SAG; 54.5% of SAG patients received four RBC units or more vs. one administered in RG. No fresh frozen plasma, cryoprecipitate, or platelets were administered in RG vs. mean 3.63, 6, and 3.62 units, respectively in SAG. Ten SAG patients (90.9%) underwent hysterectomy vs. 3 RG patients (30%). Five SAG patients (45%) required post-surgical intensive care unit (ICU) admission vs. no RG patients. Bladder injury occurred in five SAG cases (45%) vs. 2 RG (20%). One RG patient had a thromboembolic event. Perioperative lactate levels were significantly higher in SAG patients.

CONCLUSIONS

Use of REBOA during CD in women with MAP is safe and effective in preventing massive bleeding, reducing the rate of hysterectomy, and improving patient outcome.

Maternal and Neonatal Outcomes of Women Conceived Less Than 6 Months after First Trimester Dilation and Curettage

Objective: To evaluate the maternal and neonatal outcomes of pregnancies conceived ≤6 months after first trimester (<14 weeks) dilation and curettage (D&C). Methods: A retrospective computerized database study of women who conceived ≤6 months following a missed abortion and delivered in a single tertiary medical center between 2016 and 2021. The maternal and neonatal outcomes of women who had D&C were compared to those of women who had non-medical or spontaneous miscarriages. The primary outcome of this study was the rate of preterm birth (<37 weeks). Secondary outcomes were adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. Results: During the study period, 1773 women met the inclusion criteria; of those, 1087 (61.3%) women gave birth following D&C. We found no differences between the study groups in any maternal or neonatal parameter examined including preterm birth (PTB), miscarriage to pregnancy interval, fertility treatments, hypertension disorders of pregnancy, placental complications, mode of delivery and neonatal birth weights. This was confirmed on a multivariate analysis as well [aOR 1.74 (0.89−3.40), p = 0.11] for preterm birth. Conclusion: Watchful waiting or the medical treatment of a first trimester missed abortion present no more risks than D&C to pregnancies conceived within six months of the index miscarriage. Further studies in other settings to strengthen these findings are needed.

Delayed presentation of ectopic pregnancy during the COVID-19 pandemic: A retrospective study of a collateral effect

OBJECTIVE

We aimed to assess the rates of overall diagnosis of ectopic pregnancy (EP), treatment modality and associated complications during the COVID-19 pandemic compared to the exact time period in the previous year (pre-COVID-19).

METHODS

A retrospective cohort study was conducted at a single referral regional center (Shaare Zedek Medical Center, Jerusalem, Israel). Prevalence of the diagnosis of EP, treatment modality and associated complications during the COVID-19 lockdown period in the state of Israel (March 10-May 12, 2020) was compared to patients receiving the same diagnosis during the parallel timeframe in the previous year (2019).

RESULTS

Overall there were 29 and 43 cases of EP during the COVID-19 and pre COVID-19 epoch, respectively. COVID-19 period patients presented to the emergency room with significantly higher β-human chorionic gonadotrophin level; median of 1364 versus 633 IU, P = 0.001. The rate of ruptured EP was; 20.7% versus 4.3% P = 0.031, and surgical approach; 55.2% versus 27.9%, P = 0.001. Significantly higher median volume of blood loss; median volume 852 versus 300 ml, P = 0.042 were observed in patients during the COVID-19 epoch.

CONCLUSION

The COVID-19 pandemic led to delayed presentation of patients with EP, and the requirement of subsequent emergency surgical management and excessive blood loss. Special attention should be given to the decline in routine medical care during the pandemic.

Maternal and neonatal outcomes following a proactive peripartum multidisciplinary management protocol for placenta creta spectrum as compared to the urgent delivery

BACKGROUND

Adherent and invasive placenta, termed Placenta Creta Spectrum (PCS), is associated with increased maternal morbidity and mortality. Incidence and risk factors for Placenta Creta are on the rise and call to optimize the obstetric care for this condition.

OBJECTIVES

We sought to compare maternal and neonatal outcomes between a ProActive Peripartum Multidisciplinary Approach (PAMA) as compared to the urgent management of the Placenta Creta Spectrum patients.

STUDY DESIGN

We conducted a single-center prospective observational study between 2005-2016. PCS patients registered with the implementation of a PAMA protocol 2014-2016 epoch(E2) were compared with the pre-PAMA 2005-2013 epoch(E1), managed by urgent team recruitment. The PAMA protocol is grounded on a continuum of care; A. Antenatal: PCS risk assessment based on clinical history and imaging, surgical, anesthesia, urological consults and designation of a dedicated team to be present at planned surgery; B. Delivery: planned at 34-35 weeks, massive transfusion protocol activation, insertion of ureteral catheters, vertical uterine incision, placement of vessel loops on the iliac vessels, avoidance of active placenta delivery, followed by the decision of hysterectomy or uterine repair; C. Post-operative care: intensive care admission. We evaluated maternal and neonatal outcomes.

RESULTS

During the study period 158,438 deliveries were registered in our institution; we identified a total of 72 PCS cases (0.05%): 50(69.4%) in E1 and 22 (30.6%) in E2. Patient characteristics were comparable among epochs. Significantly, patients in E2 vs. E1 had fewer events of massive blood transfusion 36.0% vs. 13.6%, p = 0.05; were transfused less RBC units: median 4 vs. 1.5, p = 0.012, had no transfusion-related respiratory complications and hemorrhage control re-laparotomies. Hysterectomy and hollow visceral injury rates were comparable (72% vs. 63.7%, 26% vs. 22%; respectively). The hysterectomy pathology assessment was available for the majority of the cases in both epochs; percreta diagnosis rate significantly increased in E2. The neonatal outcome was similar among the epochs.

CONCLUSIONS

Institution of a PAMA protocol for PCS resulted in eliminating the urgent deliveries and in reducing the associated significant hemorrhagic related maternal morbidity, with no increase in the rate of hysterectomy or adverse neonatal outcome.

Assessment of propofol usefulness as an anesthetic agent during colonoscopy

BACKGROUND Propofol is used as a sedative drug during colonoscopy. In this study we analyzed the adverse effects of propofol (i.e., hemodynamic and respiratory) on patients who underwent colonoscopies. METHODS This study was performed in Qom Province, Iran. In this study, 125 patients (63 females, 62 males) were enrolled. Study patients were administered (0.5-1.5 mg/kg) intravenous propofol by an anesthesiologist. Oxygen saturation and blood pressure were recorded at three minute intervals. We used the American Society of Anesthesiology (ASA) classification to stratify patients by risk prior to the procedure. For statistical analysis, the chi-square and paired t-tests were used. A p -value less than 0.05 was considered significant. RESULTS Patients' mean age was 45.36 ± 16.19 years. ASA-I comprised 25.6% of study patients and 74.4% were categorized as ASA-II. Hypopnea occurred in 56.8% of patients and was prolonged in 32.4%. Of the study patients, 5.6% developed hypoxemia which was successfully controlled by the administration of nasal oxygen and no need for mechanical ventilation. The mean arterial blood pressure (p < 0.0001), oxygen saturation (p < 0.0001) and heart rate (p < 0.0001) significantly decreased during colonoscopy. The occurrence of hypopnea significantly increased in patients with pre-procedure oxygen saturation levels ≤ 95% (p < 0.02), age <50 years (p < 0.0001) and ASA class II (p < 0.0001) Agitation, hypotension and cough were seen in 1.6%, 1.6% and 0.8% of patients, respectively. CONCLUSION Propofol has a short half life that enables faster recovery of normal neurologic and social functions we recommend the use of propofol under supervision of anesthesiologist or a trained gastroenterologist.

Efficacy and safety of pamapimod in patients with active rheumatoid arthritis receiving stable methotrexate therapy

OBJECTIVE

To determine the efficacy and safety of pamapimod in adult patients with active rheumatoid arthritis (RA) who had an inadequate clinical response to methotrexate (MTX).

METHODS

Patients receiving stable doses of MTX were randomised to one of six dose groups and received 12 weeks of double-blind pamapimod (up to 300 mg once daily) or matching placebo. The primary efficacy measure was the proportion of patients with > or =20% improvement in RA based on the American College of Rheumatology criteria (ACR20) at 12 weeks. Secondary measures were ACR50, Disease Activity Score (DAS)/European League Against Rheumatism (EULAR) responses and the individual ACR core set of parameters. Safety measures included adverse events (AEs), laboratory testing and immunology assessments.

RESULTS

On a background of MTX, the percentage of patients with an ACR20 response at week 12 in the pamapimod groups (31% to 43%) was not significantly different from placebo (34%). Secondary efficacy end points showed a similar pattern. AEs were typically mild and included infections, gastrointestinal disturbances, dizziness and rashes; AEs resulting in discontinuation of study drug were primarily attributed to infections.

CONCLUSION

In patients with active RA receiving stable doses of MTX, pamapimod showed non-significant improvement in efficacy outcomes compared to placebo.

Cancer by negative heterosis: breast and ovarian cancer excess in hybrids of inbred ethnic groups

Breast and ovarian cancer rates in Pakistan are significantly higher than in neighboring countries. The cancer rate discrepancies cannot be explained with discrepancies of their risk factors. We propose that observed cancer excess in Pakistan is due to cancer development by negative heterosis. Heterosis occurs when a hybrid has a phenotypic characteristic significantly different from that in either parent (hybrid vigor). At a molecular level, heterosis occurs in a heterozygote when one of the two alleles is inactivated. Gene inactivation occurs by methylation of cytosine in a promoter region of a gene. Initiation of allele inactivation is linked to the factors like stress, gender, diet, or another gene. In heterozygote, inactivation of one of the two tumor-suppressor alleles leads to monoallelic expression. This increases cancer risk in the same way the risk is increased in individual who inherit a single mutated tumor-suppressor gene (hereditary cancer syndrome). In both, cancer by heterosis and inherited cancer syndrome, cancer develops after inactivation of a second allele (second hit hypothesis). In a population, conditions that favor development of cancer by heterosis are those that favor mating of a large number of different homozygotes because they produce a large number of different heterozygotes. Among a large number of heterozygotes, there is an increased chance that some of hybrids will develop cancer by heterosis. In Pakistan, conditions were favorable for cancer development by heterosis because country has a high number of different ethnic groups and brotherhoods all of which have a higher rate of homozygosity due to a high frequency of consanguineous marriages, and marriages between members of different groups occurred because of intense population mixing. Result was birth of a large number of inter-ethnic/brotherhood hybrids (heterozygotes), some of which have developed cancer by heterosis.