Red Blood Cell Transfusion in Patients With Placenta Accreta Spectrum: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate red blood cell use during delivery in patients with placenta accreta spectrum. DATA SOURCES: We searched MEDLINE, EMBASE, CINAHL, Cochrane Central, ClinicalTrials.gov, and Scopus for clinical trials and observational studies published between 2000 and 2021 in countries with developed economies. METHODS OF STUDY SELECTION: Abstracts (n=4,275) and full-text studies (n=599) were identified and reviewed by two independent reviewers. Data on transfused red blood cells were included from studies reporting means and SDs, medians with interquartile ranges, or individual patient data. The primary outcome was the weighted mean number of units of red blood cells transfused per patient. Between-study heterogeneity was assessed with an I2 statistic. Secondary analyses included red blood cell usage by placenta accreta subtype. TABULATION, INTEGRATION, AND RESULTS: Of the 599 full-text studies identified, 20 met criteria for inclusion in the systematic review, comprising 1,091 cases of placenta accreta spectrum. The number of units of red blood cells transfused was inconsistently described across studies, with five studies (25.0%) reporting means, 11 (55.0%) reporting medians, and four (20.0%) reporting individual patient data. The weighted mean number of units transfused was 5.19 (95% CI 4.12-6.26) per patient. Heterogeneity was high across studies (I2=91%). In a sensitivity analysis of five studies reporting mean data, the mean number of units transfused was 6.61 (95% CI 4.73-8.48; n=220 patients). Further quantification of units transfused by placenta accreta subtype was limited due to methodologic inconsistencies between studies and small cohort sizes. CONCLUSION: Based on the upper limit of the CI in our main analysis and the high study heterogeneity, we recommend that a minimum of 6 units of red blood cells be available before delivery for patients with placenta accreta spectrum. These findings may inform future guidelines for predelivery blood ordering and transfusion support. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021240993.

The ongoing crisis of abortion care education and training in the United States.

PURPOSE OF REVIEW: The Dobbs vs Jackson case (Dobbs) decided by the Supreme Court of the United States (SCOTUS) in 2022 rescinded the constitutional right to abortion care, resulting in immediate state bans and severe restrictions on abortion care in almost half of the states at the time of submission. This article reviews the current state of abortion education and training as well as available curricula and programmes to support continued training. RECENT FINDINGS: Prior to Dobbs, a national residency-level training programme, the Ryan Residency Training Program, has helped expand abortion care training in residency programs nationally, yet there remained many barriers to incorporating this training into practice, including practice and hospital restrictions. New state restrictions now additionally constrain almost half of all the Ob-Gyn residency programmes. Medical students benefit from education on options counselling and values exploration. SUMMARY: Abortion care education and training is in crisis. Almost half of the Ob-Gyn residents are training in states that have banned or severely restricted abortion care. This threatens to create a workforce without critical early pregnancy management knowledge and skills. Residents are more likely to provide abortion care when they have scheduled routine training. Medical students can apply options counselling and values exploration knowledge broadly. Online education resources provide some patchwork solutions to continue abortion care education and training in this heavily restrictive landscape.

Mixed methods evaluation of simulation-based training for postpartum hemorrhage management in Guatemala.

BACKGROUND: To assess if simulation-based training (SBT) of B-Lynch suture and uterine balloon tamponade (UBT) for the management of postpartum hemorrhage (PPH) impacted provider attitudes, practice patterns, and patient management in Guatemala, using a mixed-methods approach. METHODS: We conducted an in-country SBT course on the management of PPH in a governmental teaching hospital in Guatemala City, Guatemala. Participants were OB/GYN providers (n = 39) who had or had not received SBT before. Surveys and qualitative interviews evaluated provider knowledge and experiences with B-Lynch and UBT to treat PPH. RESULTS: Multiple-choice surveys indicated that providers who received SBT were more comfortable performing and teaching B-Lynch compared to those who did not (p = 0.003 and 0.005). Qualitative interviews revealed increased provider comfort with B-Lynch compared to UBT and identified multiple barriers to uterine balloon tamponade implementation. CONCLUSIONS: Simulation-based training had a stronger impact on provider comfort with B-Lynch compared to uterine balloon tamponade. Qualitative interviews provided insight into the challenges that hinder uptake of uterine balloon tamponade, namely resource limitations and decision-making hierarchies. Capturing data through a mixed-methods approach allowed for more comprehensive program evaluation.

Changing the landscape of obstetric resident education in low- and middle-income countries using simulation-based training.

OBJECTIVE: To evaluate simulation-based training (SBT) in low- and-middle-income countries (LMIC) and the long-term retention of knowledge and self-efficacy. METHODS: We conducted an SBT course on the management of postpartum hemorrhage (PPH), shoulder dystocia (SD), and maternal cardiac arrest (MCA) in three government teaching hospitals in Guatemala. We evaluated changes in knowledge and self-efficacy using a multiple-choice questionnaire for 46 obstetrics/gynecology residents. A paired Student's t test was used to analyze changes at 1 week and 6 months after the SBT. RESULTS: There was an increase in scores in clinical knowledge of MCA (p < 0. 001, 95% confidence interval [CI] 0.81-1.49) and SD (p < 0.001, 95% CI 0.41-1.02) 1 week after SBT, and a statistically insignificant increase in PPH scores (p = 0.617, 95% CI -0.96 to 0.60). This increase in scores was maintained after 6 months for MCA (p < 0.001, 95% CI 0.69-1.53), SD (p = 0.02 95% CI 0.07-0.85), and PPH (p = 0.04, 95% CI 0.01-1.26). For MCA and SD, the levels of self-efficacy were increased 1 week following training (p < 0.001, 95% CI 0.83-2.30 and p = 0.008, 95% CI 0.60-3.92, respectively), and at 6 months (p < 0.001, 95% CI 0.79-2.42 and p = 0.006, 95% CI 0.66-3.81, respectively). There was a slight increase in PPH self-efficacy scores 1 week after SBT (p = 0.73, 95% CI -6.05 to 4.41), maintained after 6 months (p = 0.38, 95% CI -6.85 to 2.85). CONCLUSION: SBT was found to be an effective and feasible method to increase short- and long-term clinical knowledge and self-efficacy of obstetric emergencies in LMIC.