Elias Kassir

Introduction: We aim to evaluate uterine artery (UtA) Doppler velocimetry in patients at risk of placenta accreta spectrum (PAS). Methods: Prospective cohort of patients referred to an academic referral center for suspected PAS. The left and right UtA were evaluated, and mean peak systolic velocity (PSV), end‐diastolic velocity (EDV), and pulsatility index (PI) were obtained and converted to gestational age (GA)‐adjusted z ‐scores. Differences in UtA Doppler indices between patients with and without PAS, and among varying degrees of placental implantation depth, were analyzed. The predictive performance of UtA Doppler velocimetry to diagnose PAS and intraoperative bleeding (IOBL) >1500 mL was calculated. A sub‐analysis of patients with and without placenta previa was conducted. Results: A total of 177 patients were included, and PAS was confirmed in 61.0% (108/177). In the complete study group, patients with PAS had significantly lower UtA‐PI and higher UtA‐PSV and UtA‐EDV ( p < 0.05) than patients without PAS. We found the following associations with PAS: UtA‐PSV ≥90th percentile for GA demonstrated an odds ratio (OR) of 4.9 (95% confidence interval [CI], 2.31–10.39; p < 0.0001); UtA‐EDV ≥90th percentile for GA demonstrated an OR of 3.49 (95% CI, 1.71–7.14; p = 0.0006); and UtA‐PI ≤25th percentile for GA demonstrated an OR of 0.71 (95% CI, 0.23–2.23; p = 0.2). The predictive performance of UtA velocities improved when analyzing only patients without placenta previa. There were no significant differences in UtA Doppler indices related to the placental implantation depth. Patients with severe IOBL (>1500 mL, n = 86) had significantly higher UtA‐PSV ( p = 0.004) and UtA‐EDV ( p = 0.0001), but no differences in UtA‐PI than those without severe IOBL ( n = 79). The association between UtA‐PSV ≥90th percentile for GA and severe IOBL demonstrated an OR of 3.67 (95% CI, 1.86–7.23; p = 0.002); UtA‐EDV ≥90th percentile for GA demonstrated an OR of 3.34 (95% CI, 1.68–6.64; p = 0.0006). The association between increased UtA velocities and severe IOBL was similar regardless of the presence of placenta previa. Conclusions: Patients with PAS showed lower UtA‐PI and higher UtA‐PSV and UtA‐EDV than those without PAS. The predictive performance of UtA Doppler velocimetry for PAS seems to improve in patients without placenta previa. Patients who experienced severe IOBL exhibited significantly higher UtA‐PSV and UtA‐EDV than those without severe IOBL.

Objectives: To evaluate the association between cervical length (CL) and unscheduled delivery in patients with placenta accreta spectrum (PAS).Methods: Retrospective cohort study of patients with suspected PAS from January 2018 to June 2024. Patients with suspected PAS underwent serial ultrasounds including transvaginal CL measurement every 4 weeks. The final CL measurement prior to delivery was analyzed. Unscheduled delivery was defined as urgent delivery prior to the scheduled date due to either bleeding or preterm contractions. A receiver operating characteristics (ROC) curve was created, the optimal CL associated with unscheduled delivery was selected, and associations and prediction analyses were performed.Results: Of 102 patients, 21 (20.6%) had an unscheduled delivery. Median gestational age at unscheduled delivery was 30w5d (IQR 29w0d–34w1d), and at scheduled delivery 34w0d (IQR 33w1d–34w4d, P = 0.001). CL was shorter in patients who had an unscheduled delivery compared to those with a scheduled delivery (mean [SD] 29.9 [10.2] mm versus 36.1 [10.3] mm, P = .02). CL was shorter (31.6 [SD 11.1] mm) among patients (n = 53) having a delivery P < .001). ROC analysis showed a CL of 30 mm as the optimal cutoff for prediction of unscheduled delivery. A significant association between CL ≤30 mm with unscheduled delivery (adjusted relative risk [aRR] 2.33, 95% CI: 1.08–5.03, P = .03) was observed after adjusting for history of spontaneous preterm birth.Conclusions: In patients with PAS, a CL ≤30 mm is associated with a higher rate of unscheduled delivery and delivery ≤34 weeks.

This study aimed to evaluate longitudinal changes in uterine artery (UtA) Doppler velocimetry in patients with placenta accreta spectrum (PAS) managed by leaving the placenta in situ (LPIS) postpartum.This is a prospective cohort study of patients with PAS managed by LPIS for either planned interval hysterectomy or uterine preservation who underwent serial postpartum ultrasounds. We included patients who had Doppler velocimetry of the UtA obtained before delivery and postpartum. Left, right, and mean (m) peak systolic velocity (PSV), end-diastolic velocity (EDV), and pulsatility index (PI) were recorded. Our goal is to describe changes in these Doppler indices over time and to make comparisons with normal postpartum reference values.A total of 34 patients were included: 19 planned for uterine-sparing management and 15 planned for interval hysterectomy. No significant differences in mUtA PI, mPSV, and mEDV were documented between predelivery values and those obtained within the first eight weeks postpartum, however after 8 weeks there was a significant increase in mUtA PI (0.80–1.49; p < 0.001), while mUtA PSV (103.8–58.6 cm/s; p = 0.002) and mEDV (53.5–15.8 cm/s; p < 0.001) decreased significantly. Patients opting for uterine-sparing management who successfully retained their uterus showed a trend for higher mUtA PI, PSV, and EDV than those who underwent an interval hysterectomy. mUtA PI postpartum values were lower in our study group compared to those reported from postpartum patients without PAS.In comparison to patients without PAS, mUtA PI is markedly lower in LPIS patients in the first 8 weeks. In patients undergoing LPIS for PAS, UtA Doppler indices start to show significant changes at ≥ 8 weeks postpartum compared to predelivery values, with a significant increase in mUtA PI and a reduction in mUtA PSV and EDV. Future studies are needed to evaluate the clinical utility of these findings.

Objective Measles immunity testing, unlike that for rubella, is not currently part of prenatal screening even though immunity to both is conferred by the measles–mumps–rubella (MMR) vaccine. Although endemic transmission of measles was declared eliminated in the United States in 2001, outbreaks have continued to occur. Given the risks associated with measles infection during pregnancy, we sought to identify risk factors for measles nonimmunity (MNI) in rubella-immune (RI) pregnant individuals. Methods We performed a retrospective observational cross-sectional study of patients receiving prenatal care and delivering at two university hospitals and a county hospital in Southern California from April 1, 2019 to February 1, 2021. Inclusion criteria were pregnant individuals ≥18 years old who had serological testing for rubella and measles during pregnancy. Demographic data were extracted from electronic medical records, including results of serological testing and chronic medical conditions. All subjects were rubella immune, and we compared measles-immune (MI) with MNI groups. Results In total, 1,813 RI individuals were identified, with 1,467 (81%) MI and 346 (19%) MNI individuals. Variables associated with an increased risk of MNI included having public health insurance (adjusted relative risk [aRR]: 1.56; 95% confidence interval [CI]: 1.24, 1.97) and Hispanic ethnicity (aRR: 1.37; 95% CI: 1.06, 1.78). Black race was associated with a decreased risk of MNI (aRR: 0.52; 95% CI: 0.29, 0.91). Birth year before 1989 demonstrated a trend toward increased risk of MNI, but this did not reach statistical significance (aRR 1.23; 95% CI: 1.00, 1.52). No differences were seen between the two groups for medical comorbidities. Conclusion Our study is the first to demonstrate risk factors for measles MNI in patients with documented rubella immunity. In the absence of universal measles serological screening recommendations, the risk factors identified could help guide clinicians in selective screening for those at risk of needing postpartum MMR vaccination. Key Points

Objective Cardiac dysfunction has been described in 60% of fetuses undergoing open myelomeningocele (MMC) repair. Routine Doppler evaluation of the umbilical artery (UA) and ductus venosus (DV) is challenging during fetal surgery. This study describes Doppler changes in the UA and DV in a cohort of fetuses during MMC repair. Methods Fetuses who underwent fetoscopic repair of MMC at a single institution between 2014 and 2017 were included in this study (n=35). Ultrasound images taken intraoperatively were analyzed to describe the changes in Doppler parameters of the UA and DV during fetal MMC repair. The timing of Doppler changes was matched with the phase of the surgery to determine whether a pattern to their appearance could be ascertained. Results Fetoscopic (n=35) fetal MMC repairs were included. Of the 35 fetoscopic MMC repairs, Doppler data of the UA was obtained in 12 cases, and Doppler data of the DV was obtained in 13 cases. In the 12 fetoscopic repairs for which there was UA data, 9 (75%) showed transient absence of end‐diastolic flow (EDF), with 5 (41.7%) of them progressing to reversal of EDF. In the 13 fetoscopic cases for which there was DV data, 9 had elevated pulsatility index; however, none of them had absent or reversed blood flow during the atrial contractions. In the 9 fetoscopic cases with absent EDF in the UA, this abnormality first appeared during the fetoscopic repair in 5 cases (55.6%), after uterus exteriorization but before CO2 insufflation in 2 cases (22.2%), after uterus replacement but before skin closure in 1 case (11.1%), and after CO2 insufflation but before the start of the MMC repair in 1 case (11.1%). The Doppler abnormalities in four fetuses with reversed EDF and in three with absent EDF resolved during surgery. Follow‐up scan one day after surgery demonstrated resolution of UA and DV Doppler abnormalities in all fetuses. Conclusion Transient Doppler abnormalities of the umbilical artery without significant changes in the ductus venosus can be seen during fetal MMC repair. The clinical significance of these Doppler findings remains unclear due to their transient and intermittent nature.