Diagnosis pitfall of interstitial pregnancy: a case report of a term pregnancy with abnormal placentation

Background Interstitial Pregnancy (IP) is a lethal condition due to high risk of sudden onset massive hemorrhage. Such conditions are managed as soon as diagnosed almost in the first trimester. There are a few case reports of IP conditions terminated after the second trimester. Herein, we introduce a term interstitial pregnancy complicated by abnormal placentation. Case presentation In this case report, we introduce a 32-year-old lady, primigravida, with an undiagnosed IP that was in her 38 weeks of gestational with placenta increta. She developed with perforated IP presenting with acute abdomen and internal bleeding at 26 weeks of gestational age. However, with a misdiagnosis impression, she got stable in operation room. Then, the pregnancy continued till 36 weeks of gestational age that was misdiagnosed with cervical cancer in prenatal work-ups. Finally, during elective cesarean section at 38 weeks, an IP with placenta increta (placenta evading from the serosa to the myometrium of the uterus) was observed. The baby was healthy with no obvious anomaly or morbidity. Conclusions Physicians should be aware to detect IP in all trimesters and pay attention to the coexisting complications such as placenta accreta to manage them more accurately.

The Risk of Postpartum Hemorrhage Following Prior Prelabor Cesarean Delivery Stratified by Abnormal Placentation: A Multicenter Historical Cohort Study

Background: Prior prelabor cesarean delivery (CD) was associated with an increase in the risk of placenta previa (PP) in a second delivery, whether it may impact postpartum hemorrhage (PPH) independent of abnormal placentation. This study aimed to assess the risk of PPH stratified by abnormal placentation following a first CD before the onset of labor (prelabor) or intrapartum CD.Methods: This multicenter, historical cohort study involved singleton, pregnant women at 28 weeks of gestation or greater with a CD history between January 2017 and December 2017 in 11 public tertiary hospitals within 7 provinces of China. PPH was analyzed in the subsequent pregnancy between women with prior prelabor CD and women with intrapartum CD. Furthermore, PPH was analyzed in pregnant women stratified by complications with PP alone [without placenta accreta spectrum (PAS) disorders], complications with PP and PAS, complications with PAS alone (without PP), and normal placentation. We performed multivariate logistic regression to calculate adjusted odds ratios (aOR) and 95% CI controlling for predefined covariates.Results: Out of 10,833 pregnant women, 1,197 (11%) women had a history of intrapartum CD and 9,636 (89%) women had a history of prelabor CD. Prior prelabor CD increased the risk of PP (aOR 1.91, 95% CI 1.40–2.60), PAS (aOR 1.68, 95% CI 1.11–2.24), and PPH (aOR 1.33, 95% CI 1.02–1.75) in a subsequent pregnancy. After stratification by complications with PP alone, PP and PAS, PAS alone, and normal placentation, prior prelabor CD only increased the risk of PPH (aOR 3.34, 95% CI 1.35–8.23) in a subsequent pregnancy complicated with PP and PAS.Conclusion: Compared to intrapartum CD, prior prelabor CD increased the risk of PPH in a subsequent pregnancy only when complicated by PP and PAS.

67Maternal Exposure to PM2.5 from a Coal Mine Fire is Associated with Gestational Diabetes Mellitus

Background In 2014, the Hazelwood coal mine fire was an unprecedented six-week severe smoke event in the Latrobe Valley, southeastern Australia. We aimed to determine whether maternal exposure to fine particulate matter (PM2.5) attributable to coal mine fire smoke was associated with gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy and abnormal placentation. Methods We defined a cohort of all births >20 weeks in the Latrobe Valley from 1 March 2012 - 31 Dec 2015 utilising administrative perinatal data. Average and peak PM2.5 was assigned to residential address at delivery using a chemical transport model. Maternal, meteorological and temporal variables were included in final log-binomial regression models. Results 3,612 singleton pregnancies were included; 766 were exposed to the smoke event. Average maternal PM2.5 exposure was 4.4 µg/m3 (IQR 2.1). Average peak PM2.5 exposure was 44.9 µg/m3 (IQR 35.0). An interquartile range increase in average and peak PM2.5 was associated with a 7% and 16% increased likelihood of GDM respectively (Average PM2.5 95%CI 1.03, 1.10; <0.0001; Peak PM2.5 95%CI 1.09, 1.22; <0.0001). No association for hypertensive disorders or abnormal placentation was observed. Conclusions This is the first study to examine obstetric complications relating to a discrete smoke event. These findings may guide the public health response to future similar events. Key messages Exposure to a smoke event was associated with an increased risk of GDM. The public health implications may be substantial with a changing climate.

Complications of Caesarean delivery part 2: Non-pregnant and pregnancy-related complications

Introduction With the rise in Caesarean deliveries, complications related to the procedure are increasingly encountered. Sonography has an indispensable role in the assessment of these complications and is often the first-line investigation of choice. Topic description: Part 2 of this pictorial review summarises the non-pregnant and pregnancy-related complications of Caesarean deliveries. Discussion Non-pregnant complications include Caesarean scar defects, scar endometriosis and malpositioned intrauterine devices. Complications related to future gestations include scar ectopic pregnancy, abnormal placentation and intrapartum uterine dehiscence or rupture. Key sonographic features of these conditions are illustrated. Pitfalls, mimics, limitations and indications for cross-sectional imaging are discussed. Conclusion Sound knowledge of the sonographic features of common non-pregnant and pregnancy-related complications of Caesarean delivery will facilitate accurate diagnosis, timely management and improved patient outcomes.

Mild Fetal Tricuspid Regurgitation in the First Trimester as a Predictor of Perinatal Outcomes

Background and Objectives: This study aimed to investigate whether mild fetal tricuspid regurgitation (TR) at 11+ 0 to 13+ 6 weeks of gestation affects perinatal outcomes. Since fetal right ventricular load is associated with placental resistance, we hypothesized that fetal mild TR would be associated with perinatal outcomes as a consequence of abnormal placentation. Materials and Methods: We retrospectively evaluated 435 women with first-trimester scan data. Blood flow across the tricuspid valve was examined in singleton pregnancies between 11+ 0 and 13+ 6 weeks of gestation. Women were categorized according to the presence or absence of fetal mild TR, and the maternal and pregnancy characteristics and perinatal outcomes were compared. Multiple linear and logistic regression analyses were conducted to identify independent predictors of perinatal outcome. Results: In the group with mild TR, there were more cases of borderline amniotic fluid index, including oligohydramnios (p = 0.031), and gestational age- and sex-specific birth weights were lower (p = 0.012). There were no significant differences in other perinatal outcomes, including preeclampsia, gestational hypertension and small for gestational age. Gestational diabetes (adjusted odds ratio (OR) 0.514, 95% confidence interval (CI) 0.312–0.947) and fetal mild TR (adjusted OR 1.602, 95% CI 1.080–2.384) were identified as factors associated with below borderline amniotic fluid index before birth. The factors that affected gestational age and sex-specific birth weight were also gestational diabetes (adjusted beta coefficient 9.673, p = 0.008) and the presence of fetal mild TR (adjusted beta coefficient −6.593, p = 0.007). Conclusions: Mild fetal TR observed in the first trimester is negatively associated with fetal growth and the amniotic fluid index at term but not with other adverse pregnancy or perinatal outcomes due to abnormal placentation.

Peripartum hysterectomy at a tertiary center

Aims: To find out the incidence, indications, complication of emergency peripartum hysterectomy in a tertiary care center. Methods: This was a retrospective study conducted over a period of 18 months from April 2017 to October 2018 at Paropakar Maternity and Women’s Hospital in Kathmandu. Data were obtained from the operation theater register and record section. Results: Out of 30917 deliveries in 18 months 18 had lifesaving emergency peripartum hysterectomy (0.58 per 1000 deliveries). The most common indication being morbidly adherent placenta/placenta previa (8; 44%) followed by ruptured uterus (5; 28%), uterine atony (4; 22%). The most common risk factor is attributed to previous cesarean section (11; 61%) followed by abnormal placentation (7; 39%). Most common morbidity was febrile morbidity followed by wound infection and bladder injury. Conclusion: Abnormal placentation and past cesarean section contributed to be the major indication of peripartum hysterectomy.