Katharine D. Wenstrom’s research while affiliated with Brown University and other places

Malignancy complicating pregnancy is fortunately rare, affecting one in 1000 to one in 1500 pregnancies. Optimal treatment involves balancing the benefit of treatment for the mother while minimizing harm to the fetus. This balance is dependent on the extent of the disease, the recommended course of treatment, and the gestational age at which treatment is considered. Both surgery and chemotherapy are generally safe in pregnancy, whereas radiation therapy is relatively contraindicated. Iatrogenic prematurity is the most common pregnancy complication, as infants are often delivered for maternal benefit. In general, however, survival does not differ from the nonpregnant population. These patients require a multidisciplinary approach for management with providers having experience in caring for these complex patients. The aim of this review was to provide an overview for obstetricians of the diagnosis and management of malignancy in pregnancy.

Cardiac disease is among the leading causes of maternal mortality during pregnancy, and relative proportion of maternal deaths attributable to cardiac disease has been increasing. Pregnancy is not recommended for women with severe pulmonary arterial hypertension and those with significant left to right shunts; such women should consider sterilization or long-term progestin-only contraception. In normal pregnancy, cardiovascular system undergoes significant physiological changes that may not be tolerated by the pregnant woman with heart disease. With loss of the placental circulation and hormones, peripheral resistance increases, and at the same time extravascular fluid is mobilized. After excluding acute pulmonary embolus, cardiac disease should be suspected in any pregnant woman who develops dyspnea, chest pain, palpitations, arrhythmias, or cyanosis, or who experiences sudden limitation of activity. Key principles in antepartum management of heart disease focus on minimizing cardiac work while optimizing perfusion of the tissues including the uteroplacental bed.

To compare the composite neonatal morbidity of pregnancies with fetal growth restriction (estimated fetal weight less than the 10th percentile) and normal compared with elevated umbilical artery systolic-to-diastolic ratios. This was a retrospective cohort study of all pregnancies complicated by fetal growth restriction with normal compared with elevated umbilical artery systolic-to-diastolic ratios from January 2008 to July 2012 at a single center. Exclusions were multiple gestation, prenatally diagnosed fetal anomalies, delivery at outside institution, and absent or reversed end diastolic flow. Maternal characteristics and perinatal outcomes including composite neonatal morbidity were compared between groups. Of 11,785 pregnancies evaluated, 789 (7%) were diagnosed with fetal growth restriction. Among 512 that met inclusion criteria, 394 (77%) had normal and 118 (23%) had elevated umbilical artery systolic-to-diastolic ratios. When fetal growth-restricted pregnancies with elevated umbilical artery systolic-to-diastolic ratios were delivered at 37 weeks of gestation were compared with those with normal umbilical artery systolic-to-diastolic ratios delivered at 39 weeks of gestation, there was no difference in the rate of neonatal intensive care unit admission (101 [25.7%] compared with 51 [43.2%]; crude odds ratio [OR] 2.5, 95% confidence interval 1.5-4.0; adjusted OR 1.37, 95% CI 0.69-2.71) or composite neonatal morbidity (60 [15.2%] compared with 24 [20.3%]; crude OR 1.42, 95% CI 0.84-2.40; adjusted OR 0.91, 95% CI 0.45-1.84). Composite neonatal morbidity is comparable in fetal growth-restricted pregnancies with elevated compared with normal umbilical artery systolic-to-diastolic ratios when delivered at 37 and 39 weeks of gestation, respectively. Planning delivery of pregnancies with fetal growth restriction and elevated systolic-to-diastolic ratios and without other complications at 37 weeks of gestation results in good outcomes. LEVEL OF EVIDENCE:: II.

Objective This study aims to compare two management protocols in pregnancies diagnosed with fetal growth restriction (FGR). Study Design All singleton pregnancies diagnosed and managed with FGR at our institution during two protocol periods were analyzed. The early term protocol (January 2008-February 2010) specified delivery at 37(0/7) weeks if antenatal testing was reassuring, but did not specify the timing of delivery if umbilical artery (UA) Doppler systolic:diastolic (S:D) ratios were elevated (>95th percentile for gestational age [GA]). The term protocol (March 2010-July 2012) specified delivery at 39(0/7) weeks with normal S:D ratios and 37(0/7) weeks with elevated S:D ratios when antenatal testing was reassuring. Results There were 228 and 312 women in the early term and term protocol, respectively, who met inclusion criteria. Compared with the early term group, the term group had an increased median GA at delivery (37.1 vs. 38.6%, p < 0.001), decreased deliveries less than 37(0/7) weeks (37 vs. 24%, p = 0.01) and decreased neonatal intensive care unit (NICU) admissions (38 vs. 28%, p = 0.02). Conclusion A protocol specifying delivery at 39(0/7) weeks when UA S:D ratios are normal and delivery at 37(0/7) weeks when UA S:D ratios are elevated when other antenatal testing is reassuring in FGR: (1) prolonged gestation, (2) decreased preterm births, and (3) decreased NICU admissions. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Key content In order to provide appropriate counselling about the risk to future pregnancies imposed by caesarean delivery, providers must be knowledgeable about and able to synthesise a multitude of variables such as institutional policies, the clinical implications of each current delivery option for future pregnancies, patient understanding of maternal and neonatal risks and benefits, the woman's reasons for requesting this type of delivery and the woman's desired family size. The rate of successful vaginal birth after caesarean section ranges 50–85%, with lower rates associated with both modifiable factors (gestational age >40 weeks, maternal obesity, short interpregnancy interval and increased birthweight) and non‐modifiable factors (maternal age, non‐white ethnicity, pre‐eclampsia and recurrence of the indication for the initial caesarean delivery). In future pregnancies, the risk of adverse outcomes such as haemorrhage, endometritis, operative injury, hysterectomy and maternal death goes up with each additional caesarean section. Learning objectives To be knowledgeable about and able to provide accurate counselling for three important clinical situations: caesarean delivery on maternal request; women with a history of one or two caesarean deliveries; and women with a history of three or more caesarean deliveries. Ethical issues When counselling women about the risks of caesarean delivery on future pregnancies, providers should always consider the principles of beneficence and non‐maleficence while synthesising a myriad of scenarios and outcomes. If properly counselled on the risks, benefits and alternatives of a delivery decision, her autonomy should be respected.

Since the first human fetal surgery was reported in 1965, several different fetal surgical procedures have been developed and perfected, resulting in significantly improved outcomes for many fetuses. The currently accepted list of fetal conditions for which antenatal surgery is considered include lower urinary tract obstruction, twin-twin transfusion syndrome, myelomeningocele, congenital diaphragmatic hernia, neck masses occluding the trachea, and tumors such as congenital cystic adenomatoid malformation or sacrococcygeal teratoma when associated with development of fetal hydrops. Until recently, it has been difficult to determine the true benefits of several fetal surgeries because outcomes were reported as uncontrolled case series. However, several prospective randomized trials have been attempted and others are ongoing, supporting a more evidence-based approach to antenatal intervention. Problems that have yet to be completely overcome include the inability to identify ideal fetal candidates for antenatal intervention, to determine the optimal timing of intervention, and to prevent preterm birth after fetal surgery. Confronting a fetal abnormality raises unique and complex issues for the family. For this reason, in addition to a maternal-fetal medicine specialist experienced in prenatal diagnosis, a pediatric surgeon, an experienced operating room team including a knowledgeable anesthesiologist, and a neonatologist, the family considering fetal surgery should have access to psychosocial support and a bioethicist.