Vasa Previa Research Articles

Reproductive and Obstetric Outcomes After Hysteroscopic Removal of Retained Products of Conception

To evaluate the reproductive outcomes in women treated for retained products of conception (RPOC) by hysteroscopy (morcellation vs loop resection). Cohort study. A teaching and university hospital. Patients included in a previous randomized controlled trial on hysteroscopic removal of RPOC comparing morcellation (n = 46) with loop resection (n = 40). Hysteroscopic morcellation versus loop resection. The primary outcome measures were live birth and pregnancy complications (including abnormal placentation [placenta accreta/increta/percreta], placenta previa, vasa previa, retained placenta after delivery or incomplete expulsion with the need for manual removal or curettage, and RPOC), uterine rupture, and other complications (blood loss, preterm labor, preterm premature rupture of membranes, hypertensive disorders of pregnancy, and intrauterine growth restriction). The live birth rate was 88.9% in the morcellation group and 68.2% in the loop resection group (p = .09). Uterine rupture occurred in 1 patient in the morcellation group (4.2%) (p = 1.00). Placental complications were found in 20.8% and 22.2% of the hysteroscopic morcellation and loop resection groups, respectively (p = .33), and other pregnancy complications were seen in 33.3% and 16.6% of the 2 groups (p = .33). The secondary outcome was time to pregnancy. The median time to pregnancy was 14 weeks (interquartile range [IQR], 5-33 weeks) in the morcellation group and 15 weeks (IQR, 6-37 weeks) in the loop resection group (p = .96). Hysteroscopic removal of RPOC seems to have no detrimental effect on reproductive outcome and no significant effect on pregnancy rate.

Vasa Previa: A New Paradigm in Patient Hospitalization, Timing of Delivery and Corticosteroid Use [11A

INTRODUCTION: Vasa Previa occurs when fetally-derived umbilical cord vessels cross the internal os of the cervix. The aim of this study was to evaluate parameters that influence outpatient versus inpatient management in these cases. METHODS: Research Ethics Board approval was obtained for this study. Consecutive cases of vasa previa as diagnosed at Mount Sinai Hospital, Toronto from January 2008 to December 2017 were retrospectively reviewed. Cases were categorized into 3 arms for analysis: outpatients (OP), indicated hospitalized (IH) and non-indicated hospitalized (NIH). The NIH arm included asymptomatic patients admitted for surveillance, while the IH arm included symptomatic patients admitted for antepartum hemorrhage. RESULTS: 84 cases of vasa previa were diagnosed during the study period. The IH group was admitted a median of 22.5 days longer vs the NIH group up to delivery. The IH group had the highest frequency of unplanned caesareans at 46.2%, vs 7.1% and 11.1% of cases in the NIH and OP groups, respectively. Despite having an equal number of unplanned caesareans, the NIH group delivered a median 1.7 weeks earlier vs the OP group (P=.0040). NIH patients were also more than twice as likely to receive corticosteroid therapy inappropriately vs the OP group (57.1% vs 27.8%, P=.0359). A median (IQR) of 5 (3.5-7.6) weeks between corticosteroid administration and delivery existed among patients who received this therapy inappropriately. CONCLUSION: Our evidence suggests that physicians have difficulty predicting imminent preterm delivery for proper corticosteroid use in this population, but may be able to offer asymptomatic patients the option of outpatient management.

A Radiologist's Guide to the Performance and Interpretation of Obstetric Doppler US.

Doppler US provides a unique window to the fetoplacental circulation, allowing assessment of fetal well-being. Doppler US of the umbilical artery is an integral component of managing the fetus with growth restriction; and Doppler US of the middle cerebral artery, as a noninvasive means of detecting fetal anemia, has revolutionized the management of pregnancies complicated by alloimmunization. Serial use of amniocentesis, with its attendant risks, has been replaced by serial Doppler US examinations. Invasive procedures are now reserved for the treatment of anemia with intrauterine transfusion. Technique is critical to obtain the best waveforms for ease of shape assessment, velocity measurement, and calculation of various ratios. In this article, the safety of Doppler US is reviewed, the fetal circulation is described, and the role of Doppler US is demonstrated in first-trimester screening and in the evaluation of growth restriction, anemia, and other causes of fetal compromise in the second and third trimesters. Sampling technique is explained, and normal and abnormal waveforms are illustrated for the ductus venosus, umbilical artery, umbilical vein, middle cerebral artery, and uterine artery. Some examples of clinical cases are provided to illustrate how the results are used in clinical practice. Clinical examples of velamentous insertion and vasa previa are also provided to aid the practicing radiologist with recognition of these entities. In particular, vasa previa is considered a critical finding; it alters pregnancy management, requiring hospital admission, administration of steroid therapy, and planned early cesarean delivery. ©RSNA, 2019.

Choosing Wisely: Bedrest-A Panacea for All That Ails the Gravida?

Bedrest has been frequently prescribed for various high-risk conditions during pregnancy. A common indication cited is concern regarding increased risk of spontaneous preterm birth, known to be associated with gestations with twins or higher-order multiples, polyhydramnios, presence of preterm contractions with or without evidence of cervical change, sonographic cervical shortening, presence of a dilated cervix with bulging membranes, or preterm premature rupture of membranes. In some cases, there is concern that excessive movement may increase the risk of antepartum hemorrhage, as may be with placenta previa, with or without a higher risk of a morbidly adherent placenta or a vasa previa. It is also thought that improved splanchnic perfusion with bedrest may enhance blood supply to the uterus with possible benefit in conditions such as preeclampsia (or gestational hypertension) or fetal growth restriction. However, there is no evidence of any benefit of bedrest or reduced activity during pregnancy for either of these conditions. On the contrary, there is evidence of harm, in addition to the fact that exercise is known to be beneficial in pregnancy.

In Vitro Fertilization and Vasa Previa: A Report of Two Cases

Vasa previa (VP) is a dangerous obstetric condition associated with perinatal mortality and morbidity. In vitro fertilization (IVF) is a risk factor for VP due to the high incidence of abnormal placentation. The diagnosis should be made prenatally, because fetal mortality can be extremely high. We report two cases to demonstrate the accuracy of transvaginal ultrasound in the prenatal diagnosis of VP. A 40-year-old primiparous Caucasian woman with IVF pregnancy was diagnosed with VP at 29 weeks of gestation and was hospitalized for observation at 31 weeks of gestation. She delivered a male newborn weighing 2,380 g, with an Apgar score of 10 at 5 minutes, by elective cesarean section at 34 weeks + 4 days of gestation, without complications. A 36-year-old primiparous Caucasian woman with IVF pregnancy was diagnosed with placenta previa, bilobed placenta increta and VP. The cord insertion was velamentous. She was hospitalized for observation at 26 weeks of gestation. She delivered a female newborn weighing 2,140 g, with an Apgar score of 9 at 5 minutes, by emergency cesarean section at 33 weeks + 4 days of gestation due to vaginal bleeding. The prenatal diagnosis of VP was associated with a favorable outcome in the two cases, supporting previous observations that IVF is a risk factor for VP and that all IVF pregnancies should be screened by transvaginal ultrasound.

Fetal death from ruptured vasa previa: a tragic event in the ultrasonographic era

Fetal death from ruptured vasa previa: a tragic event in the ultrasonographic era

CARING FOR WOMEN WITH UNANTICIPATED VASA PRAEVIA: A QUALITATIVE STUDY WITH AUSTRALIAN MIDWIVES AND DOCTORS

CARING FOR WOMEN WITH UNANTICIPATED VASA PRAEVIA: A QUALITATIVE STUDY WITH AUSTRALIAN MIDWIVES AND DOCTORS

Vasa previa and extreme prematurity: a population-based study

To determine population-based risks of preterm birth associated with vasa previa. Included were 945,950 singleton, live birth cesarean deliveries with and without vasa previa (gestational ages 24-41 weeks) in California between 2007 and 2012. Odds ratios (ORs) of preterm birth were estimated using logistic regression. In total, 586 were complicated by vasa previa (0.06%). In total, 369 (63%) of those with vasa previa were delivered <37 weeks, compared with 91,662 (10%) of those without. Odds of extreme and very preterm birth were substantially higher for pregnancies with vasa previaeven after controlling for comorbidities known to contribute to prematurity, with ORs of 4.6 (95% confidence interval, CI: 1.7-12.5) and 16.0 (95% CI: 10.3-24.8), respectively. Based on these population-based data, most patients with vasa previa are delivered between 32 and 36 weeks gestation; however, a clinically significant portion occur before 32 weeks. These data are helpful in counseling patients with vasa previa regarding prematurity risk.

Near miss: клинический случай благополучного исхода родов у беременной с Vasa Previa

Near miss: клинический случай благополучного исхода родов у беременной с Vasa Previa

Fatal outcome in dichorionic twin pregnancy with velamentous cord insertion – case report

Membranous umbilical vessels at the placental insertion represents a velamentous umbilical cord without Wharton’s jelly, the rest of the umbilical cord being usually normal. The lack of Wharton’s jelly makes the vessels prone to compression and rupture, especially when they are located in the membranes covering the cervical os – in vasa praevia. Velamentous cord insertion is more common in twin pregnancies than in singletons. We report the evolution and management in a case of a twin dichorionic pregnancy with a single velamentous cord insertion. A 19-year-old woman, primigravida, para I, without prior investigations, presented at the ambulatory compartment of the “Elias” University Emergency Hospital Bucharest for a consult. An abdominal ultrasound was performed, showing a twin pregnancy with both alive, male fetuses, with significant difference between the estimated fetal weights. The patient refused the admission. After four days, she returned at the emergency ward with uterine contractions. The ultrasound revealed fetus A alive and fetus B without heartbeat. An emergency caesarean section was performed: a healthy neonate of 2690 g with APGAR 8, and a stillborn of 1241 g were delivered. Postpartum, it was determined that the pregnancy was dichorionic, diamniotic, with central umbilical cord insertion of the fetus A and a velamentous cord insertion of fetus B. The velamentous insertion on the interamniotic membrane for fetus B explained the fetal growth restriction and his antepartum death by rupture of a vessel.

Birthing through tramlines – a pictorial tale of vasa praevia from diagnosis to delivery

Birthing through tramlines – a pictorial tale of vasa praevia from diagnosis to delivery

332: Variation in outcome reporting in studies on Vasa Previa: A Systematic Review

To evaluate outcomes reported in studies on the antenatal diagnosis and management of Vasa Previa. MEDLINE, EMBASE, COCHRANE, PubMed and Clinicaltrials.gov were searched up to the March of 2018 for all published studies on Vasa Previa using combinations of the following MeSH and keyword terms: vasa previa, placenta previa, low lying placenta, succenturiate lobe or placenta, bilobed or bilobate placenta, velamentous insertion. Title/abstract screening and data extraction was conducted independently and in duplicate by two reviewers for all studies until total agreement for eligibility was achieved. Data extraction was also conducted in duplicate for over 60% of studies reviewed. All original human research that described maternal/obstetric and fetal/neonatal outcomes relating to pregnancies with Vasa Previa were included for analysis. In total, 160 published studies were examined for outcomes that pertained to pregnancies with Vasa Previa. There was a wide range of reported outcomes, many of which were reported sparingly. The most commonly reported maternal outcomes included the mode of delivery, presence of antepartum hemorrhage, time of diagnosis, rupture of membranes, and presence of known risk factors such as a low-lying placenta, succenturiate or bi-lobed placenta and (velamentous) cord insertion. The most commonly reported fetal/neonatal outcomes included fetal heart rate, gestational age at delivery, birth weight, Apgar score, presence of neonatal anemia, cord gas measurements, need for blood transfusion and death. Importantly, only three studies reported on data related to life impacts, such maternal social and emotional functioning, perceived delivery of care or resource utilization. Despite the profound effect a diagnosis of Vasa Previa has on pregnant women, families, and healthcare systems, outcomes related to life impact and resource utilization were seldom reported. There is need for development of a core outcome set, a minimum standard set of outcomes that takes into account outcomes considered important by pregnant women with Vasa Previa as well as other stakeholders involved in their care.

394: Timing of delivery in women with vasa previa: A decision analysis

394: Timing of delivery in women with vasa previa: A decision analysis

Providing quality care for women with vasa praevia: Challenges and barriers faced by Australian midwives

ObjectiveTo explore the barriers to providing quality maternity care for women with vasa praevia as identified by Australian midwives. DesignA qualitative descriptive study using semi-structured in-depth telephone interviews. SettingAustralian maternity system. MethodsMidwives were recruited from across Australia. Interviews were audio-recorded, transcribed verbatim, and analysed using thematic analysis. ParticipantsTwenty midwives from five Australian states practising in 15 different public or private hospitals who had cared for at least one woman with vasa praevia during 2010–2016 were interviewed. More than half of the participants held senior positions. Twelve were involved in a neonatal death or ‘near-miss’ due to vasa praevia. FindingsTwo categories and five themes were identified in relation to barriers to the provision of quality care. Practitioner-level barriers included two themes: identifying lack of midwifery education and lack of knowledge. System-level barriers included lack of a local policy to guide practice, limited information for women, and paucity of research about vasa praevia. ConclusionMidwives experienced a number of barriers in caring for women with vasa praevia. Offering more comprehensive pre-registration and continuing professional education to midwives, developing local protocols, and providing clear written information for women may improve the provision of quality care. Implications for practiceMidwives have a critical role in caring for and supporting women with vasa praevia. Improving midwives’ knowledge with contemporary evidence and clinical guidelines could enable them to deliver safer maternity care and improve a women's journey through this potentially catastrophic condition.

Vasa Praevia: Diagnosis and Management: Green-top Guideline No. 27b.

This is the fourth edition of this guideline. The first, published in 2001, was entitled Placenta Praevia: Diagnosis and Management; the second, published in 2005, was entitled Placenta Praevia and Placenta Praevia Accreta: Diagnosis and Management; and the third, published in 2011, was entitled Placenta Praevia, Placenta Praevia Accreta and Vasa Praevia: Diagnosis and Management. The management and diagnosis of placenta praevia and placenta accreta is addressed in Green‐top Guideline No. 27a.

Prenatal ultrasound diagnosis of velamentous insertion of the umbilical cord: clinical cases and literature review

Seven cases of ultrasound diagnosis of velamentous insertion (VCI) of the umbilical cord at singleton pregnancies on 21–34 weeks of gestation are presented. The ultrasound picture two of the VIC types is presented: fixed in 5 cases and free in 2 cases. In one case the VCI was in the lower third of the uterus and the wound has been diagnosed the vasa previa. In other cases, the VCI was in middle third of the uterus. In all cases delivery was at 37–39.1 weeks of gestation. In 4 cases Cesarean sections were performed. In two of the VCI cases elective Ce sarean sections were performed for the following indications: previous Cesarean section and vasa previa. VCI can reliably be detected prenatally by gray-scale and color Doppler ultrasound. For fixed VCI located in the middle-upper of the uterus, no change in standard obstetrical management seems to be required.

Vasa previa: easy to miss.

Vasa praevia (VP) is a condition that can result in a devastating fetal outcome. This is especially true if it is not diagnosed during the antepartum period. Some have reported that in these cases, the neonatal survival rate is less than 50%.

Impact of targeted scanning protocols on perinatal outcomes in pregnancies at risk of placenta accreta spectrum or vasa previa

Placenta accreta spectrum and vasa previa (VP) are congenital disorders of placentation associated with high morbidity and mortality for both mothers and newborns when undiagnosed before delivery. Prenatal diagnosis of these conditions is essential to allow multidisciplinary management and thus improve perinatal outcomes. The objective of the study was to compare perinatal outcome in women with placenta accreta spectrum or vasa previa before and after implementation of targeted scanning protocols. This retrospective study included 2 nonconcurrent cohorts for each condition before and after implementation of the corresponding protocols (2004-1012 vs 2013-2016 for placenta accreta spectrum and 1988-2007 vs 2008-2016 for vasa previa). Clinical reports of women diagnosed with placenta accreta spectrum and vasa previa during the study periods were reviewed and outcomes were compared. In total, there were 97 cases of placenta accreta spectrum and 51 cases with vasa previa, all confirmed at delivery. In both cohorts, the prenatal detection rate increased after implementation of the scanning protocols (28 of 65 cases [43.1%] vs 31 of 32 cases [96.9%], P < .001, for placenta accreta spectrum and 9 of 18 cases [50%] vs 29 of 33 cases [87.9%], 87.9%, P < .01 for vasa previa). The perinatal outcome improved also significantly in both cohorts after implementation of the protocols. In the placenta accreta spectrum cohort, the estimated blood loss and the postoperative hospitalization stay decreased between periods (1520 ± 845 vs 1168 ± 707 mL, P < .01, and 10.9 ± 14.1 vs 5.7 ± 2.2 days, P < .05, respectively). In the vasa previa cohort, the number of 5 minute Apgar score ≤5 and umbilical cord pH <7 decreased between periods (5 of 18 cases [27.8%] vs 1 of 33 cases [3%]; P < .05, and 4 of 18 cases [22.2%] vs 1 of 33 cases [3%], P < .05, respectively). The implementation of standardized prenatal targeted scanning protocols for pregnant women with risk factors for placenta accreta spectrum and vasa previa was associated with improved maternal and neonatal outcomes. The continuous increases in the rates of caesarean deliveries and use of assisted reproductive technology highlights the need to develop training programs and introduce targeted scanning protocols at the national and international levels.

Successful outcome birth in full term pregnancy velamentous insertion of the umbilical cord – vasa previa

Disclosure of incident on our successful outcome childbirth in term pregnancy velamentous insertion of the umbilical cord – vasa previa. Pregnant firstborn with free individuals and obstetrical history covering the 39th week of pregnancy is introduced in Maternity Clinic of our with symptomatology of automatic start birth. Sudden and to thoroughly grade vaginal hemorrhage found immediately after technical rupture of fetal membranes accompanied by decelerations of the fetal heartbeat raised the possible diagnosis of velamentous insertion of the umbilical cord – vasa previa and the interest undergone emergency cesarean section. After removal of the fetus and placenta was there synovial adherence cord. The caesarean section was performed smoothly with physiological loss blood. There was no need for blood transfusion in neonates, as well as it did not take neonatal support. Following a smooth postoperative course left together with the postpartum at fifth day of hospitalization. At this paper on the basis of current data a brief literature review of rare disease entities this respect mainly the diagnosis, treatment and prognosis.

Early sonographic detection of a succenturiate placenta after IVF in a 42-year-old woman with multiple comorbidities

We present a case of a 42-year-old woman with a pregnancy resulting from in vitro fertilisation and a medical history including two spontaneous abortions, hypercoagulable state and other comorbidities. At...