Current concepts in the use of cell salvage in obstetrics.

PURPOSE OF REVIEW: The worldwide leading cause of maternal death is severe maternal hemorrhage. Maternal hemorrhage can be profound leading to an entire loss of blood volume. In the past two decades, Patient Blood Management has evolved to improve patient's care and safety. In surgeries with increased blood loss exceeding 500 ml, the use of cell salvage is strongly recommended in order to preserve the patient's own blood volume and to minimize the need for allogeneic red blood cell (RBC) transfusion. In this review, recent evidence and controversies of the use of cell salvage in obstetrics are discussed. RECENT FINDINGS: Numerous medical societies as well as national and international guidelines recommend the use of cell salvage during maternal hemorrhage. SUMMARY: Intraoperative cell salvage is a strategy to maintain the patient's own blood volume and decrease the need for allogeneic RBC transfusion. Historically, cell salvage has been avoided in the obstetric population due to concerns of iatrogenic amniotic fluid embolism (AFE) or induction of maternal alloimmunization. However, no definite case of AFE has been reported so far. Cell salvage is strongly recommended and cost-effective in patients with predictably high rates of blood loss and RBC transfusion, such as women with placenta accreta spectrum disorder. However, in order to ensure sufficient practical experience in a multiprofessional obstetric setting, liberal use of cell salvage appears advisable.

The prediction of preeclampsia: the way forward.

Despite intensive investigation, we still cannot adequately predict, treat, or prevent preeclampsia. We have gained awareness that preeclampsia is a syndrome not a disease and is heterogeneous in its presentation and pathophysiology, which may indicate differing underlying phenotypes, and that the impact extends beyond pregnancy per se. Effects on the fetus and mother extend many years after pregnancy, as evidenced by fetal programming of adult disease and increased risk of the development of maternal cardiovascular disease. The increased occurrence of preeclampsia in women with preexisting risk factors suggests that the stress of pregnancy may expose subclinical vascular disease as opposed to preeclampsia damaging the vasculature. The heterogeneity of preeclampsia has blighted efforts to predict preeclampsia early in gestation and has thwarted success in attempts at therapy with treatments, such as low-dose aspirin or global antioxidants. There is a critical need to identify the phenotypes to enable their specific prediction and treatment. Such studies require considerably larger collections of patients than employed in past and current studies. This does not necessarily imply much larger patient numbers in single studies but can be facilitated by the ability to easily combine many smaller studies. This can be accomplished by agreeing on a priori standardized and harmonized clinical data and biospecimen collection across new studies. Such standards are being established by international groups of investigators. Leadership by international organizations, perhaps adopting a carrot and stick approach, to overcome investigator, institutional and funder reticence toward data sharing is required to ensure adoption of such standards. Future studies should include women in both low- and high-resource settings and employ social media and novel methods for data collection and analysis, including machine learning and artificial intelligence. The goal is to identify the pathophysiology underlying differing preeclampsia phenotypes, their successful prediction with the design, and the implementation of phenotype-specific therapies.

The evolution of the diagnostic criteria of preeclampsia-eclampsia.

As the understanding of the pathophysiology of preeclampsia has improved, its diagnostic criteria have evolved. The classical triad of hypertension, edema, and proteinuria has become hypertension and organ dysfunction-renal, hepatic, neurologic, hematological, or uteroplacental. However, the most recent definitions have largely been based off consensus and expert opinion, not primary research. In this review, we explore how the criteria have evolved, particularly through the second half of the 20th and the beginning of the 21st century and offer a critical appraisal of the evidence that has led the criteria to where they stand today. Some key themes are the following: the debate between having a simple and convenient blood pressure cutoff vs a blood pressure cutoff that accounts for influencing factors such as age and weight; whether a uniform blood pressure threshold, a rise in blood pressure, or a combination is most discriminatory; whether existing evidence supports blood pressure and proteinuria thresholds in diagnosing preeclampsia; and whether using flow-charts and decision trees might be more appropriate than a single set of criteria. We also discuss the future of a preeclampsia diagnosis. We challenge the move toward a broad (vs restrictive) diagnosis, arguing instead for criteria that directly relate to the prognosis of preeclampsia and the response to treatments.

Current Trends in Compensation for Fellowship in Minimally Invasive Gynecologic Surgery Graduates: A 6-Year Follow-Up.

STUDY OBJECTIVE: To present updated information regarding compensation patterns for Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS)-graduated physicians in the United States beginning practice during the last 10 years, focusing on the variables that have an impact on differences in salary, including gender, fellowship duration, geographic region, practice setting, and practice mix. DESIGN: An online survey was sent to FMIGS graduates between March 15, 2019 and April 12, 2019. Information on physicians' demographics, compensation (on the basis of location, practice model, productivity benchmarks, academic rank, and years in practice), and attitudes toward fairness in compensation was collected. SETTING: Online survey. PARTICIPANTS: FMIGS graduates practicing in the United States. INTERVENTION: E-mail survey. MEASUREMENTS AND MAIN RESULTS: We surveyed 298 US FMIGS surgeons who had graduated during the last 10 years (2009-2018). The response rate was 48.7%. Most of the respondents were women (69%). Most of the graduates (84.8%) completed 2- or 3-year fellowship programs. After adjustment for inflation, the median starting salary for the first postfellowship job was $252 074 ($223 986-$279 983) (Table 1). The median time spent in the first job was 2.6 years, and the median total salary at the current year rose to $278 379.4 ($241 437-$350 976). The median salary for respondents entering a second postfellowship job started at $280 945 ($261 409-$329 603). Significantly lower compensation was reported for female FMIGS graduates in their initial postfellowship jobs and was consistently lower than for that of men over time. Most FMIGS graduates (59.7%) reported feeling inadequately compensated for their level of specialization. CONCLUSION: A trend toward higher self-reported salaries is noted for FMIGS graduates in recent years, with significant differences in compensation between men and women. Among obstetrics and gynecology subspecialists, FMIGS graduates earn significantly less than other fellowship-trained physicians, with median salaries that are lower than those of generalist obstetrics and gynecology physicians.

Impact of the COVID-19 Pandemic on Excess Perinatal Mortality and Morbidity in Israel.

OBJECTIVE: The 2020 COVID-19 pandemic has been associated with excess mortality and morbidity in adults and teenagers over 14 years of age, but there is still limited evidence on the direct and indirect impact of the pandemic on pregnancy. We aimed to evaluate the effect of the first wave of the COVID-19 pandemic on obstetrical emergency attendance in a low-risk population and the corresponding perinatal outcomes. STUDY DESIGN: This is a single center retrospective cohort study of all singleton births between February 21 and April 30. Prenatal emergency labor ward admission numbers and obstetric outcomes during the peak of the first COVID-19 pandemic of 2020 in Israel were compared with the combined corresponding periods for the years 2017 to 2019. RESULTS: During the 2020 COVID-19 pandemic, the mean number of prenatal emergency labor ward admissions was lower, both by daily count and per woman, in comparison to the combined matching periods in 2017, 2018, and 2019 (48.6 ± 12.2 vs. 57.8 ± 14.4, p < 0.0001 and 1.74 ± 1.1 vs. 1.92 ± 1.2, p < 0.0001, respectively). A significantly (p = 0.0370) higher rate of stillbirth was noted in the study group (0.4%) compared with the control group (0.1%). All study group patients were negative for COVID-19. Gestational age at delivery, rates of premature delivery at <28, 34, and 37 weeks, pregnancy complications, postdate delivery at >40 and 41 weeks, mode of delivery, and numbers of emergency cesarean deliveries were similar in both groups. There was no difference in the intrapartum fetal death rate between the groups. CONCLUSION: The COVID-19 pandemic stay-at-home policy combined with patient fear of contracting the disease in hospital could explain the associated higher rate of stillbirth. This collateral perinatal damage follows a decreased in prenatal emergency labor ward admissions during the first wave of COVID-19 in Israel. KEY POINTS: · Less obstetrical ER attendance is observed during the pandemic.. · There is a parallel increase in stillbirth rate.. · Stillbirth cases tested negative for COVID-19.. · Lockdown and pandemic panic are possible causes..

Differential Uptake of Telehealth for Prenatal Care in a Large New York City Academic Obstetrical Practice during the COVID-19 Pandemic.

During the coronavirus disease 2019 (COVID-19) pandemic in New York City, telehealth was rapidly implemented for obstetric patients. Though telehealth for prenatal care is safe and effective, significant concerns exist regarding equity in access among low-income populations. We performed a retrospective cohort study evaluating utilization of telehealth for prenatal care in a large academic practice in New York City, comparing women with public and private insurance. We found that patients with public insurance were less likely to have at least one telehealth visit than women with private insurance (60.9 vs. 87.3%, p < 0.001). After stratifying by borough, this difference remained significant in Brooklyn, one of the boroughs hardest hit by the pandemic. As COVID-19 continues to spread around the country, obstetric providers must work to ensure that all patients, particularly those with public insurance, have equal access to telehealth. KEY POINTS: · Telehealth for prenatal care is frequently utilized during the COVID-19 pandemic.. · Significant concerns exist regarding equity in access among lower-income populations.. · Women with public insurance in New York City were less likely to access telehealth for prenatal care..

The Use of Copper as an Antimicrobial Agent in Health Care, Including Obstetrics and Gynecology.

Health care-associated infections (HAIs) are a global problem associated with significant morbidity and mortality. Controlling the spread of antimicrobial-resistant bacteria is a major public health challenge, and antimicrobial resistance has become one of the most important global problems in current times. The antimicrobial effect of copper has been known for centuries, and ongoing research is being conducted on the use of copper-coated hard and soft surfaces for reduction of microbial contamination and, subsequently, reduction of HAIs. This review provides an overview of the historical and current evidence of the antimicrobial and wound-healing properties of copper and explores its possible utility in obstetrics and gynecology.

Introduction to artificial intelligence in ultrasound imaging in obstetrics and gynecology.

Artificial intelligence (AI) uses data and algorithms to aim to draw conclusions that are as good as, or even better than, those drawn by humans. AI is already part of our daily life; it is behind face recognition technology, speech recognition in virtual assistants (such as Amazon Alexa, Apple's Siri, Google Assistant and Microsoft Cortana) and self-driving cars. AI software has been able to beat world champions in chess, Go and recently even Poker. Relevant to our community, it is a prominent source of innovation in healthcare, already helping to develop new drugs, support clinical decisions and provide quality assurance in radiology. The list of medical image-analysis AI applications with USA Food and Drug Administration or European Union (soon to fall under European Union Medical Device Regulation) approval is growing rapidly and covers diverse clinical needs, such as detection of arrhythmia using a smartwatch or automatic triage of critical imaging studies to the top of the radiologist's worklist. Deep learning, a leading tool of AI, performs particularly well in image pattern recognition and, therefore, can be of great benefit to doctors who rely heavily on images, such as sonologists, radiographers and pathologists. Although obstetric and gynecological ultrasound are two of the most commonly performed imaging studies, AI has had little impact on this field so far. Nevertheless, there is huge potential for AI to assist in repetitive ultrasound tasks, such as automatically identifying good-quality acquisitions and providing instant quality assurance. For this potential to thrive, interdisciplinary communication between AI developers and ultrasound professionals is necessary. In this article, we explore the fundamentals of medical imaging AI, from theory to applicability, and introduce some key terms to medical professionals in the field of ultrasound. We believe that wider knowledge of AI will help accelerate its integration into healthcare. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Annual report of the Women's Health Care Committee, Japan Society of Obstetrics and Gynecology, 2019.

Since 2010, the Women's Health Care Committee has continuously addressed issues closely linked to women's quality of life. The five agendas this committee has engaged for this academic year are as follows: (i) clinical study of urinary complications in perinatal and post-partum women's health care; (ii) enlightenment of infectious diseases in Obstetrics and Gynecology in Japan; (iii) educational activities regarding management guidelines for health care in female athletes; (iv) training program for women's health-care advisers; and (v) pregnancy- and lactation-associated osteoporosis (PLOP). The detailed activities of the five subcommittees are described herein. This report is based on the Japanese version of our annual report (Acta Obst Gynaec Jpn 2019;71(6): 889-898), which publicizes the activities of our committee.

Caring for Pregnant Patients with COVID-19: Practical Tips Getting from Policy to Practice.

Novel coronavirus disease 2019 (COVID-19) is a pandemic with most American cases in New York. As an institution residing in a high-prevalence zip code, with over 8,000 births annually, we have cared for over 80 COVID-19-infected pregnant women, and have encountered many challenges in applying new national standards for care. In this article, we review how to change outpatient and inpatient practices, develop, and disseminate new hospital protocols, and we highlight the psychosocial challenges for pregnant patients and their providers. KEY POINTS: · Novel coronavirus disease 2019 (COVID-19) information rapidly changes.. · Multidisciplinary communication is key.. · This study addresses psychosocial challenges..

Periviability: A Review of Key Concepts and Management for Perinatal Nursing.

One of the most complex clinical problems in obstetrics and neonatology is caring for pregnant women at the threshold of viability. Births near viability boundaries are grave events that carry a high prevalence of neonatal death or an increased potential for severe lifelong complications and disabilities among those who survive. Compared with several decades ago, premature infants receiving neonatal care by today's standards have better outcomes than those born in other eras. However, preterm labor at periviability represents a more complex counseling and management challenge. Although preterm birth incidence between 20/7 and 25/7 weeks has remained unchanged, survival rates at earlier gestational ages have increased as perinatal and neonatal specialties have become more adept at caring for this at-risk population. Women face difficult choices about obstetric and neonatal interventions in light of uncertainties around survival and outcomes. This article reviews current neonatal statistics in reference to short- and long-term outcomes, key concepts in obstetric clinical management of an anticipated periviable birth, and counseling guidance to ensure shared-decision making.

Tackling poorly selected, collected, and reported outcomes in obstetrics and gynecology research.

Clinical research should ultimately improve patient care. To enable this, randomized controlled trials must select, collect, and report outcomes that are both relevant to clinical practice and genuinely reflect the perspectives of key stakeholders including health care professionals, researchers, and patients. Unfortunately, many randomized controlled trials fall short of this requirement. Complex issues, including a failure to take into account the perspectives of key stakeholders when selecting outcomes, variations in outcome definitions and measurement instruments, and outcome reporting bias make research evidence difficult to interpret, undermining the translation of research into clinical practice. Problems with poor outcome selection, measurement, and reporting can be addressed by developing, disseminating, and implementing core outcome sets. A core outcome set represents a minimum data set of outcomes developed using robust consensus science methods engaging diverse stakeholders including health care professionals, researchers, and patients. Core outcomes should be routinely utilized by researchers, collected in a standardized manner, and reported consistently in the final publication. They are currently being developed across our specialty including infertility, endometriosis, and preeclampsia. Recognizing poorly selected, collected, and reported outcomes as serious hindrances to progress in our specialty, more than 80 journals including the Journal, have come together to support the Core Outcomes in Women's and Newborn Health (CROWN) initiative. The consortium supports researchers to develop, disseminate, and implement core outcome sets. Implementing core outcome sets could make a profound contribution to addressing poorly selected, collected, and reported outcomes. Implementation should ensure future randomized controlled trials hold the necessary reach and relevance to inform clinical practice, enhance patient care, and improve patient outcomes.

Family planning in adolescents.

PURPOSE OF REVIEW: As politics continue to shape contraception and abortion care, providers have a responsibility to address the specific needs of the adolescent patient. Here we review the current literature on contraception and abortion in adolescents. RECENT FINDINGS: Shared decision-making among patients, parents, and providers is the cornerstone of successful adolescent family planning. Providers should be aware of local state regulations related to consent in minors. When provided directive and noncoercive contraception counseling at no cost, adolescents are motivated and effective decision-makers in their care. Long-acting reversible contraceptives should be offered as the first-line method of contraception in adolescents. SUMMARY: Family planning in adolescents presents unique challenges to obstetrician-gynecologists. Improved access to contraception and abortion services is significantly lowering unintended pregnancies rates in adolescents, but more data assessing the effectiveness of interventions in marginalized communities are needed.

Burnout in Obstetricians and Gynecologists.

Professional burnout threatens all high-functioning professionals and affects not only the individual, but, by extension, the patients they serve. The characteristics that make someone competitive for medical school, residency, or successful in academics or practice, make us particularly vulnerable to burnout: compulsive dedication to goals (and patients), motivation to succeed, self-reliance, leadership experience, delayed gratification, and others. Estimates of the prevalence of burnout in medicine vary widely but are consistently >40% and often as high as 75%. Obstetricians and gynecologists are not unique in suffering from burnout but do rank among the top medical specialties for the rate of professional burnout reported. When burnout is present, there is reduced job satisfaction, lower productivity, increased medical errors (and morbidity), degraded interpersonal interactions, and higher physician dropout rates. Career dissatisfaction, early retirement, and even regret surrounding the original choice of career are all common when burnout is present. There is a growing body of individual actions that can be taken to reduce or reverse the impact of burnout, but the first steps are to understand the causes and identify the symptoms.

The Impact of Burnout on the Obstetrics and Gynecology Workforce.

Although there has been discussion of a shortage of surgical specialties including OB/GYN, consensus is difficult because of the multiple variables involved in estimating both supply and demand. In addition, burnout has become more recognized as a variable that has not been taken into account in estimating a shortage of OB/GYNs. We estimate OB/GYN physician shortages of 17%, 24%, and 31% by 2030, 2040, and 2050, respectively. Here, we examine the impact of burnout on the OB/GYN workforce. Specifically, we address the associations of burnout, reduction in clinical productivity as well as early retirement. We also discuss the implications of the substantial increase of female OB/GYNs to ∼66% of workforce over the next 10 years and how this may impact the impending OB/GYN shortage. Finally, we briefly consider possible solutions to workforce issues causing burnout.

Annual report of Reproductive Endocrinology Committee, Japan Society of Obstetrics and Gynecology, 2019.

The Japan Society of Obstetrics and Gynecology Reproductive Endocrinology Committee summarizes the activities of each subcommittee below from April 2017 to March 2019. Current important issues regarding reproductive medicine were examined and discussed from social, political, ethical and scientific viewpoints. A nation-wide survey targeted at OB/GYN facilities revealed the usual procedure in diagnosis and management of fertility-desiring POI patients and fertility outcomes of the patients. How to introduce and adapt FIGO AUB systems to obstetric and gynecologic practices in Japan was examined and discussed.

Effect of Increasing Malpractice Insurance Cost and Subsequent Practice of Defensive Medicine on Out-of-Hospital Birth Rates in the United States.

BACKGROUND: Across the United States, the burden of malpractice litigation has influenced obstetricians and obstetric institutions to avoid high-risk patients, favor cesarean delivery, and decrease availability of trial of labor after cesarean. Recently, the United States has experienced an increase in out-of-hospital (OOH) births. OBJECTIVE: The main purpose of this article is to investigate the association between malpractice insurance premium (MIP) and OOH births in the United States from 2000 to 2014. STUDY DESIGN: We analyzed changes in OOH birth rates and MIP from 2000 to 2014 using birth data from the National Vital Statistics System and Medical Liability Monitor's annual survey, respectively. The change in OOH birth rates was then compared with the change in MIP. RESULTS: Between 2000 and 2014, there has been approximately 60% increase in MIP from national average of $40,949 to $65,210 (p < 0.05). OOH births increased 57% from 39,398 births to 59,674 births (p < 0.05). There was a significant positive correlation between increase in MIP and increase in OOH births (p < 0.05, R 2 = 0.14). CONCLUSION: MIP and OOH birth rates have a significantly associated increase from 2000 to 2014. Given that malpractice climate affects other aspects of obstetric practice, we cautiously propose that increasing MIP may be associated with an increase in OOH births.

Surgery, obstetrics and anaesthesia: a Cambrian explosion for global health.

Our current global health structure has not yet evolved to do what the world needs of it. Despite significant advances in some areas of public health over the past few decades, disparities in health have worsened in many areas. The historical approach of global health governance to health issues has been overwhelmingly led by vertical, single disease efforts. Yet, this structure cannot effectively implement broad-reaching international development goals set forth by the United Nations. The solution requires a rapid evolution of the present health system conceptualisation. As the Cambrian period brought skeletal infrastructure to life on our planet with vertebrates, allowing life to take on new capabilities never before witnessed on earth, so will surgery, obstetrics and anaesthesia provide the much needed healthcare delivery infrastructure that will allow health system strengthening to take global healthcare along a new path. Surgery, anaesthesia and obstetrics form the core foundation upon which the whole of global health is built and serve as the skeletal structure and indicator of robust health systems. Integrating these domains as the backbone of health system strengthening will finally allow global health to stand and support all sectors of healthcare delivery as an equal partner in health.

Examining Trends in Obstetric Quality Measures for Monitoring Health Care Disparities.

BACKGROUND: Elective delivery (ED) before 39 weeks, low-risk cesarean delivery, and episiotomy are routinely reported obstetric quality measures and have been the focus of quality improvement initiatives over the past decade. OBJECTIVE: To estimate trends and differences in obstetric quality measures by race/ethnicity. RESEARCH DESIGN: We used 2008-2014 linked birth certificate-hospital discharge data from New York City to measure ED before 39 gestational weeks (ED <39), low-risk cesarean, and episiotomy by race/ethnicity. Measures were following the Joint Commission and National Quality Forum specifications. Average annual percent change (AAPC) was estimated using Poisson regression for each measure by race/ethnicity. Risk differences (RD) for non-Hispanic black women, Hispanic women, and Asian women compared with non-Hispanic white women were calculated. RESULTS: ED<39 decreased among whites [AAPC=-2.7; 95% confidence interval (CI), -3.7 to -1.7), while it increased among blacks (AAPC=1.3; 95% CI, 0.1-2.6) and Hispanics (AAPC=2.4; 95% CI, 1.4-3.4). Low-risk cesarean decreased among whites (AAPC=-2.8; 95% CI, -4.6 to -1.0), and episiotomy decreased among all groups. In 2008, white women had higher risk of most measures, but by 2014 incidence of ED<39 was increased among Hispanics (RD=2/100 deliveries; 95% CI, 2-4) and low-risk cesarean was increased among blacks (RD=3/100; 95% CI, 0.5-6), compared with whites. Incidence of episiotomy was lower among blacks and Hispanics than whites, and higher among Asian women throughout the study period. CONCLUSIONS: Existing measures do not adequately assess health care disparities due to modest risk differences; nonetheless, continued monitoring of trends is warranted to detect possible emergent disparities.