Infant Maternal Perinatal Advanced Care Team: A Pilot Collaboration for Families Facing a Life-Threatening Fetal Diagnosis.

Background: The Infant Maternal Perinatal Advanced Care Team program was launched in 2018 to enhance perinatal palliative care services in Toronto, Canada. Methods: Pilot patients were (1) carrying a fetus with a life-limiting diagnosis and (2) receiving care at the high-risk fetal center. Individualized care included opportunities for establishing goals, labor/delivery planning, grief support, and pediatric palliative care support. Results: A total of 107 patients were included during the two-year clinical pilot program. Of those who continued their pregnancy, 45% had care goals focused on comfort while 55% had goals focused on life prolongation. A significant proportion in both groups experienced a fetal or neonatal death. For babies who received comfort-focused care, one-third were transferred to hospice or home. Conclusions: A comprehensive perinatal palliative care pathway ensures that more families receive options of pre- and postnatal palliative care supports in varied circumstances where there is significant risk of fetal and neonatal mortality.

Reimagining Perinatal Palliative Care: A Broader Role for Support in the Face of Uncertainty.

Perinatal medicine is confronted by a growing number of complex fetal conditions that can be diagnosed prenatally. The evolution of potentially life-prolonging interventions for the baby before and after birth contributes to prognostic uncertainty. For clinicians who counsel families in these circumstances, determining which ones might benefit from early palliative care referral can be challenging. We assert that all women carrying a fetus diagnosed with a life-threatening condition for which comfort-focused care at birth is one ethically reasonable option ought to be offered palliative care support prenatally, regardless of the chosen plan of care. Early palliative care support can contribute to informed decision making, enhance psychological and grief support, and provide opportunities for care planning that includes ways to respect and honor the life of the fetus or baby, however long it may be.

Fetal Surgery for Open Spina Bifida in Canada: Initial Results.

OBJECTIVE: Fetal myelomeningocele closure results in better infant outcomes than postnatal closure at the cost of potential prematurity and maternal morbidity. Our aim is to describe the setup of a fetal myelomeningocele closure program in Canada and document its outcomes. METHODS: We conducted a retrospective review of all open fetal myelomeningocele closure surgeries performed at the Ontario Fetal Centre in its first 3 years of operation (2017-2020). Maternal and fetal baseline characteristics, surgical details, pregnancy outcomes, and infant follow-up until 1 year of age were recorded. RESULTS: Twenty-seven women underwent fetal myelomeningocele closure surgery, 10 of whom (37%) resided outside of Ontario. Mean gestational age at surgery was 25.0 ± 0.7 weeks. All surgeries were technically uncomplicated and no fetal deaths occurred. There was a significant negative correlation between increasing experience and skin-to-skin surgical time (R²â€¯= 0.36; P = 0.001). Of the 26 patients who have delivered, 4 (15.4%) experienced preterm prelabour rupture of membranes. Mean gestational age at delivery was 34.9±3.0 weeks. All but 1 patient delivered by cesarean. Maternal complications occurred in 9 women (34.6%). There were no maternal deaths, but 3 (11.5%) infant deaths. Of the 14 surviving infants who have reached at least 1 year of age, 5 (35.7%) underwent ventriculo-peritoneal shunting. Of the 9 infants who have not yet reached 1 year of age, 3 (33.3%) underwent endoscopic third ventriculostomy and none underwent shunting. CONCLUSION: Fetal open spina bifida closure can be performed in Canada, with results similar to those reported by other international expert centres. Long-term follow-up is ongoing.

Fetal heart rate monitoring in nonobstetric surgery: a systematic review of the evidence.

OBJECTIVE: Concern for fetal well-being during maternal nonobstetric surgery may result in obstetricians and other maternity care providers being asked to perform intraoperative fetal heart rate (FHR) monitoring. We systematically reviewed the evidence regarding the use of FHR monitoring during nonobstetric surgery after potential fetal viability (>22 weeks gestational age), and examined the FHR patterns and outcomes reported. DATA SOURCES: A systematic review of the evidence was performed. Sources included databases (MEDLINE, EMBASE, Cochrane, and CENTRAL), hand searching, guidelines, conference proceedings, and literature reviews. Online searching was performed to include literature published from 1966 to May 2019. STUDY ELIGIBILITY CRITERIA: All studies reviewing care of pregnant women undergoing nonobstetric surgery where FHR monitoring was performed intraoperatively. Data were extracted from appropriate full-text articles using a data abstraction form. STUDY APPRAISAL AND SYNTHESIS: Case reports and case series only were identified. A total of 74 cases were reviewed, encompassing maternal general surgery (n = 41, cardiovascular surgery (n = 13) and neurosurgery/orthopedics (n = 20). Median gestational age at time of maternal surgery was 30 weeks (range, 22-36 weeks). In 41 cases, findings of FHR monitoring were not reported. Abnormal tracings were observed in 29 cases, as either reduced variability (n = 13) or fetal bradycardia (n = 17). All but 3 bradycardias reported occurred during maternal cardiac surgery involving aortic clamping and cardiopulmonary bypass. In 1 case, FHR monitoring was not possible because of a surgical pneumoperitoneum; there was 1 fetal tachycardia associated with maternal pyrexia, and three cases in which FHR monitoring was deemed stable or normal. Three preterm infants were delivered simultaneously at the time of general surgery as a result of FHR abnormalities (at 30, 33, and 34 weeks respectively), 2 as a result of fetal bradycardia and 1 because of protracted reduced variablity. CONCLUSION: The evidence for intraoperative fetal monitoring is based on case reports and cases series. Maternal cardiac surgery involving cardiopulmonary bypass commonly results in fetal bradycardia, which may be challenging to interpret. Obstetricians should be aware of FHR pattern changes in response to anesthesia and surgery that do not justify iatrogenic preterm cesarean delivery.

Obstetric and Anaesthesia Checklists for the Management of Morbidly Adherent Placenta.

OBJECTIVE: To develop an integrated checklist for the management of patients with suspected morbidly adherent placenta (MAP). METHODS: A checklist process was developed incrementally by clinicians in the disciplines of maternal-fetal medicine, gynaecology, medical imaging, and anaesthesia for management of women with suspected MAP. RESULTS: Over a five-year period of debriefing after individual cases, a comprehensive checklist system was developed. The checklist is activated upon referral if MAP is suspected at an initial maternal-fetal medicine consultation; the process is subsequently guided by a clinical nurse specialist, leading to a standardized program of care. CONCLUSIONS: Having a checklist process facilitates standardized care and optimal communication between specialists, providing team-based care for women with this potentially serious complication of pregnancy.

MRI Significantly Improves Disease Staging to Direct Surgical Planning for Abnormal Invasive Placentation: A Single Centre Experience.

OBJECTIVE: To describe the role of ultrasound and MRI in defining the extent of disease and guiding perioperative and surgical management of abnormal invasive placentation (AIP). METHODS: We conducted a review of 65 cases of invasive placentation diagnosed antenatally with use of ultrasound and/or MRI in a single tertiary centre between January 2000 and December 2014. Cases were assigned a grade based on the depth of invasion and location of invasion within the uterus as described in ultrasound and MRI reports. These grades were then compared with grades assigned using a combination of pathology and dictated surgical reports. RESULTS: Ultrasound correctly identified the presence of AIP in 91.9% of cases but was accurate in predicting the stage of invasion in only 38.7% of cases. Ultrasound identified only 6.3% of cases with parametrial involvement. MRI correctly identified the presence of AIP in 98.4% of cases and was accurate in predicting the stage of invasion in 61.3% of cases. MRI accurately detected parametrial involvement in 68.8% of cases. CONCLUSIONS: Our results suggest that all women with signs of AIP on ultrasound scanning should be referred for MRI to assess the extent of placental invasion adequately and consequently to allow for adequate perioperative and surgical planning for delivery.

Multidisciplinary management of invasive placenta previa.

OBJECTIVE: To assess the effectiveness of a multidisciplinary team approach to reduce severe maternal morbidity in women with invasive placenta previa. METHODS: We conducted a prospective study of 33 women with placenta previa and increta-percreta (diagnosed by ultrasound and/or magnetic resonance imaging) delivering at Mount Sinai Hospital, Toronto, following the introduction in January 2008 of a team-based approach to women with this condition. We included women who delivered by June 2012. We reviewed antenatal outpatient and inpatient records for use of six pre-defined team components by the attending staff obstetrician: (1) antenatal maternal-fetal medicine consultation, (2) surgical gynaecology consultation, (3) antenatal MRI, (4) interventional radiology consultation and preoperative placement of balloon catheters in the anterior divisions of the internal iliac arteries, (5) pre-planned surgical date, and (6) surgery performed by members of the invasive placenta surgical team. Antenatal course, delivery, and postpartum details were recorded to derive a five-point composite severe maternal morbidity score based on the presence or absence of: (1) ICU admission following delivery, (2) transfusion > 2 units of blood, (3) general anaesthesia start or conversion, (4) operating time in highest quartile (> 125 minutes), and (5) significant postoperative complications (readmission, prolonged postpartum stay, and/or pulmonary embolism). RESULTS: All 33 women survived during this time period. Two thirds (22/33) had either five or six of the six components of multidisciplinary care. Increasing use of multidisciplinary team components was associated with a significant reduction in composite morbidity (R2 = 0.228, P = 0.005). CONCLUSION: Team-based assessment and management of women with invasive placenta previa is likely to improve maternal outcomes and should be encouraged on a regional basis.

Objectif : Évaluer l'efficacité d'une approche d'équipe multidisciplinaire visant l'atténuation de la morbidité maternelle grave chez les femmes qui présentent un placenta prævia invasif. Méthodes : Nous avons mené une étude prospective auprès de 33 femmes qui présentaient un placenta prævia et increta-percreta (diagnostiqué par échographie et/ou imagerie par résonance magnétique) et qui accouchaient au Mount Sinai Hospital de Toronto, à la suite du lancement (en janvier 2008) d'une approche d'équipe visant les femmes qui présentaient une telle placentation. Nous avons inclus les accouchements chez les femmes visées jusqu'en juin 2012. Nous avons analysé les dossiers prénataux (services externes et services hospitaliers) en vue d'y repérer l'utilisation par l'obstétricien titulaire de six composantes d'équipe prédéfinies : (1) consultation prénatale en médecine fœto-maternelle; (2) consultation en chirurgie gynécologique; (3) IRM prénatale; (4) consultation en radiologie interventionnelle et mise en place préopératoire de sondes à ballonnet dans les divisions antérieures des artères iliaques internes; (5) planification à l'avance de la date de chirurgie; et (6) chirurgie menée par des membres de l'équipe chirurgicale vouée aux cas de placenta invasif. Les détails de l'évolution prénatale, de l'accouchement et de la période postpartum ont été consignés afin d'établir un score composite de morbidité maternelle grave en cinq points fondé sur la présence ou l'absence de ce qui suit : (1) admission à l'USI à la suite de l'accouchement; (2) transfusion de plus de deux unités de sang; (3) anesthésie générale (administration ou conversion); (4) temps opératoire se situant dans le quartile le plus élevé (> 125 minutes); et (5) complications postopératoires significatives (réhospitalisation, hospitalisation postpartum prolongée et/ou embolie pulmonaire). Résultats : Les 33 participantes ont survécu au cours de cette période. Les deux tiers (22/33) d'entre elles présentaient cinq ou six des six composantes des soins multidisciplinaires. L'utilisation croissante des composantes des soins multidisciplinaires a été associée à une baisse significative de la morbidité composite (R2 = 0,228, P = 0,005). Conclusion : L'évaluation et la prise en charge en équipe des femmes qui présentent un placenta prævia invasif sont susceptibles d'améliorer les issues maternelles et devraient être favorisées sur une base régionale.