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International Journal of Gynaecology... Nov 2023To examine the association between assisted reproductive technology (ART) and abnormal placentation.
OBJECTIVE
To examine the association between assisted reproductive technology (ART) and abnormal placentation.
METHODS
This is a retrospective cohort study querying the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. The study population included 14, 970, 064 deliveries for national estimates from January 2012 to September 2015. The exposure was 48, 240 pregnancies after ART. The main outcome measure encompassed three abnormal placentation pathologies (placenta previa [PP], placenta accreta spectrum [PAS], and vasa previa [VP]). Propensity score matching was performed to assess the exposure-outcome association.
RESULTS
Pregnancy after ART was more likely to have a diagnosis of PAS (2.8 vs 1.0 per 1000 deliveries; adjusted odds ratio [aOR], 2.06 [95% confidence interval (CI), 1.44-2.93]), PP (24.5 vs 8.6 per 1000; aOR, 2.98 [95% CI, 2.64-3.35]), and VP (2.3 vs <0.3 per 1000; aOR, 11.3 [95% CI, 5.86-21.8]) compared with pregnancy without ART. Similarly, pregnancy after ART was associated with an increased likelihood of having multiple types of abnormal placentation, including VP with PP (aOR, 15.4 [95% CI, 6.15-38.4]) and PAS with PP (aOR, 2.80 [95% CI, 1.32-5.92]) compared with non-ART pregnancy.
CONCLUSIONS
This national-level analysis suggests that pregnancy after ART is associated with a significantly increased risk of abnormal placentation, including PAS, PP, and VP.
Topics: Female; Humans; Pregnancy; Fertilization; Placenta Accreta; Placenta Previa; Placentation; Reproductive Techniques, Assisted; Retrospective Studies; Risk Factors; Vasa Previa
PubMed: 37183534
DOI: 10.1002/ijgo.14850 -
BMJ Open Sep 2023To derive accurate estimates of the incidence of vasa praevia (VP) in a routine population of unselected pregnancies. (Meta-Analysis)
Meta-Analysis
OBJECTIVES
To derive accurate estimates of the incidence of vasa praevia (VP) in a routine population of unselected pregnancies.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES
A search of MEDLINE, EMBASE, CINAHL and the Cochrane database was performed to review relevant citations reporting outcomes in pregnancies with VP from January 2000 until 5 April 2023.
ELIGIBILITY CRITERIA FOR SELECTION OF STUDIES
Prospective or retrospective cohort or population studies that provided data regarding VP cases in routine unselected pregnancies during the study period. We included studies published in the English language after the year 2000 to reflect contemporary obstetric and neonatal practice.
DATA EXTRACTION AND SYNTHESIS
Two reviewers independently screened the retrieved citations and extracted data. The methodological quality of studies was assessed using the Newcastle-Ottawa Scale, and Preferred Reporting Items for Systematic reviews and Meta-Analyses was used to ensure standardised reporting of studies.
RESULTS
A total of 3847 citations were screened and 82 full-text manuscripts were retrieved for analysis. There were 24 studies that met the inclusion criteria, of which 12 studies reported prenatal diagnosis with a systematic protocol of screening. There were 1320 pregnancies with VP in a total population of 2 278 561 pregnancies; the weighted pooled incidence of VP was 0.79 (95% CI: 0.59 to 1.01) per 1000 pregnancies, corresponding to 1 case of VP per 1271 (95% CI: 990 to 1692) pregnancies. Nested subanalysis of studies reporting screening for VP based on a specific protocol identified 395 pregnancies with VP in a population of 732 654 pregnancies with weighted pooled incidence of 0.82 (95% CI: 0.53 to 1.18) per 1000 pregnancies (1 case of VP per 1218 (95% CI: 847 to 1901) pregnancies).
CONCLUSION
The incidence of VP in unselected pregnancies is 1 in 1218 pregnancies. This is higher than is previously reported and can be used as a basis to assess whether screening for this condition should be part of routine clinical practice. Incorporation of strategies to screen for VP in routine clinical practice is likely to prevent 5% of stillbirths.
PROSPERO REGISTRATION NUMBER
CRD42020125495.
Topics: Infant, Newborn; Female; Pregnancy; Humans; Incidence; Prospective Studies; Retrospective Studies; Vasa Previa; Databases, Factual
PubMed: 37730391
DOI: 10.1136/bmjopen-2023-075245 -
European Journal of Obstetrics,... Feb 2024Vasa praevia is a serious pregnancy complication that is potentially life-threatening for the fetus. The possible benefits of prophylactic hospital admission of... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Vasa praevia is a serious pregnancy complication that is potentially life-threatening for the fetus. The possible benefits of prophylactic hospital admission of asymptomatic women diagnosed with vasa praevia antenatally remain unclear. This study aims to compare the pregnancy outcomes of inpatient versus outpatient management in women with a prenatal diagnosis of vasa praevia.
METHODS
A systematic search of four electronic databases was conducted and two reviewers independently screened studies for eligibility. The inclusion criteria incorporated studies with prenatally diagnosed vasa praevia, a distinction on whether women were managed as inpatients and/or outpatients and where perinatal mortality was recorded as an outcome. The primary outcome of the study was perinatal mortality with additional outcomes of perinatal morbidity, need for emergency caesarean and antenatal steroid administration. Reporting of the results followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.
RESULTS
The search produced 2,300 studies with ten of these studies included in the qualitative synthesis and four included in the quantitative analysis. There was no significant difference in perinatal mortality (OR 1.12, 95 % CI 0.10-12.07, p = 0.93, I = 0 %) or morbidity between women managed as inpatients or outpatients. The prophylactic inpatient group had higher rates of earlier gestational delivery and antenatal corticosteroid administration (OR 10.78, 95 % CI 1.07-108.74, p = 0.04, I = 82 %), but lower rates of emergency caesareans (OR 0.35, 95 % CI 0.17-0.72, p = 0.004, I = 0 %).
CONCLUSION
There were no significant differences in perinatal mortality or morbidity rates observed between inpatient and outpatient management of asymptomatic women with antenatally diagnosed vasa praevia. However, outpatient management is associated with prolonged gestation, a decrease in antenatal corticosteroid administration, and higher odds of emergency caesarean. Outpatient management of prenatally diagnosed vasa praevia seems appropriate for carefully selected asymptomatic women.
Topics: Pregnancy; Female; Humans; Vasa Previa; Outpatients; Inpatients; Prenatal Diagnosis; Perinatal Death; Adrenal Cortex Hormones
PubMed: 38057179
DOI: 10.1016/j.ejogrb.2023.11.033 -
American Journal of Perinatology May 2024We aimed to compare costs of two strategies for third-trimester type II vasa previa management: (1) fetoscopic laser ablation surgery (FLS) referral and (2) standard...
OBJECTIVE
We aimed to compare costs of two strategies for third-trimester type II vasa previa management: (1) fetoscopic laser ablation surgery (FLS) referral and (2) standard management (SM).
STUDY DESIGN
A decision analytic model and cost-benefit analysis from a health care perspective were performed. The population included patients with type II vasa previa at approximately 32 weeks. SM entailed 32-week antepartum admission and cesarean at approximately 35 weeks. FLS referral included consultation and possible laser surgery at 32 weeks for willing/eligible candidates. Successful laser surgery allowed the possibility of term vaginal delivery. Outcomes included antepartum admission, preterm birth, cesarean, neonatal transfusion, and death. Sensitivity analyses were performed.
RESULTS
In base case analysis, FLS referral was cost saving compared with SM (total cost per patient $65,717.10 vs. 71,628.16). FLS referrals yielded fewer antepartum admissions, cesareans, premature births, neonatal transfusions, and deaths. Eligible referred patients choosing FLS incurred a total cost of $41,702.46, a >40% decrease compared with SM. FLS referral was cost saving in all one-way sensitivity analyses except when antepartum admission costs were low. In threshold analyses, FLS referral was cost saving unless laser surgery cost was >$39,892 (2.75x expected cost), antepartum admission cost for monitoring of vasa previa or ruptured membranes was <$7,455, <11% patients were eligible for laser surgery, and when <12% of eligible patients chose laser surgery. In two-way sensitivity analysis, FLS referral was cost saving except at very high laser surgery costs and extremely low antepartum admission costs.
CONCLUSION
Referral for FLS for type II vasa previa was cost saving and improved outcomes compared with SM, despite upfront costs, fetoscopy-related risks, and many patients being ineligible or not opting for surgery after referral.
KEY POINTS
· Vasa previa rupture may lead to fetal exsanguination and death.. · Late preterm cesarean is common practice for prenatally diagnosed vasa previa.. · Successful fetoscopic laser ablation for type II vasa previa has been described.. · Laser ablation of vasa previa allows for a safe-term vaginal delivery.. · Referral for laser surgery is cost saving and is associated with improved outcomes..
Topics: Humans; Pregnancy; Female; Cost-Benefit Analysis; Vasa Previa; Fetoscopy; Laser Therapy; Cesarean Section; Pregnancy Trimester, Third; Decision Support Techniques; Premature Birth; Referral and Consultation; Infant, Newborn; Adult
PubMed: 37494587
DOI: 10.1055/s-0043-1771262 -
Case Reports in Women's Health Dec 2023Type 3 vasa previa is a new concept. Herein, a case is reported of a 35-year-old woman, pregnant following in vitro fertilization, in whom vasa previa was detected on...
Type 3 vasa previa with no low-lying placenta, with central umbilical cord insertion at the upper uterine segment, and with aberrant vessels on the broad membrane: A case report.
Type 3 vasa previa is a new concept. Herein, a case is reported of a 35-year-old woman, pregnant following in vitro fertilization, in whom vasa previa was detected on color Doppler ultrasound at 26 weeks, with no finding of a low-lying placenta. A cesarean section was performed at 34 weeks and 3 days. Gross examination of the placenta showed Type 3 vasa previa with findings somewhat different from previous reports: two aberrant fetal vessels with branching on the broad membrane, and central cord insertion which was farther from the longitudinal center of the placenta than were the running vessels on the membrane. Vasa previa cannot be excluded due to normal cord insertion at the upper uterine segment, absence of placenta previa, or a low-lying placenta in the second trimester. Careful ultrasound screening can promote neonatal survival in patients with Type 3 vasa previa.
PubMed: 37946796
DOI: 10.1016/j.crwh.2023.e00558 -
Journal of Ultrasound in Medicine :... Mar 2024Our institution introduced universal vasa previa (VP) screening utilizing transabdominal ultrasound with color Doppler for all pregnancies at the second trimester...
OBJECTIVES
Our institution introduced universal vasa previa (VP) screening utilizing transabdominal ultrasound with color Doppler for all pregnancies at the second trimester anatomy scan. Our study sought to describe the clinical impact of this intervention.
METHODS
Radiology records from the 12 months pre- and post-intervention were queried for "vasa previa." Records included for analysis were those with a first-time diagnosis or discussion of VP at the anatomy scan. Cases were categorized by outcome: (Group 1) True VP, with subgroups A, unresolved by time of delivery and B, resolved by delivery; (Group 2) False positives; (Group 3) Possible VP without definitive diagnosis; and (Group 4) VP ruled out, for example, "no features of VP." Group size was expressed as a percentage of total anatomy scans during pre- or post-intervention periods respectively. Absolute and relative percent change were calculated for each group.
RESULTS
In the pre-intervention period, 1 case (0.36% of total scans) was categorized in Group 1A, 1 case (0.36%) in Group 3, and 7 cases (2.53%) in Group 4. In the post-intervention period, 2 cases (0.30%) were in Group 1A, 4 cases (0.61%) in Group 1B, 2 cases (0.30%) in Group 2, 1 case (0.15%) in Group 3, and 7 cases (1.06%) in Group 4. There was a +153% relative change in true positives, from 0.36 to 0.91%.
CONCLUSIONS
Universal color Doppler screening may have increased detection (sensitivity) while simultaneously increasing false positives (decreased specificity). While decreasing sensitivity is not ideal, this is acceptable given the potential catastrophic outcome of a missed VP.
Topics: Pregnancy; Female; Humans; Vasa Previa; Umbilical Cord; Ultrasonography, Prenatal; Ultrasonography, Doppler, Color; Pregnancy Trimester, Second
PubMed: 38009660
DOI: 10.1002/jum.16378 -
BMC Pregnancy and Childbirth Oct 2023Antepartum and intrapartum hemorrhage from vasa previa (VP) is one of the main causes of intrauterine fetal death (IUFD). Here, we present two cases with type I VP in...
Antepartum and intrapartum hemorrhage from vasa previa (VP) is one of the main causes of intrauterine fetal death (IUFD). Here, we present two cases with type I VP in which velamentous cord insertion below the fetal head and overlying the cervix were reported by prenatal ultrasound scanning, and IUFD occoured after 35 weeks with no signs of prenatal bleeding but with engaged fetal head at presentation. We hypothesized that the IUFD may attributed to the compression of the unprotected umbilical vessels by the engaged fetal head. Thus we suggest that VP with a velamentous cord insertion should be considered for earlier termination of the pregnancy to avoid the risk of non-hemorrhagic adverse fetal outcomes.
Topics: Pregnancy; Female; Humans; Vasa Previa; Fetal Death; Umbilical Cord; Stillbirth; Ultrasonography, Prenatal; Hemorrhage
PubMed: 37789298
DOI: 10.1186/s12884-023-06019-0 -
Ultrasound in Obstetrics & Gynecology :... May 2024
PubMed: 38708446
DOI: 10.1002/uog.27677 -
Acta Obstetricia Et Gynecologica... Jul 2024Vasa previa (VP), defined as unprotected fetal vessels traversing the membranes over the cervix, is associated with a high perinatal mortality when undiagnosed...
INTRODUCTION
Vasa previa (VP), defined as unprotected fetal vessels traversing the membranes over the cervix, is associated with a high perinatal mortality when undiagnosed prenatally. Conversely, prenatal diagnosis with ultrasound and cesarean delivery before the membranes rupture is associated with excellent outcomes. However, controversy exists regarding screening for VP. In the UK, routine screening for VP is not recommended. The objective of this study was to report the incidence of VP and our experience in the detection of VP with a universal screening protocol at the time of the second-trimester fetal anomaly scan with third-trimester confirmation in an unselected population of pregnancies.
MATERIAL AND METHODS
We performed a single-center historical cohort study of all pregnant women who underwent routine second-trimester anomaly screening scans at West Middlesex University Hospital, London, UK, between 2012 and 2016. Over 5 years, every patient undergoing routine anomaly screening was evaluated for VP using a systematic protocol during their 20-week anomaly scan. Suspected cases of VP were rescanned in the third trimester by specialist sonographers with an interest in VP. The primary outcomes were the incidence and detection of VP.
RESULTS
During the study period, 24 690 anatomy scans were performed. A total of 64 patients were identified as having potential VP at the second-trimester anomaly screening scan, of which 19 were confirmed by the specialist sonographer in the third trimester and at delivery. The screen positive rate was 0.26% (95% confidence interval [CI] 0.20%-0.32%). VP at birth was found in 19/24690 births (1:1299 [95% CI: 1:832-1:2030] births). Universal screening for VP using our protocol had a sensitivity of 100% and a specificity of 99.78% (95% CI: 99.72%-99.84%). The false-positive rate of the second-trimester screen was 0.18% (95% CI: 0.13-0.24). There were no false positives or false negatives at delivery. Of the 19 patients with confirmed VP, 17 had scheduled cesarean deliveries, and two required emergency deliveries due to antepartum hemorrhage. One baby died, giving a perinatal mortality of 5%.
CONCLUSIONS
VP complicates approximately 1:1300 pregnancies. Routine screening for VP yielded a 100% detection rate. We suggest the inclusion of structured VP assessment in standard fetal anomaly screening programs.
Topics: Humans; Female; Pregnancy; Vasa Previa; Ultrasonography, Prenatal; Adult; Pregnancy Trimester, Second; Cohort Studies; Incidence; Pregnancy Trimester, Third; United Kingdom
PubMed: 38594913
DOI: 10.1111/aogs.14839 -
Cureus Mar 2024Vasa previa is a rare but potentially life-threatening condition to the fetus. Timely antenatal diagnosis and delivery by cesarean section (CS) can lead to a favorable...
Vasa previa is a rare but potentially life-threatening condition to the fetus. Timely antenatal diagnosis and delivery by cesarean section (CS) can lead to a favorable outcome. Here, we report a case of recurrent pregnancy loss (G3A2) with vasa previa, which was diagnosed prenatally by ultrasound. She was admitted at her 31st week with bleeding per vaginum (PV) provisionally diagnosed as antepartum hemorrhage (APH) and managed conservatively as placenta previa. Follow-up ultrasonography (USG) revealed vasa previa at 33 weeks. The fetus was delivered by lower segment cesarean section (LSCS) after careful separation of the membranes and avoiding damage to the vessels as there was velamentous insertion of cord with the lower margin of the placenta in the lower segment. The baby was cared for in the neonatal intensive care unit due to prematurity and discharged after six days. This case report highlights the importance of prenatal ultrasound in diagnosing vasa previa and planning an elective cesarean section with caution intraoperatively for the safe delivery of the baby.
PubMed: 38576689
DOI: 10.7759/cureus.55578