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Cesarean deliveries are common in the United States, occurring in approximately one-third of deliveries in 2021. Given this high rate of cesarean deliveries, it is important for all clinicians caring for the pregnant person-infant dyad to be educated about cesarean deliveries. In this review, we describe the indications for cesarean delivery, the evidence-based practices of preoperative planning to ensure safe deliveries, and the clinical decision-making behind various cesarean incisions. In addition, we discuss the most common complications of cesarean deliveries for the pregnant person-infant dyad.
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Cesárea , Humanos , Embarazo , Femenino , Pediatras , Toma de Decisiones Clínicas , Recién Nacido , Cuidados Preoperatorios/normas , Cuidados Preoperatorios/métodosRESUMEN
Cardiogenic shock in pregnancy is rare but is associated with significant morbidity and mortality. Timely recognition with multidisciplinary management is necessary for optimal maternal and fetal outcomes. Here we present a case of cardiogenic shock in the antepartum period managed with mechanical circulatory support as a bridge to pregnancy viability.
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INTRODUCTION: Among SGA newborns, those < 5th % for GA are more likely to have adverse outcomes than those at 5-9th %. The differential morbidity and mortality may be due to abnormal placental pathology between groups. Our purpose was to compare placental pathology characteristics and composite placental pathology among SGA infants with birth weights <5th % vs. 5-9th %. METHODS: This study is a secondary analysis of a multicenter, retrospective cohort study. Placental pathological variables and composite placental pathology (CPP) among SGA infants <5th % and 5-9th % were compared. Multivariable logistic regression was used to model the probability of an infant's birth weight being classified as <5th % based on pathology characteristics. RESULTS: Of 11,487 live singleton births, 925 SGA infants met inclusion criteria. Placental pathology was available for review in 407 (44 %) SGA infants: 210 (51.6 %) <5th % and 197 (48.4 %) 5-9th %. A decreased placental weight for GA, was more common in the <5th % group compared to the 5-9th % group (p = 0.0019). No significant differences in the distribution of pathological variables or in CPP (p = 0.3) was observed between the two centile groups. A decreased placental weight was the only reliable predictor of an infant's birth weight centile group (p = 0.0018). CONCLUSIONS: Placental hypoplasia, reflected by a decreased placental weight for GA, was significantly more common among SGA infants < 5th % compared to the 5-9th %. There was no difference in placental pathological features or CPP between the two centile groups of SGA infants.
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Recién Nacido Pequeño para la Edad Gestacional , Placenta , Peso al Nacer , Femenino , Edad Gestacional , Humanos , Lactante , Recién Nacido , Embarazo , Estudios RetrospectivosRESUMEN
This chapter represents a selection of 8 clinical scenarios that may commonly be encountered. They help summarize some of the literature and teaching points of the previous chapters. They are not meant to represent every possible presentation of thyroid disease, but rather to present common symptoms and findings that may aid a clinician in making a diagnosis or in selecting initial treatment.
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Complicaciones del Embarazo/diagnóstico , Complicaciones del Embarazo/terapia , Enfermedades de la Tiroides/diagnóstico , Enfermedades de la Tiroides/terapia , Adulto , Antitiroideos/uso terapéutico , Cetoacidosis Diabética/diagnóstico , Cetoacidosis Diabética/terapia , Femenino , Humanos , Metimazol/uso terapéutico , Atención Preconceptiva , Embarazo , Propiltiouracilo/uso terapéutico , Pruebas de Función de la TiroidesRESUMEN
Endocrine emergencies in pregnancy can be life threatening and are associated with increased morbidity for both the mother and fetus. Thyroid storm, diabetic ketoacidosis, and hypercalcemic crisis require a high clinical suspicion, rapid treatment, and multidisciplinary care to ensure best outcomes. Critical care consultation and intensive care unit admission are often warranted. Fetal testing may initially be concerning; however often improves with correction of the underlying metabolic derangement(s) and delivery is generally avoided until maternal status improves.
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Cetoacidosis Diabética , Hiperparatiroidismo , Complicaciones del Embarazo , Crisis Tiroidea , Antitiroideos/uso terapéutico , Cetoacidosis Diabética/diagnóstico , Cetoacidosis Diabética/terapia , Urgencias Médicas , Femenino , Humanos , Hiperparatiroidismo/diagnóstico , Hiperparatiroidismo/terapia , Grupo de Atención al Paciente , Embarazo , Complicaciones del Embarazo/diagnóstico , Complicaciones del Embarazo/terapia , Crisis Tiroidea/diagnóstico , Crisis Tiroidea/terapiaRESUMEN
BACKGROUND: Epidural analgesia is associated with a fourfold increased rate of intrapartum fever. The likely pathophysiology is a noninfectious maternal inflammatory activation. Safe interventions to reduce maternal and neonatal exposures to intrapartum fever and inflammation are needed. OBJECTIVE: The purpose of this study was to determine if prophylactic epidural steroids decrease fetal exposure to hyperthermia and inflammatory cytokines following epidural analgesia. STUDY DESIGN: This is a randomized, double-blinded, placebo controlled trial. Term nulliparous women requesting epidural analgesia received 80 mg methylprednisolone or preservative-free normal saline via the epidural catheter at placement. The primary outcome was maternal temperature >100.4°F. Secondary outcomes included fetal exposure to inflammation as assessed by cord blood interleukin-6 (IL-6) levels and rates of funisitis. Power analysis estimated a sample size requirement of 276, but new Food and Drug Administration (FDA) recommendations advising a black box warning on epidural steroids resulted in early study termination. RESULTS: A total of 116 subjects were enrolled: 58 treatments and 58 placebos. There was no difference in the rate of maternal intrapartum fever or cord blood IL-6 levels between treatment arms. No complications listed in the FDA warning occurred. CONCLUSION: Prophylactic epidural methylprednisolone was not effective in reducing intrapartum fever or neonatal inflammation following epidural analgesia. Alternate mechanisms and preventative strategies should be considered.
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Analgesia Epidural/efectos adversos , Analgesia Obstétrica/efectos adversos , Fiebre/prevención & control , Glucocorticoides/uso terapéutico , Enfermedades del Recién Nacido/prevención & control , Inflamación/prevención & control , Interleucina-6/sangre , Metilprednisolona/uso terapéutico , Adulto , Método Doble Ciego , Femenino , Sangre Fetal/inmunología , Fiebre/etiología , Humanos , Recién Nacido , Enfermedades del Recién Nacido/etiología , Inflamación/etiología , Masculino , Embarazo , Factores de RiesgoRESUMEN
BACKGROUND: Given the high rate of preterm birth (PTB) nationwide and data from RCTs demonstrating risk reduction with vitamin D supplementation, the Medical University of South Carolina (MUSC) implemented a new standard of care for pregnant women to receive vitamin D testing and supplementation. OBJECTIVES: To determine if the reported inverse relationship between maternal 25(OH)D and PTB risk could be replicated at MUSC, an urban medical center treating a large, diverse population. METHODS: Medical record data were obtained for pregnant patients aged 18-45 years between September 2015 and December 2016. During this time, a protocol that included 25(OH)D testing at first prenatal visit with recommended follow-up testing was initiated. Free vitamin D supplements were offered and the treatment goal was ≥40 ng/mL. PTB rates (<37 weeks) were calculated, and logistic regression and locally weighted regression (LOESS) were used to explore the association between 25(OH)D and PTB. Subgroup analyses were also conducted. RESULTS: Among women with a live, singleton birth and at least one 25(OH)D test during pregnancy (N = 1,064), the overall PTB rate was 13%. The LOESS curve showed gestational age rising with increasing 25(OH)D. Women with 25(OH)D ≥40 ng/mL had a 62% lower risk of PTB compared to those <20 ng/mL (p<0.0001). After adjusting for socioeconomic variables, this lower risk remained (OR = 0.41, p = 0.002). Similar decreases in PTB risk were observed for PTB subtypes (spontaneous: 58%, p = 0.02; indicated: 61%, p = 0.006), by race/ethnicity (white: 65%, p = 0.03; non-white: 68%, p = 0.008), and among women with a prior PTB (80%, p = 0.02). Among women with initial 25(OH)D <40 ng/mL, PTB rates were 60% lower for those with ≥40 vs. <40 ng/mL on a follow-up test (p = 0.006); 38% for whites (p = 0.33) and 78% for non-whites (p = 0.01). CONCLUSIONS: Maternal 25(OH)D concentrations ≥40 ng/mL were associated with substantial reduction in PTB risk in a large, diverse population of women.
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Nacimiento Prematuro/etiología , Vitamina D/administración & dosificación , Adulto , Suplementos Dietéticos , Femenino , Edad Gestacional , Hospitales Urbanos , Humanos , Modelos Logísticos , Embarazo , Atención Prenatal , Factores de Riesgo , Deficiencia de Vitamina D/etiología , Deficiencia de Vitamina D/prevención & controlRESUMEN
BACKGROUND: The association between small-for-gestational-age (birthweight <10th percentile for gestational age) and neonatal morbidity is well established. Yet, there is a paucity of data on the relationship between suspected small for gestational age (sonographic-estimated fetal weight <10th percentile) at 2 thresholds and subsequent neonatal morbidity. OBJECTIVE: The objective of this study was to determine the relationship between sonographic-estimated fetal weight <5th percentile vs 5-9th percentile and neonatal morbidity. STUDY DESIGN: This retrospective study involved 5 centers and included nonanomalous, singletons with sonographic-estimated fetal weight <10th percentile for gestational age who delivered from 2009-2012. Composite neonatal morbidity included respiratory distress syndrome, proven sepsis, intraventricular hemorrhage grade III or IV, necrotizing enterocolitis, thrombocytopenia, seizures, or death. Odd ratios were adjusted for center, maternal age, race, body mass index at first visit, smoking status, use of alcohol, use of drugs, and neonatal gender. RESULTS: Of 834 women with suspected small-for-gestational-age fetuses, 513 (62%) had sonographic-estimated fetal weight <5th percentile, and 321 (38%) had sonographic-estimated fetal weight of 5-9th percentile for gestational age. At delivery, 81% of women with a suspected small-for-gestational-age fetus had a confirmed small-for-gestational-age fetus. In the group with a sonographic-estimated fetal weight <5th percentile, 59% of neonates had birthweight <5th percentile; in the group with a sonographic-estimated fetal weight 5-9th percentile, 41% had birthweight <5th percentile, and 36% had birthweight at 5-9th percentile. Neonatal intensive care unit admission differed significantly for those fetuses at <5th percentile (29%) compared with those fetuses at 5-9th percentile (15%; P<.001). The composite neonatal morbidity among the sonographic-estimated fetal weight <5th percentile group was higher than the sonographic-estimated fetal weight of 5-9th percentile group (31% vs 13%; adjusted odds ratio, 2.41; 95% confidence interval, 1.53-3.80). Similar findings were noted when the analysis was limited to sonographic-estimated fetal weight within 28 days of delivery (adjusted odds ratio, 2.22; 95% confidence interval, 1.34-3.67). CONCLUSION: Eight of 10 suspected small-for-gestational-age fetuses had birthweight <10th percentile for gestational age; the prediction of actual birthweight was more accurate in the <5th percentile group. Neonates with sonographic-estimated fetal weight of <5th percentile were more likely to be admitted to the neonatal intensive care unit and have complications than were those neonates with sonographic-estimated fetal weight of 5-9th percentile.
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Peso Fetal , Ultrasonografía Prenatal , Adulto , Peso al Nacer , Estudios de Cohortes , Femenino , Edad Gestacional , Gráficos de Crecimiento , Humanos , Recién Nacido , Recién Nacido Pequeño para la Edad Gestacional , Embarazo , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: Thrombocytopenia has been considered a relative or even absolute contraindication to neuraxial techniques due to the risk of epidural hematoma. There is limited literature to estimate the risk of epidural hematoma in thrombocytopenic parturients. The authors reviewed a large perioperative database and performed a systematic review to further define the risk of epidural hematoma requiring surgical decompression in this population. METHODS: The authors performed a retrospective cohort study using the Multicenter Perioperative Outcomes Group database to identify thrombocytopenic parturients who received a neuraxial technique and to estimate the risk of epidural hematoma. Patients were stratified by platelet count, and those requiring surgical decompression were identified. A systematic review was performed, and risk estimates were combined with those from the existing literature. RESULTS: A total of 573 parturients with a platelet count less than 100,000 mm who received a neuraxial technique across 14 institutions were identified in the Multicenter Perioperative Outcomes Group database, and a total of 1,524 parturients were identified after combining the data from the systematic review. No cases of epidural hematoma requiring surgical decompression were observed. The upper bound of the 95% CI for the risk of epidural hematoma for a platelet count of 0 to 49,000 mm is 11%, for 50,000 to 69,000 mm is 3%, and for 70,000 to 100,000 mm is 0.2%. CONCLUSIONS: The number of thrombocytopenic parturients in the literature who received neuraxial techniques without complication has been significantly increased. The risk of epidural hematoma associated with neuraxial techniques in parturients at a platelet count less than 70,000 mm remains poorly defined due to limited observations.
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Anestesia Epidural/efectos adversos , Anestesia Obstétrica/efectos adversos , Hematoma Espinal Epidural/etiología , Trombocitopenia/complicaciones , Adulto , Estudios de Cohortes , Descompresión Quirúrgica , Femenino , Hematoma Espinal Epidural/cirugía , Humanos , Recuento de Plaquetas/estadística & datos numéricos , Embarazo , Estudios Retrospectivos , RiesgoRESUMEN
Endocrine emergencies such as thyroid storm and diabetic ketoacidosis should be considered life-threatening disease processes in the obstetric population. Diagnosis requires a high clinical suspicion with prompt initiation of treatment, supportive care and intervention. A multidisciplinary team of specialists, including maternal fetal medicine, endocrinology, medical intensivist, neonatologists and anesthesiology should be assembled to achieve the best out-comes for mother and baby.
Las emergencias endocrinas, tales como la tormenta tiroidea y la cetoacidosis diabética, deben ser consideradas como procesos mórbidos que ponen en riesgo la vida de la población obstétrica. El diagnóstico requiere gran sospecha clínica e inicio inmediato del tratamiento, soporte clínico e intervención. Se debe organizar un equipo multidisciplinario de especialistas que incluyan la medicina maternofetal, endocrinología, intensivista médico, neonatólogos y anestesiólogos, de manera de lograr el mejor resultado para la madre y el bebe.
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BACKGROUND: The primary aim of this study was to estimate the risk of neuraxial hematoma associated with neuraxial anesthetic procedures in thrombocytopenic parturients. METHODS: A multicenter retrospective cohort study design was used to estimate the risk for spinal-epidural hematoma in parturients with a platelet count of <100,000/mm receiving neuraxial anesthesia and the risk of complications in thrombocytopenic parturients who receive general anesthesia. RESULTS: No cases of spinal hematoma were observed in 102 thrombocytopenic parturients receiving epidural analgesia or 71 receiving spinal anesthesia. Including data from the previous published series (total n = 499), the exact binomial 95% confidence interval for the risk of spinal-epidural hematoma was 0% to 0.6%. Given the small number of patients at each specific platelet count, the theoretical risks at individual platelet count strata are presented. Overall aggregate serious morbidity rate in women who received general anesthesia secondary to thrombocytopenia was 6.5% (95% confidence interval, 2.1%-14.5%). CONCLUSIONS: Our work supports the relative maternal safety of neuraxial anesthesia in parturients with mild thrombocytopenia and estimates the maternal complication rate associated with the avoidance of neuraxial anesthesia. Remaining uncertainties at lower platelet counts make a national "low platelet" registry critical to a more accurate assessment of the risk of epidural hematoma and would aid in standardization of anesthesia practice.
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Anestesia Obstétrica/métodos , Complicaciones Hematológicas del Embarazo/sangre , Trombocitopenia/sangre , Trombocitopenia/complicaciones , Estudios de Cohortes , Femenino , Humanos , Recuento de Plaquetas/métodos , Embarazo , Complicaciones Hematológicas del Embarazo/diagnóstico , Estudios Retrospectivos , Trombocitopenia/diagnósticoRESUMEN
Several potentially fatal endocrine emergencies in relation to obstetrics and gynecology are discussed in the article. Rates of case fatality vary in different series, but range from 10% to 30%. Rapid recognition, prompt supportive care, and intervention likely maximize maternal and fetal outcomes.