Pitfalls in the Second Half of Pregnancy Charlotte Page Wills, MD - - PDF document

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Pitfalls in the Second Half of Pregnancy Charlotte Page Wills, MD - - PDF document

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Pitfalls in the Second Half of Pregnancy Charlotte Page Wills, MD Associate Program Director Alameda Health System-Highland Hospital EM Residency, Oakland, CA Associate Clinical Professor of Emergency Medicine University of California, San

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SLIDE 1

Pitfalls in the Second Half

  • f Pregnancy

Charlotte Page Wills, MD

Associate Program Director Alameda Health System-Highland Hospital EM Residency, Oakland, CA Associate Clinical Professor of Emergency Medicine University of California, San Francisco School of Medicine

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SLIDE 2

Financial Disclosures: None!

3

  • The following is NOT meant to replace the

expertise and guidance of a skilled Obstetrician and Perinatologist!

  • Expert consultation should always be sought in the

care of any pregnant patient greater than twenty weeks gestation or other high risk obstetric case.

  • This lecture recognizes, however, that the

resources of an expert consultant may not always be immediately available, and aims to provide basic guidance in the approach to Emergency Department management of these patients.

Disclaimer!

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SLIDE 3

In the next 30 minutes…

  • Highlight changes in physiology important to managing

patients in the second half of pregnancy.

  • Describe the basic approach to initiate evaluation and

management of the gravid patient.

  • Describe how to evaluate a fetus as viable or nonviable.
  • Illustrate the pitfalls of pre-eclampsia and preterm labor.
  • Discuss some of the obstetric emergencies that can

arise in the ED precipitous delivery.

26 yo woman complaining of headache and abdominal cramping stating she is 6 months

  • pregnant. BP is 158/98 and HR is 118.
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SLIDE 4

maternal well-being gestational age labor status fetal well-being maternal well-being

  • What’s normal? Know the physiologic

changes that occur in pregnancy.

  • Where do I start? Perform standard

maneuvers for resuscitation in all pregnant patients.

  • What’s wrong with her? Identify

underlying disease and treat aggressively.

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SLIDE 5

High Volume, Low Pressure

BP Hct CO Vol HR SVR

Second and Third Trimester Resuscitation

  • Dilutional anemia: replace volume loss; in sepsis

transfuse!

  • Oxygenation: high oxygen content, increased

minute ventilation and TV.

  • Aortocaval compression: pelvic tilt or manual

uterine distraction.

  • Progesterone: anticipate a difficult airway and

aspiration.

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SLIDE 6

Aortocaval Compression

  • IVC may be completely obstructed

in the supine position.

  • Uterus receives 30% of cardiac
  • utput.
  • Compression occurs at 20 weeks.
  • CPR only produces about 10%

normal CO.

Avoiding Compression

  • Tilt the backboard
  • Blanket roll
  • Manual distraction of the

uterus

Accuracy of emergency physicians using ultrasound to determine gestational age in pregnant women Sachita Shah, Nathan Teismann, Brita Zaia, Farnaz Vahidnia, Gerin River, Dan Price, Arun Nagdev American Journal of Emergency Medicine - 29 March 2010 (10.1016/j.ajem.2009.07.024)

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SLIDE 7

labor status fetal well-being maternal well-being gestational age gestational age

  • Traditional: Last menstrual period,

fundal height.

  • Difficult in the obese patient.
  • Is inaccurate with multiple

gestations.

  • Ultrasound:
  • Can be learned easily.
  • Can be quickly performed.
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SLIDE 8

Rapid Pregnancy Dating by EP’s

  • Sonographers had a wide range of experience.
  • Exams had a high degree of correlation with gold s
  • Measurements of BPD and FL took less than one m
  • Was more accurate than measuring fundal height.
  • 96% ULS versus 80% for FH

Accuracy of emergency physicians using ultrasound to determine gestational age in pregnant women Sachita Shah, Nathan Teismann, Brita Zaia, Farnaz Vahidnia, Gerin River, Dan Price, Arun Nagdev American Journal of Emergency Medicine - 29 March 2010 (10.1016/j.ajem.2009.07.024)

BPD Measurement

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SLIDE 9

labor status fetal well-being maternal well-being gestational age

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SLIDE 10

labor status

  • Labor: contractions with progression of the cervix
  • Requires uterine monitoring.
  • Requires examination of the cervix visually and

manually or by ultrasound.

  • Bleeding: may be from labor, trauma, or the placenta
  • Requires extreme caution with the vaginal/cervical

examination.

  • Membranes: may rupture from labor or infection
  • Requires determining presence or absence of

amniotic fluid.

  • Visual inspection: pooling
  • f amniotic fluid on sterile

speculum exam. Most sensitive finding.

  • Ferning: arborization of

salt crystals in amniotic fluid.

  • Nitrazine Paper: amniotic

fluid has a pH of 6.5 or higher.

Evaluating the Membranes

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SLIDE 11
  • Exams should be

sterile.

  • Minimize digital exams
  • rates of infection go up

with numbers of exams in PROM.

  • CONTRAINDICATED if

you suspect placenta previa.

Cervical Evaluation

labor status maternal well-being fetal well-being gestational age

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SLIDE 12

fetal well-being

  • Fetal heart rate (FHR) and activity: fetal monitor.
  • Can use bedside ultrasound to assess both
  • For greater than 20 weeks, fetal monitoring is

standard.

  • MUST come with a provider who can interpret

fetal strips.

  • Fetal distress or intrauterine infection
  • Both are indications to deliver a viable fetus

Supplies for Baby

  • Resuscitation surface:

infant warmer, surface with plenty of dry linens near an

  • xygen source.
  • Infant mask and anesthesia

bag/ambu bag.

  • Dedicated person to dry,

stimulate, warm the infant

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SLIDE 13

Pregnant HTN Headache

Pre‐eclampsia Headache

  • Hypertensive
  • No bleeding
  • Mildly tender uterus

CBC CMP Uric acid, LDH DIC Panel

UA

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SLIDE 14
  • Hemolysis
  • Elevated LFTs
  • Platelet consumption
  • Elevated creatinine
  • Proteinuria

Damaged Endothelium

BP Hct CO Vol HR SVR

High Volume, Low Pressure

High Pressure, Low Volume

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SLIDE 15

End-Organ Damage

  • PRES
  • Renal failure
  • Placental abruption
  • DIC

maternal well-being gestational age labor status fetal well-being

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SLIDE 16

Managing Pre-eclampsia

  • BP control: labetalol, nifedipine, hydralazine.
  • Magnesium infusion for severe pre-eclampsia.
  • Avoid lasix - patients are already volume depleted.
  • Avoid excessive fluids - patients third space

because of endothelial damage and proteinuria.

labor status maternal well-being fetal well-being gestational age

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SLIDE 17

Preterm Labor: Corticosteroid Administration

  • Accelerates fetal lung maturation.
  • Reduces respiratory distress syndrome, intraventricular

hemorrhage, and necrotizing enterocolitis.

  • Reduction in overall neonatal death.
  • Does NOT increase the risk of maternal or neonatal

infection.

  • Betamethasone
  • Dexamathasone

Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews 2006, Issue 3, Art No CD004454

Tocolytics: An Overview

  • Magnesium sulfate
  • Beta-mimetics: terbutaline, ritodrine
  • Prostaglandin inhibitors: indomethacin, ketorolac, COX
  • Calcium channel blockers: nifedipine, nicardipine
  • Nitric oxide donors: nitroglycerin and glyceryl trinitrate
  • Oxytocin receptor antagonists: atosiban
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SLIDE 18

Stopping Labor

Should Tocolytics Be Used and Which One?

  • Proposed approach: use of tocolytics to delay labor

for 48 hours to allow steroid administration.

  • The ‘best’ tocolytic is controversial.
  • ***Terbutaline no longer recommended.***
  • Oral nifedipine may be superior prior to 37 weeks.
  • Indomethacin may be superior prior to 32 weeks.
  • Combinations-77% patients experience

adverse side affects Tocolytic therapy: A Meta-Analysis and Decision Analysis D Haas et al. Obstetrics and Gynecology vol 113 no 3 March 2009

Magnesium sulfate for Preventing Preterm Birth in Threatened Preterm

  • Labour. Cochrane Database of

Systematic Reviews 2006, Issue 4 Art No CD002255 Magnesium sulfate for Preterm Labor and Preterm Birth B Mercer et al. Obsterics and Gynecology vol 114 no 3 Sept 2009

http://www.fda.gov/Safety/MedWatch/SafetyInfor mation/SafetyAlertsforHumanMedicalProducts/uc m243843.htm

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SLIDE 19

But Do Tocolytics Work?

  • 2002 Cochrane Review of 23 trials including 2000 pregnancies.
  • 2009 Systematic review of 19 trials including 1,281 pregnancies.
  • 2009 Meta-analysis and decision analysis of 58 trials.
  • 2014 Cochrane Review of 8 trials with 408 pregnancies.
  • Author conclusions in all four:
  • conflicting results regarding delivery within 48 hours or 7 days.
  • no trend in reduction in the outcome of newborn birth weight below

2,500 grams or in neonatal mortality.

Premature Preterm Rupture of Membranes: Consequences of PPROM

  • Intra-amniotic infection
  • Risk is higher with lower gestational age.
  • Avoid the digital cervical exam!
  • Fetal malpresentation necessitating cesarean section.
  • Placental abruption
  • Post-partum hemorrhage
  • Complications of bed rest
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SLIDE 20

Managing PPROM: Conservative Management

  • Steroids: to accelerate fetal lung maturity.
  • Betamethasone: 12mg IM for two doses Q12 hours.
  • Dexamethasone: 6mg IM for four doses Q 12 hours.
  • Antibiotics: increased the latency period up to 3

weeks.

  • Ampicillin and erythromycin IV for 2 days, then amoxicillin and

erythromycin for 5 days.

  • Avoid amoxicillin-clavulanate-increased risk of NEC.

Premature Rupture of the Membranes B Mercer Obstetrics and Gynecology vol 101 no 1 Jan 2003

+ROM Pushing

Delivers

Pregnant

I had no idea!

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SLIDE 21

maternal well-being gestational age labor status fetal well-being

Pregnancy for Emergency Providers

week 13 week 27 weeks 23‐24

3 inches 15 grams 12 inches 400‐600 grams 15 inches 900 grams

week 20

pre‐viable to viable

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SLIDE 22

Clinically Determining Viability: Weight

  • Less than 400 grams is

considered nonviable.

  • Requires quick access to an

infant scale.

Survival By Weight

Weight Survival Mod-Severe Disability 401-500g 11% * 501-600g 27% 29% 601-700g 63% 30% 701-800g 74% 28%

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SLIDE 23

Clinically Determining Viability: Ballard Score

The Threshold of Viability

Gestational age Survival Moderate-Severe Morbidity

23 11-30% 56% 24 26-52% 53% 25 54-76% 46%

Perinatal Care at the Threshold of Viability H MacDonald et al, Pediatrics 2002: 110; 1024-1027

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SLIDE 24

Non-initiation of a Code

  • Age less than 23 weeks.
  • Weight less than 400 grams.
  • Anencephaly.
  • Lethal malformation: Trisomy 13 or 18.
  • Calling a code: asystole greater than 15 minutes.

34 weeks Pregnant +ROM Pushing

Labor

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SLIDE 25

Cord Prolapse

  • To the OR if possible.
  • Elevate the presenting part.
  • Kneeling position or steep

Trendelenberg.

  • Infusing the bladder with

saline - although not as helpful if a presenting part is visible.

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SLIDE 26

Breech Delivery

  • To the OR if possible!
  • DO NOT PULL until the umbilicus is

delivered.

  • Infant should deliver face down.
  • Preterm infants are more likely to be breech.
  • http://www.birthingway.com/footling_breech.htm#

Shoulder Dystocia

  • “Turtle sign”.
  • Difficult to predict.
  • Fetal macrosomia
  • Precipitous delivery
  • NO fundal pressure/hold

pushing until repositioned.

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SLIDE 27

Reducing Dystocia

  • McRobert’s Maneuver
  • Suprapubic pressure
  • Delivering the posterior shoulder
  • Rubin, Woods Corkscrew
  • Zavenelli Maneuver

Thermal Care

  • The item we are most likely to overlook

and under-manage

  • Association between hypothermia and

mortality: acidosis, respiratory distress, NEC, intraventricular hemorrhage

  • The smaller you are, the faster you lose
  • heat. BIG problem less than 30 weeks.
  • Warm blankets, portable warming

mattresses, warming tables, hats.

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SLIDE 28

Quick Trick

  • No blankets?
  • “micro-preemie”?
  • Use a 5 gallon

freezer bag

  • Cut a hole in the top

and seal the bottom

Post-Partum Care

  • Do not pull on the umbilical

cord.

  • Gush of blood prior to

placental detachment.

  • Keep the mom warm and

dry.

  • Be vigilant for postpartum

hemorrhage.

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SLIDE 29

Postpartum Hemorrhage

  • Greater than 500 cc blood
  • Leading cause of death
  • worldwide. In the US, second

after VTE.

  • Uterine atony and lacerations.
  • Risk factors include advanced

prior hemorrhage, older age, fetal macrosomia.

Resuscitating PPH

  • Manual Interventions:
  • Fundal massage, explore for

lacerations, manual uterine exploration for retained products.

  • Medical Interventions:
  • Oxytocin, methylergonovine (ergot

alkaloid), misoprostil.

  • Resuscitation with fluids and

blood.

  • TXA now second-line.
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SLIDE 30

What we covered…

  • Highlight changes in physiology important to managing

patients in the second half of pregnancy.

  • Describe the basic approach to initiate evaluation and

management of the gravid patient.

  • Describe how to evaluate a fetus as viable or nonviable.
  • Illustrate the pitfalls of pre-eclampsia and preterm labor.
  • Discuss some of the obstetric emergencies that can

arise in the ED precipitous delivery.

  • Committee Opinion no. 514: emergent therapy for acute-onset, severe hypertension with

preeclampsia or eclampsia. - Committee on Obstetric Practice - Obstet Gynecol - 01-DEC-2011; 118(6): 1465-8

  • Caring for women with hypertension in pregnancy. Sibai BM - JAMA - 3-OCT-2007; 298(13): 1566-8
  • Abalos E., Duley L., Steyn D.W., et al: Antihypertensive drug therapy for mild to moderate

hypertension during pregnancy. Cochrane Database Syst Rev 1. 2007;CD002252

  • ACOG Committee on Obstetric Practice : Diagnosis and management of preeclampsia and
  • eclampsia. ACOG practice bulletin no. 33. American College of Obstetricians and
  • Gynecologists. Obstet Gynecol 99. 159-167.2002
  • Hypertension and pregnancy. Deak TM - Emerg Med Clin North Am - 01-NOV-2012; 30(4): 903-17
  • Nonobstetric abdominal pain and surgical emergencies in pregnancy.

Diegelmann L - Emerg Med Clin North Am - 01-NOV-2012; 30(4): 885-901

  • Critical obstetric and gynecologic procedures in the emergency department.

Mercado J - Emerg Med Clin North Am - 01-FEB-2013; 31(1): 207-36

  • Precipitous and difficult deliveries.

Silver DW - Emerg Med Clin North Am - 01-NOV-2012; 30(4): 961-75

  • GhGherman R.: Shoulder dystocia: prevention and management. Obstet Gynecol Clin North

Am 32. 297-305.200

  • Serman R.: Shoulder dystocia: an evidence based evaluation of the obstetric nightmare. Clin

Obstet Gynecol 45. 345-362.2002;

  • Complications in late pregnancy. Meguerdichian D - Emerg Med Clin North Am - 01-NOV-2012;

30(4): 919-36

  • Complications of second and third trimester pregnancies. K. Abbrescia Emerg Med Clin of N Am Vol

21 Issue 3 August 2003

  • Early Goal Directed Therapy for Sepsis During Pregnancy. D Guinn Obstet Gynecol Clin N Am Vol

34 2007

  • Accuracy of Emergency Physicians Using Ultrasound to Determine Gestational Age in Pregnant
  • Women. S Shah, N Teismann, B Zaia, F Vahidnia, G River, D Price, A Nagdev Am Journal of Emerg

Med March 2010

  • The Enigma of Spontaneous Preterm Birth L Muglia, M Katz NEJM Feb 11, 2010
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SLIDE 31
  • Complications of second and third trimester pregnancies. K. Abbrescia Emerg Med Clin of N Am

Vol 21 Issue 3 August 2003

  • Early Goal Directed Therapy for Sepsis During Pregnancy. D Guinn Obstet Gynecol Clin N Am Vol

34 2007

  • Accuracy of Emergency Physicians Using Ultrasound to Determine Gestational Age in Pregnant
  • Women. S Shah, N Teismann, B Zaia, F Vahidnia, G River, D Price, A Nagdev Am Journal of Emerg

Med March 2010

  • The Enigma of Spontaneous Preterm Birth L Muglia, M Katz NEJM Feb 11, 2010
  • Infections Related to Pregnancy. D Gorgas Emerg Med Clin N Am Vol 26, Issue 2 May 2008
  • Cervical Dilation: Accuracy of Visual and Digital Examinations C Brown. Obstet and Gynecol Vol 81

No 2 Feb 1993

  • Antenatal Corticosteroids for Accelerating Fetal Lung Maturation for Women at Risk of Preterm

Birth (Review) Roberts D, Dalziel S Cochrane Database of Systematic Reviews 2006, Issue 3 Art No: CD004454

  • Cervical Assessment by Ultrasound for Preventing Preterm Delivery (Review) Bergella V Baxter JK

Cochrane Database of Systematic Reviews 2009. Issue 3, Art No: CD007235

  • Cervical Sonography in Preterm Labor Obstetrics and Gynecology July 1994 Vol 84, no 1.
  • Magnesium Sulfate: The First-Line Tocolytic. D Lewis. Obstet Gynecol Clin N Am 32(2205) 485-500
  • Biochemical Markers for the Prediction of Preterm Labor. J Yeast Obstet Gynecol Clin N Am

32(2205) 369-381

  • Prediction and Early Detection of Preterm Labor. J Iams Obstetrics and Gynecology Vol 101. no 2

Feb 2003

  • Major Obstetric Hemorrhage. F Mercier et al Anesthesiology Clin 26(2008) 53-66
  • Nontraumatic Abdominal Surgical Emergencies in the Pregnant Patient. K Challoner. Emerg Med

Clin N Am. 21 (2003) 97-985

  • Outcomes of Expectantly Managed Preterm Premature Rupture of Membranes Occurring Before 24 Weeks
  • f Gestation. T Manuck et al Obstetrics and Gynecology Vol. 114 No.1 July 2009
  • A Systematic Review of Pregnancy Outcome Following Preterm Premature Rupture of Membranes at a

Previable Gestational Age. H Dewan. Aust NZ J Obstet Gynaecol. Nov 2001, Vol 41 Issue 4; 389-94

  • Conservative Management of Preterm Premature Rupture of Membranes Between 18 and 23 Weeks of

Gestation--Maternal and Neonatal Outcome. U Verma, Eur J Obstet Gynecol Reprod Biol. Sep=Oct 2006; Vol 128(1-2)

  • Neonatal Outcome in Preterm Deliveries Between 23 and 27 Weeks/ Gestation With and Without Preterm

Premature Rupture of Membranes. DE Newman Arc Gynecol Obstet Jul 2009 280(1): 7-11

  • Expectant Management in Spontaneous Preterm Premature Rupture of Membranes between and 24 Weeks’
  • Gestation. S Falk J Perinatol 2004 Oct; 24(10): 611-6
  • Clinical Course of Premature Rupture of the Membranes. J Alexander Semin Perinatol Oct 1996; 20(5): 369-

74

  • Premature Rupture of Membranes:ACOG Practice Bulletin. Number 80 April 2007. Obstet and Gynecol Vol

109, No 4

  • Preterm Premature Rupture of the Membranes. B Mercer Obstet and Gynecol Jan 2003 Vol 101 No 1
  • Expectant Management of Midtrimester Premature Rupture of the Membranes: A Plea for Limits. S Grisaru-

Granovsky J Perinatology 2003; 23:235-239

  • Antibiotic Therapy in Preterm Premature Rupture of the Membranes. M Yudin J Obstet Gynaecol Can 2009

Sep 31(9):863-7

  • Effects of Digital Vaginal Examinations on Latency Period in Preterm Premature Rupture of Membranes D

Lewis Obstetrics and Gynecology Vol 80, No 4 October 1992

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SLIDE 32
  • Antenatal Corticosteroids for Accelerating Fetal Lung Maturation for Women at Risk of Preterm Birth

(Review) Roberts D, Dalziel S Cochrane Database of Systematic Reviews 2006, Issue 3 Art No: CD004454

  • Cervical Assessment by Ultrasound for Preventing Preterm Delivery (Review) Bergella V Baxter JK

Cochrane Database of Systematic Reviews 2009. Issue 3, Art No: CD007235

  • Cervical Sonography in Preterm Labor Obstetrics and Gynecology July 1994 Vol 84, no 1.
  • Magnesium Sulfate: The First-Line Tocolytic. D Lewis. Obstet Gynecol Clin N Am 32(2205) 485-500
  • Biochemical Markers for the Prediction of Preterm Labor. J Yeast Obstet Gynecol Clin N Am 32(2205)

369-381

  • Prediction and Early Detection of Preterm Labor. J Iams Obstetrics and Gynecology Vol 101. no 2 Feb

2003

  • Major Obstetric Hemorrhage. F Mercier et al Anesthesiology Clin 26(2008) 53-66
  • Nontraumatic Abdominal Surgical Emergencies in the Pregnant Patient. K Challoner. Emerg Med Clin N
  • Am. 21 (2003) 97-985
  • Extreme Preterm Birth: Onset of Delivery and Its Effect on Infant Survival and Morbidity, M Johanzon

Obstet Gynecol Jan 2008; 111(1): 42-50

  • Perinatal Care at the Threshold of Viability. H MacDonald Pediatric 2002; 110; 1024-1027
  • Very Low Birthweight Outcome of the National Institute of Child Health adn Human Development

Neonatal Research Network, January 1995-Dec 1996. Pediatric 2000; 107(1)

  • American Academy of Pediatrics. Special Considerations. In Braner, Kattwinkel et al. Textbook of

Neonatal Resuscitation. 4th Ed Elk Grove Village, IL 2000: 7-19

  • the Extremely Premature Neonate: Anticipating and Managing Care. N Yeaney. BMJ 11 July 2009

Volume 339

  • Medical Legal Issue in the Prevention of Prematurity. D Seubert Clinics in Perinatology Vol 34, Issue 2

(June 2007)

  • Medical Staff Guidelines for the Periviability Pregnancy Counseling and Medical Treatment of Extremely

Premature Infants. J Kaempf. Pediatrics 2006; 117:22-29

  • Clinical Report-Antenatal Counseling regarding Resuscitation at an Extremely Low Gestational Age. D

Batton American Academy of Pediatrics/ Pediatrics vol 124 number 1, july 2009

  • Antenatal Corticosteroids for Accelerating Fetal Lung Maturation for Women at Risk of Preterm Birth

(Review) Roberts D, Dalziel S Cochrane Database of Systematic Reviews 2006, Issue 3 Art No: CD004454

  • Cervical Assessment by Ultrasound for Preventing Preterm Delivery (Review) Bergella V Baxter JK

Cochrane Database of Systematic Reviews 2009. Issue 3, Art No: CD007235

  • Cervical Sonography in Preterm Labor Obstetrics and Gynecology July 1994 Vol 84, no 1.
  • Magnesium Sulfate: The First-Line Tocolytic. D Lewis. Obstet Gynecol Clin N Am 32(2205) 485-500
  • Biochemical Markers for the Prediction of Preterm Labor. J Yeast Obstet Gynecol Clin N Am 32(2205)

369-381

  • Prediction and Early Detection of Preterm Labor. J Iams Obstetrics and Gynecology Vol 101. no 2 Feb

2003

  • Major Obstetric Hemorrhage. F Mercier et al Anesthesiology Clin 26(2008) 53-66
  • Nontraumatic Abdominal Surgical Emergencies in the Pregnant Patient. K Challoner. Emerg Med Clin N
  • Am. 21 (2003) 97-985
  • Cervical Ectopic Pregnancy K. Fyksha Am J Obstet Gyn 2014
  • Successful rescue hysteroscopic resection of a cervical ectopic pregnancy previously treated with

methotrexate with no combined safety precautions. Mangino FP, Ceccarello M, Di Lorenzo G, D'Ottavio G, Bogatti P, Ricci G. Clin Exp Obstet Gynecol. 2014;41(2):214-6.

  • Management of a cervical heterotopic pregnancy presenting with first-trimester bleeding: case report

and review of the literature. Moragianni VA, Hamar BD, McArdle C, Ryley DA. Fertil Steril. 2012 Jul;98(1):89-94. doi: 10.1016/j.fertnstert.2012.04.003. Epub 2012 May 12.

  • The diagnosis, treatment, and follow-up of cesarean scar pregnancy.

Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, Pineda G, Arslan AA. Am J Obstet Gynecol. 2012 Jul;207(1):44.e1-13. doi: 10.1016/j.ajog.2012.04.018. Epub 2012 Apr 16.

  • Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and

cesarean scar pregnancy. A review. Timor-Tritsch IE, Monteagudo A. Am J Obstet Gynecol. 2012 Jul;207(1):14-29. doi: 10.1016/j.ajog.2012.03.007. Epub 2012 Mar 10.