Luteal Phase Defects and Progesterone Supplementation

Importance

Luteal phase defects (LPDs), or an insufficiency of progesterone production during the luteal phase of the menstrual cycle, have been identified as a potential cause of recurrent pregnancy loss (RPL), but its exact contribution to RPL is not well-defined. In addition, the role of exogenous progesterone supplementation during pregnancy remains controversial.

Objective

The goal of this review is to provide an updated, evidence-based summary of LPD, including prevalence and potential pathophysiologic mechanisms, and to explore the current controversies regarding progesterone supplementation for management and treatment of RPL.

Evidence Acquisition

A literature review identified relevant research using a PubMed search, Cochrane summaries, review articles, textbook chapters, databases, and society guidelines.

Results

Endogenous progesterone plays a crucial role in the first trimester of pregnancy, and therefore, insufficiency may contribute to RPL. However, the precise relationship between LPD and RPL remains unclear. Luteal phase defect is primarily a clinical diagnosis based on a luteal phase less than 10 days. Although there may be a possibility of incorporating a combined clinical and biochemical approach in defining LPD, the current lack of validated diagnostic criteria creates a challenge for its routine incorporation in the workup of infertility. Moreover, no treatment modality has demonstrated efficacy in improving fertility outcomes for LPD patients, including progesterone supplementation, whose inconsistent data do not sufficiently support its routine use, despite its minimal risk. It is imperative that women diagnosed with LPD should be worked up for other potential conditions that may contribute to a shortened luteal phase. Future work needs to focus on identifying a reproducible diagnostic test for LPD to guide treatment.

Conclusions and Relevance

Currently, the perceived relationship between LPD and RPL is challenged by conflicting data. Therefore, patients with an abnormal luteal phase should undergo a thorough workup to address any other potential etiologies. Although supplemental progesterone is commonly utilized for treatment of LPD and RPL, inconsistent supporting data call for exogenous hormone therapy to be only used in a research setting or after a thorough discussion of its shortcomings.

Maternal morbidity in pregnancies affected by anencephaly

Using national birth-registry data, composite maternal morbidity is increased in pregnancies affected by anencephaly when compared to unaffected pregnancies.

Validation of a sonographic checklist for the detection of histologic placenta accreta spectrum

BACKGROUND

To standardize research terminology and to reduce unanticipated placenta accreta spectrum, the European Working Group for Abnormally Invasive Placenta developed a consensus checklist for reporting suspected placenta accreta spectrum observed during an antenatal ultrasound. The diagnostic accuracy of the European Working Group for Abnormally Invasive Placenta checklist has not been assessed.

OBJECTIVE

This study aimed to test the performance of the European Working Group for Abnormally Invasive Placenta sonographic checklist in predicting histologic placenta accreta spectrum.

STUDY DESIGN

This was a multisite, blinded, retrospective review of transabdominal ultrasound studies performed between 26 to 32 weeks' gestation for subjects with histologic placenta accreta spectrum between 2016 and 2020. We matched a control cohort of subjects without histologic placenta accreta spectrum in a 1:1 ratio. To reduce reader bias, we matched the control cohort for known risk factors including previa, number of previous cesarean deliveries, previous dilation and curettage, in vitro fertilization, and clinical factors affecting image quality including multiple gestation, body mass index, and gestational age at the ultrasound. Nine sonologists from 5 referral centers, blinded to the histologic outcomes, interpreted the randomized ultrasound studies using the European Working Group for Abnormally Invasive Placenta checklist. The primary outcome was the sensitivity and specificity of the checklist to predict placenta accreta spectrum. Two separate sensitivity analyses were performed. First, we excluded subjects with mild disease (ie, only assessed subjects with histologic increta and percreta). Second, we excluded interpretations from the 2 most junior sonologists.

RESULTS

A total of 78 subjects were included (39 placenta accreta spectrum, 39 matched control). Clinical risk factors and image quality markers were statistically similar between the cohorts. The checklist sensitivity (95% confidence interval) was 76.6% (63.4-90.6) and the specificity (95% confidence interval) was 92.0% (63.4-99.9) with a positive and negative likelihood ratio of 9.6 and 0.3, respectively. When we excluded subjects with mild placenta accreta spectrum disease, the sensitivity (95% confidence interval) increased to 84.7% (73.6-96.4) and the specificity was unchanged at 92.0% (83.2-99.9). Sensitivity and specificity were unchanged when the interpretations from the 2 most junior sonologists were excluded.

CONCLUSION

The 2016 European Working Group for Abnormally Invasive Placenta checklist for interpreting placenta accreta spectrum has a reasonable performance in detecting histologic placenta accreta spectrum and excluding cases without placenta accreta spectum.

A Rational and Standardized Prenatal Examination

Importance

As prenatal care is in transition after the COVID-19 pandemic, reviewing fundamental physical examination approaches is necessary for providers examining obstetrical patients.

Objective

The objective of this review is 3-fold: (1) convey why the age of telemedicine necessitates reconsideration of the standardized physical examination in routine prenatal care; (2) identify the screening efficacy of examination maneuvers used within a standard prenatal examination of the neck, heart, lungs, abdomen, breasts, skin, lower extremities, pelvis, and fetal growth; and (3) propose an evidence-based prenatal physical examination.

Evidence Acquisition

A comprehensive literature review identified relevant research, review articles, textbook chapters, databases, and societal guidelines.

Results

We conclude that an evidence-based prenatal examination for asymptomatic patients includes the following maneuvers: inspection and palpation for thyromegaly and cervical lymphadenopathy, cardiac auscultation, fundal height measurement, and a pelvic examination for purposes including testing for gonorrhea and chlamydia, assessing pelvimetry, and assessing cervical dilation later in the pregnancy, intrapartum, or in the setting of ultrasonogram-detected prelabor preterm cervical shortening.

Conclusions and Relevance

Although not true of all physical examination maneuvers, this article demonstrates that there are maneuvers that continue to play important screening roles in asymptomatic patients. With the increase in virtual visits and fewer in-person prenatal appointments, the rational basis for maneuvers recommended in this review should inform decision making around the prenatal examination performed.

Risk Factors for Adverse Maternal Outcomes Among Patients with Severe Preeclampsia Before 34 Weeks

OBJECTIVE

To characterize rates of maternal morbidity associated with early (<34 weeks) preeclampsia with severe features (esPREX), and to determine factors associated with developing these morbidities.

STUDY DESIGN

Retrospective cohort study of patients with esPREX at a single institution from 2013-2019. Inclusion criteria were admission between 23-34 weeks and diagnosis of preeclampsia with severe features. Maternal morbidity defined as death, sepsis, ICU admission, acute renal insufficiency(AKI), postpartum(PP) dilation and curation(D&C), PP hysterectomy, venous thromboembolism(VTE), PP hemorrhage(PPH), PP wound infection, PP endometritis, pelvic abscess, PP pneumonia, readmission, and/or need for blood transfusion. Death, ICU admission, VTE, AKI, PP hysterectomy, sepsis, and/or transfusion of >2 units were considered severe maternal morbidity(SMM). Simple statistics used to compare characteristics among patients experiencing any morbidity and those not. Poisson regression used to assess relative risks.

RESULTS

Of 260 patients included, 77(29.6%) experienced maternal morbidity and 16(6.2%) experienced SMM. PPH(n=46, 17.7%) was the most common morbidity, though 15(5.8%) patients were readmitted, 16(6.2%) needed a blood transfusion, and 14(5.4%) had AKI. Patients who experienced maternal morbidity were more likely to be advanced maternal age, have pre-existing diabetes, have multiparity, and deliver non-vaginally (all p<0.05). Diagnosis of pre-eclampsia < 28 weeks or longer latency from diagnosis to delivery were not associated with increased maternal morbidity. In regression models, the relative risk of maternal morbidity remained significant for twins(aRR 2.29;95%CI:1.59,3.30), and pre-existing diabetes(aOR 1.69;95%CI:1.09,2.63), while attempted vaginal delivery was protective (aOR 0.63;95%CI:0.42,0.94).

CONCLUSION

In this cohort, more than 1 in 4 patients diagnosed with esPREX experienced maternal morbidity, while 1 in 16 patients experienced SMM. Twins and pre-gestational diabetes were associated with higher risk of morbidity, while attempted vaginal delivery was protective. These data may be helpful in promoting risk reduction and counseling patients diagnosed with esPREX.

Transfusion Requirements with Hybrid Management of Placenta Accreta Spectrum Incorporating Targeted Embolization and a Selective Use of Delayed Hysterectomy

OBJECTIVE

This study compares the number of units of red blood cells (RBCs) transfused in patients with placenta accreta spectrum (PAS) treated with or without a multidisciplinary algorithm that includes placental uterine arterial embolization (P-UAE) and selective use of either immediate or delayed hysterectomy.

STUDY DESIGN

This is a retrospective study of deliveries conducted at a tertiary care hospital from 2001 to 2018 with pathology-confirmed PAS. Those with previable pregnancies or microinvasive histology were excluded. To improve the equity of comparison, analyses were made separately among scheduled and unscheduled cases, therefore patients were assigned to one of four cohorts as follows: (1) scheduled/per-algorithm, (2) scheduled/off-algorithm, (3) unscheduled/per-algorithm, or (4) unscheduled/off-algorithm. Primary outcomes included RBCs transfused and estimated blood loss (EBL). Secondary outcomes included perioperative complications and disposition.

RESULTS

Overall, 95 patients were identified, with 87 patients meeting inclusion criteria: 36 treated per-algorithm (30 scheduled and 6 unscheduled) and 51 off-algorithm patients (24 scheduled and 27 unscheduled). Among scheduled deliveries, 9 (30.0%) patients treated per-algorithm received RBCs compared with 20 (83.3%) patients treated off-algorithm (p < 0.01), with a median (interquartile range [IQR]) of 3.0 (2.0, 4.0) and 6.0 (2.5, 7.5) units transfused (p = 0.13), respectively. Among unscheduled deliveries, 5 (83.3%) per-algorithm patients were transfused RBCs compared with 25 (92.6%) off-algorithm patients (p = 0.47) with a median (IQR) of 4.0 (2.0, 6.0) and 8.0 (3.0, 10.0) units transfused (p = 0.47), respectively. Perioperative complications were similar between cohorts.

CONCLUSION

A multidisciplinary algorithm including P-UAE and selective use of delayed hysterectomy is associated with a lower rate of blood transfusion in scheduled but not unscheduled cases.

KEY POINTS

· An algorithm with delayed hysterectomy had less transfusion in scheduled, but not unscheduled, cases.. · Over time, more cases were managed per algorithm; among scheduled cases, the transfusion rate and volume transfused decreased.. · There were similar transfusion outcomes among off-algorithm cases, regardless if delivery was scheduled..

Gestational weight gain and patterns of breastfeeding among patients with class III obesity

BACKGROUND

Maternal obesity is associated with delayed lactogenesis and shorter duration of breastfeeding compared to patients with a normal BMI.

RESEARCH AIM/QUESTION

We investigated the impact of excessive gestational weight gain, defined as greater than the Institute of Medicine guidelines (>9.1 kg), on the initiation and duration of breastfeeding in patients with class III obesity.

METHODS

Retrospective cohort of patients with body mass index ≥40 in first trimester, delivering a singleton term infant at a tertiary care center between July 2013 and December 2017. Primary outcome was exclusive breastfeeding at discharge and at postpartum visit. Secondary outcomes included any breastfeeding at discharge and postpartum visit, and cessation of breastfeeding by the postpartum visit. Descriptive statistics were used to compare those whose gestational weight gain exceeded (eIOM) versus met (mIOM) Institute of Medicine guidelines. Regression models were performed to adjust for baseline confounding factors.

RESULTS

Of 294 women included, 117(39.8%) were in the eIOM group. These women were more likely to be primigravida, have a higher delivery BMI, greater delivery blood loss, and have a neonate admitted to the intensive care unit. Exclusive breastfeeding at discharge was not different between eIOM and mIOM (66.7% vs 70.9%, p = .44), nor did eIOM impact likelihood of exclusive breastfeeding at postpartum visit (40.1% vs 34.2%, p = .31). When controlling for confounding factors, breastfeeding at discharge (aOR 1.54 95% CI [0.68-3.49]) or postpartum visit (aOR 0.67[0.31-1.47]) did not differ between eIOM compared to mIOM.

CONCLUSIONS

Among women with class III obesity, excessive gestational weight gain did not impact the rate of exclusive breastfeeding at discharge or postpartum visit.

Clinical factors associated with cytomegalovirus shedding among seropositive pregnant women

BACKGROUND

Both neighborhood disadvantage and close contact with children have been associated with seroprevalence of cytomegalovirus in pregnancy. However, it is unknown which individual factors influence whether seropositive women are likely to have ongoing viral shedding.

OBJECTIVE

This study aimed to define the frequency of and risk factors for ongoing maternal cytomegalovirus shedding across gestation among seropositive pregnant women.

STUDY DESIGN

This was a prospective cohort study of women who were cytomegalovirus seropositive at a single tertiary care hospital between September 1, 2018, and September 1, 2020. The participants were eligible if positive for cytomegalovirus immunoglobulin G during the first trimester of pregnancy. Urine samples were planned to be collected from each trimester. DNA was isolated in urine samples to detect and quantitate cytomegalovirus immediate-early 1 gene. Participants were classified as "ever shedder" if cytomegalovirus was detected in any urine sample and "never shedder" if cytomegalovirus was never detected. Patient demographics and characteristics were compared between groups. Stochastic search variable selection (with a posterior probability of inclusion of >0.5) was used to identify predictors of cytomegalovirus shedding at any time point. Forward selection modeling was used as a sensitivity check for independent risks.

RESULTS

A total of 240 participants who were cytomegalovirus immunoglobulin G seropositive were enrolled, with 567 urine samples analyzed across gestation. Fifty-eight participants (24.2%) were "never shedders", and 182 participants (75.8%) were "ever shedders." The characteristics and demographics were similar between cohorts. With stochastic search variable selection, nulliparity was the only variable selected (odds ratio, 1.82; 95% credible interval, 1.00-4.09; Bayes factor, 2.22). Furthermore, nulliparity was selected with standard logistic regression, with an odds ratio and 95% confidence interval of 1.89 (1.00-3.58). Sociodemographic characteristics, such as age, race, education level, occupation, children at home, children in daycare, housing type, insurance type, income, and concurrent infections, were not associated with shedding. The only positive neonatal sample (0.42%) was detected from a participant who had cytomegalovirus detected in all 3 time points.

CONCLUSION

Approximately 75% of women who were positive for cytomegalovirus immunoglobulin G shed virus at some point during gestation. Nulliparity was the only variable selected that was associated with shedding.

Anesthetic management of placenta accreta spectrum at an academic center and a comparison of the combined spinal epidural with the double catheter technique: A retrospective study

STUDY OBJECTIVES

To describe the anesthetic management and outcomes of placenta accreta spectrum (PAS) cases at our institution over a 19 year period and to compare outcomes associated with the lumbar combined spinal epidural (CSE) technique versus the double catheter technique (lumbar CSE with thoracic epidural catheter).

DESIGN

Retrospective cohort study.

SETTING

Labor and delivery unit at a tertiary care center.

PATIENTS

113 female patients who had histologically confirmed PAS on the final pathology report after cesarean delivery or cesarean hysterectomy.

INTERVENTION

Neuraxial anesthesia, including CSE and the double catheter technique, and general anesthesia for PAS cases (including scheduled and unscheduled cases and those known or unknown as PAS preoperatively).

MEASUREMENTS

The medical records were reviewed for demographic information, intraoperative management, anesthetic technique, and outcomes. We describe anesthetic management and outcomes of cases classified as scheduled vs. unscheduled and known vs. unknown PAS. We also compare the CSE and double catheter techniques with the primary outcome being conversion to general anesthesia (GA).

MAIN RESULTS

We included 113 cases: 60 (53.1%) scheduled/known cases, 12 (10.6%), scheduled/unknown cases, 22 (19.5%) unscheduled/known, and 19 (16.8%) unscheduled/unknown cases. All scheduled cases except two were started with a neuraxial technique. General anesthesia (GA) was used to start 18/41 (44%) of unscheduled cases. The double catheter technique (n = 35) was associated with a lower GA conversion rate (5.7% vs. 29.7%, P = 0.036) compared to the CSE technique (n = 37).

CONCLUSIONS

Neuraxial anesthesia is the most commonly used technique for PAS cases in our practice. The double catheter technique was associated with lower GA conversion rates compared to the CSE technique in our cohort.

Placental uterine artery embolization followed by delayed hysterectomy for placenta percreta: A case series

•

Approximately 23% of women intending delayed hysterectomy for placenta accreta spectrum will have an unscheduled surgery.

•

Targeted embolization for placenta accreta spectrum appears to be a safe and feasible adjunct to surgical management.

•

Placental regression may contribute to discrepancy between intraoperative and pathology diagnoses in delayed hysterectomy.

•

A multidisciplinary approach to placenta accreta spectrum is associated with a lower blood loss.

We describe outcomes of patients with suspected placenta percreta treated with placental uterine artery embolization (P-UAE) followed by delayed hysterectomy. This is a prospective case series of subjects from 2005 to 2018 with suspected placenta percreta who underwent P-UAE at the time of cesarean delivery followed by delayed hysterectomy. Both scheduled and unscheduled surgical cases were included. Maternal characteristics, surgical approaches, intra- and postoperative outcomes were abstracted from medical records. In total, twenty-two subjects were included. Median (interquartile range, IQR) delivery gestational age was 34.6 (31.9, 35.7) weeks, occurring as scheduled in 17 (77.3%) subjects and unscheduled in 5 (22.7%). Delayed hysterectomy was performed as scheduled in 17 (77.3%) subjects at a median (IQR) 40.5 (38.0, 44.0) days after delivery, and 5 (22.7%) subjects had a hysterectomy prior to scheduled date, median (IQR) 27.0 (17.0, 35.0) days after delivery. Indications for the 5 unscheduled hysterectomies included bleeding (n = 3) and suspected endometritis (n = 2). Three subjects (13.6%) received a blood transfusion (1, 3, 3 units) during delivery, and 7 (31.8%) were transfused during delayed hysterectomy (median [IQR] 2 [1,3] units). Three (13.6%) subjects had bladder resection at the time of hysterectomy; 1 (4.5%) had an unintentional cystotomy and 1 (4.5%) had a ureteral injury. P-UAE followed by delayed hysterectomy appears to be a safe and feasible, although appropriate patient selection and close surveillance are imperative, as 22.7% of patients underwent unscheduled hysterectomy.

Premature Rupture of Membranes with Concurrent Viral Infection

Treatment of viral infections is geared toward ameliorating maternal symptoms and minimizing perinatal transmission. Multidisciplinary teams often are required to manage sequelae due to viral diseases in patients with preterm premature rupture of membranes (PPROM). although data are scarce regarding the antepartum management of common viruses in PPROM, essential principles may be extrapolated from national guidelines and studies in gravid patients. The well-established risks of prematurity are weighed against the often unclear risks of vertical transmission.

Gestational Weight Gain and Postpartum Depression in Women with Class III Obesity

OBJECTIVE

We investigated the association between gestational weight gain (GWG) and postpartum depression (PPD) in women with class III obesity.

STUDY DESIGN

This is a retrospective cohort of women with body mass index (BMI) ≥ 40 kg/m² at entry to care, first prenatal visit ≤14 weeks gestation, with singleton, nonanomalous pregnancies who delivered at term from July 2013 to December 2017. Women missing data regarding PPD were excluded. Primary outcome was PPD; classified as Edinburgh Postnatal Depression Scale (EPDS) score >13/30 or provider's report of depression. Participants were classified, according to Institute of Medicine GWG guidelines (11-20 pounds), as either less than 11 pounds (LT11) or at/more than 11 pounds (GT11). Bivariate statistics compared demographics and pregnancy characteristics. Logistic regression used to estimate odds of primary outcome.

RESULTS

Of 275 women, 96 (34.9%) gained LT11 and 179 (65.1%) gained GT11 during pregnancy. The rate of PPD was 8.7% (n = 24), 9 (9.4%) in the LT11 group and 15 (8.4%) in the GT11 group (p = 0.82, odds ratio: 1.13, 95% confidence interval [CI]: 0.48, 2.69). When controlling for entry BMI and multiparity, adjusted odds of PPD was 1.07 (95% CI: 0.44, 2.63). No correlation was found between GWG and EPDS.

CONCLUSION

A relationship between GWG and PPD in class III obese women was not found in this cohort.

Artificial Intelligence in Health Care: Insights From an Educational Forum

Discussions surrounding the future of artificial intelligenc (AI) in healthcare often cause consternation among healthcare professionals. These feelings may stem from a lack of formal education on AI and how to be a leader of AI implementation in medical systems. To address this, our academic medical center hosted an educational summit exploring how to become a leader of AI in healthcare. This article presents three lessons learned from hosting this summit, thus providing guidance for developing medical curriculum on the topic of AI in healthcare.

Conscience in the Public Square: The Pivoting Positions of the USCCB and ACLU around the Religious Freedom Restoration Act

The debate on the meaning of the Religious Freedom Restoration Act (RFRA) is rapidly developing. Taking three snapshots in the bill's history (in 1993 at its origin, in 2014 during Burwell v. Hobby Lobby, and in 2015 after Obergefell v. Hodges), this essay evaluates the stances taken on the RFRA by the American Civil Liberties Union (ACLU) and the US Conference of Catholic Bishops (USCCB). Although the ACLU initially supported the bill, it now campaigns against it. In contrast the USCCB, once hesitant to endorse the RFRA, fervently defends it today. Evaluating these pivoting positions, this essay suggests that at the heart of the debate on RFRA lies a difference in understanding the right to follow one's conscience in the public square.

Lay Summary: This essay evaluates how the ACLU and the USCCB differ in their understanding of conscience. Next, the essay demonstrates that this difference leads to opposing viewpoints on the Religious Freedom Restoration Act today. Although both initially supported the Religious Freedom Restoration Act at its signing in 1993, the ACLU has now disavowed the bill after it had been used to permit following religious-based conscience in the public square.