Outcomes in patients with early-onset fetal growth restriction without fetal or genetic anomalies

Early-onset poor fetal growth is associated with poor pregnancy outcomes but frequently is due to fetal structural and/or chromosomal abnormalities. We sought to determine outcomes in patients with early-onset fetal growth restriction without diagnosed fetal or genetic anomalies and to identify additional risk factors for poor outcomes in these patients. This was retrospective cohort study of singleton pregnancies in women with early-onset growth restriction defined as a sonographic estimated fetal weight <10% diagnosed between 16–28 weeks’ gestation. One hundred forty-two patients were identified who met inclusion and exclusion criteria and 20 patients were found to have fetal structural or chromosomal abnormalities. In the remaining 122 patients, the incidence of intrauterine fetal demise was 5.7% and there were high rates of preterm birth <37 weeks (20%), birth weight <10% (59.3%), and gestational hypertension (14.1%). Later gestational age at diagnosis and the presence of echogenic bowel and abnormal initial umbilical artery Dopplers were associated with poor pregnancy outcome. We concluded that patients with early-onset fetal growth restriction with no fetal structural or genetic abnormality have a high risk of poor pregnancy outcomes. Gestational age at diagnosis and certain ultrasound findings are associated with a higher risk for poor pregnancy outcome.

Risk Factors for Blood Transfusion in patients undergoing high-order Cesarean delivery

For patients undergoing cesarean delivery, the risk of the operation usually increases with each successive cesarean delivery.  At Maternal Fetal Medicine Associates we care for many women with several prior cesarean deliveries and therefore perform many “high-order” cesarean deliveries (3rd or higher cesarean delivery).

Emergent Primary Cesarean Delivery and Maternal Operative Morbidity

Sometimes women in labor require a cesarean delivery.  These deliveries can be categorized as nonurgent, urgent, or emergent, based on the circumstances.  Emergent (also known as “stat”) cesarean deliveries are usually performed when concerns over the health of the fetus are so significant that every minute counts.  In these situations, the operation itself it performed very quickly from the first incision until delivery of the baby, which can be as quick as one to two minutes.   One potential concern with this type of surgical technique is whether there is an increased risk to the mother when performing an emergent cesarean delivery.

Vaginal Birth After Cesarean Delivery for Arrest of Descent

Many pregnant women with a prior cesarean delivery have the option to attempt a vaginal birth after cesarean (VBAC), also known as TOLAC (trial of labor after cesarean).  The decision whether to attempt VBAC or to schedule a repeat cesarean delivery depends on the woman’s preferences, as well as two clinical factors:  the risk of VBAC and the likelihood of a successful VBAC. The risk of VBAC depends on several factors regarding the original cesarean delivery, as well as the overall health of the mother and her pregnancy.  Regarding the likelihood of success, one important variable is the reason for the previous cesarean.  For women who achieved full cervical dilation and began pushing but had a cesarean for “arrest of descent” (the baby did not descend into the pelvis), they were traditionally told that the likelihood of a successful VBAC was 50% or less.

A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy

Dr. Monteagudo, a Maternal Fetal Medicine Specialist at MFMA, is internationally renowned for her expertise in OBGYN ultrasound. Furthermore, she has helped pioneer a minimally invasive method for the treatment of cesarean scar pregnancy through her cooperative research with the American Journal of Obstetrics & Gynecology. In this study, A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy, the use of a cervical ripening double-balloon catheter is proposed as a minimally invasive method for inducing pregnancy; while also safely preventing excessive bleeding.

Suture Compared With Staple Closure of Skin Incision for High-Order Cesarean Deliveries

When closing the skin incision for a cesarean delivery, the options include surgical clips (staples) and sutures.  In women undergoing their first or second cesarean delivery, most data suggest that using suture is associated with fewer wound complications, specifically infection and separation (the wound reopening).  However, most studies do not include women undergoing their third or higher cesarean delivery, which can be much more technically challenging operations.

Since MFM Associates is a referral practice for women undergoing complicated and higher-order cesarean deliveries, we have extensive experience with this complicated operation.   In this study, published in Obstetrics and Gynecology in March 2017, we found that suture closure was associated with a lower rate of wound complications in women undergoing their third or higher-order cesarean deliveries as well.   This study could help other doctors decide how to best close the skin incision for their patients as well.

Labor and Delivery of Twin Pregnancies

Twin pregnancies represent 3% of all births in the United States.  Currently, approximately 75% of all twin pregnancies are delivered via cesarean.   However, recent studies suggest that this high rate may not be necessary and that vaginal delivery of twins can be achieved safely for the mother and her twins.  At MFM Associates, we care for and deliver many twin pregnancies.  The article below is a review of twin delivery written by Dr. Stephanie Melka, Dr. James Miller, and Dr. Nathan Fox.  It was published in December 2017 in Obstetrics and Gynecology Clinics of North America.

Twin Pregnancy in Women 45 Years or Older

With advances in assisted reproductive technology including In-vitro fertilization (IVF) and egg donation, women are now able to conceive well into their 40’s and 50’s.  However, uncertainty exists regarding the safety of these pregnancies for women and their newborns.  Additionally, twin pregnancy is a common result of IVF, and all twin pregnancies are higher-risk pregnancies.

Pregnancy Outcomes in Patients With Prior Uterine Rupture or Dehiscence

Women with a history of uterine rupture in labor or women with a uterine “window” (extreme thinning of the lower uterine portion) are often told that they should not conceive again because the risks are too great.  In this study, we reported excellent outcomes in a cohort of women with prior uterine rupture or uterine window.  With close monitoring and early delivery, none of the women in this study had any severe complications.

Rescue Corticosteroids in Twin Pregnancies and Short-Term Neonatal Outcomes

Singleton babies born prematurely, particularly those born prior to 34 weeks, have improved outcomes if their mothers received antenatal corticosteroids (AQCS) prior to delivery.   Recent studies suggest that a second (“rescue”) course of ACS further improve outcomes.   Twin pregnancies have a far higher risk of preterm birth, but there are less data examining the effect of corticosteroids and rescue corticosteroids on neonatal outcomes.  In this study, we found that twins born prior to 34 weeks had improved short-term outcomes if their mothers were exposed to a rescue course of ACS.