Low-Cost, Scalable Simulations in Obstetric Trauma and Resuscitative Hysterotomy for Emergency Medicine Residents.

Introduction: Simulation-based learning is essential for health care providers to prepare for rare obstetric emergencies, such as severe trauma and maternal cardiac arrest. These situations demand rapid and prompt actions, often testing the skill of emergency physicians. Resuscitative hysterotomy (RH), a critical procedure in maternal cardiac arrest, requires technical expertise, coordination, and anatomical knowledge. The high cost of commercial trainers and complex existing models restricts accessibility. This resource introduces a low-cost anatomically accurate RH task trainer and assesses its effectiveness in improving skills and confidence among trainee emergency physicians. Methods: A 20-minute-long case scenario depicted the resuscitation of a pregnant trauma patient with tension pneumothorax and uterine rupture, culminating in maternal cardiac arrest necessitating RH. Residents performed RH on the task trainer under faculty guidance. Feedback followed the Pendleton model, and an online questionnaire gauged the residents' experiences. Results: Thirty emergency medicine residents participated in the simulation. The questionnaire revealed positive responses, confirming the session's relevance and enhancement of clinical skills and confidence. Discussion: Our results underscore the RH task trainer's critical role in improving residents' skills and confidence during obstetric trauma simulations. Its realism and effectiveness were notably well received. Future refinements aim to augment fidelity while preserving affordability and integrating regular reinforcement sessions. This innovative educational approach equips health care professionals to respond adeptly to rare and challenging obstetric emergencies, ultimately elevating outcomes for mothers and infants during critical situations.

Enhancing maternal survival in traumatic cardiovascular collapse during pregnancy: A case series on resuscitative hysterotomy (RH) from a level 1 trauma center.

BACKGROUND: Trauma during pregnancy presents multifaceted risks to both the developing fetus and the expectant mother due to pregnancy-induced physiological adaptations that affect the response to traumatic injuries. The infrequent occurrence of cardiac arrest during pregnancy necessitates interventions such as perimortem cesarean section (PMCS), now termed resuscitative hysterotomy. While early resuscitative hysterotomy focused primarily on fetal survival, more recent literature reports substantial maternal benefits. Resuscitative hysterotomy can lead to the restoration of maternal pulse and blood pressure within minutes and has shown potential to improve maternal outcomes. RH has been demonstrated to aid in fetal and maternal survival in hemodynamic unstable pregnant patients before cardiovascular collapse. The linguistic change from PMCS to resuscitative hysterotomy is a shift towards maternal-centric approaches and survival. OBJECTIVE: In this series, we evaluate the outcomes of resuscitative hysterotomy performed before or after cardiovascular collapse to maximize maternal survival while concurrently optimizing fetal outcomes. METHODS: We performed a retrospective case series review of 4 consecutive pregnant trauma patients who underwent RH due to hemodynamic instability. In addition, we conducted a descriptive analysis of all pregnant patients from 2013 to May 2024 who presented due to a traumatic injury but did not require a RH. RESULTS: The average age of patients undergoing RH was 26.5 ± 6.8 years. All patients were in the third trimester with a mean gestational age of 32.3 ± 0.5 weeks. Fifty percent (50 %) of patients were involved in motor vehicle accidents, one (25 %) pedestrian was hit by a vehicle, and one (25 %) had GSW to the head. The median time to RH was 14.5 min. The mean estimated blood loss (EBL) was 625 mL ±108.9 mL. The maternal survival rate was 50 %, with a fetal survival rate of 100 %. Three patients achieved hemodynamic stability; however, one of the patients progressed to death by neurological criteria. Therefore, we achieved 50 % of maternal survival. A resuscitative hysterotomy was performed due to early signs of maternal hemorrhagic shock and suggestive features of ongoing bleeding (persistent maternal tachycardia despite adequate analgesia and resuscitation, persistent maternal bradycardia, gradual decline of BP, and FHR abnormalities) in three patients. The remaining patient was found to have cardiac arrest at the scene with a brief return of spontaneous circulation and received resuscitative hysterotomy in the ED to restore cardiovascular function. CONCLUSION: RH in pregnant patients with traumatic injury and impending hemorrhagic shock or cardiovascular collapse may provide maternal survival benefits by supporting circulatory function and promoting resuscitation with no additional risks to fetal outcomes. Quick decision-making is crucial to the implementation of this life-saving procedure. Further research with a more significant number of patients is needed to validate the efficacy of RH in maximizing maternal survival. This case series adds to the evolving literature on RH, shedding light on practical aspects and maternal outcomes to inform ongoing discussions and strategies for maternal cardiopulmonary resuscitation.

Prenatal Neurosurgical Counseling for Myelomeningocele and Treatment-Determining Factors for Fetal Repair.

INTRODUCTION: Spina bifida guidelines recommend neurosurgical involvement in prenatal counseling to inform decision-making between prenatal and postnatal myelomeningocele (MMC) repair. This study examines whether families with MMC presenting to one fetal center had timely neurosurgical prenatal counseling (nPNC) encounters and assesses modifiable and non-modifiable treatment-determining factors. METHODS: History and timing of nPNC were quantified among infants undergoing postnatal and prenatal MMC repair, pregnant patients referred, and MMC studies in a fetal MRI database (2015-2023). Fetal repair exclusions, presentation timing, social determinants, and reported rationale for not selecting offered fetal therapy were assessed. RESULTS: Nearly all patients (34/35; 97%) engaged in nPNC, 82% prior to 24 weeks GA. Fourteen patients were excluded from fetal repair for lack of hindbrain herniation (43%), obstetric exclusions (21%), fetal exclusions (21%), suspected closed defect (7%), and delayed presentation (7%). These patients ultimately underwent postnatal repair (71%), and pregnancy termination (14%). The 20 fetal-repair-eligible patients selected fetal repair (50%), postnatal repair (45%), and pregnancy termination (5%). Reasons for declining fetal repair included risk (55%) and cost (22%). CONCLUSIONS: Among MMC families presenting to a regional fetal therapy center, nPNC was widely extended, in a mostly timely fashion. Very few were deterred from fetal repair by potentially modifiable barriers.

Do Not Get Your Uterus Twisted: A Case Report of a 180-Degree Torsion of Term Gravid Uterus and a Review of the Literature.

Gravid uterine torsion less than 45 degrees is a common phenomenon of the third trimester. Torsion greater than 45 degrees represents a rare, pathologic, and obstetric emergency. The rotation of the uterus on a longitudinal plane can result in vascular compromise, and it has potential for catastrophic maternal-fetal complications. We report the case of a 22-year-old G3P1011, third pregnancy with history of one full-term live newborn, one spontaneous abortion, and presented at 38 weeks gestation with complaints of abdominal pressure and recurrent transverse fetal presentation. She underwent an external cephalic version (ECV), which resulted in fetal distress necessitating an emergency cesarean section. After successful delivery of the live newborn, an inspection of the uterus identified a uterine torsion of 180 degrees with delivery through a posterior hysterotomy incision. She had no postoperative complications and carried a subsequent pregnancy to term that was delivered via repeat cesarean section five years later. Gravid uterine torsion should be included in the differential diagnosis for patients presenting with abdominal pain and fetal intolerance to labor. A higher suspicion should be held for patients with a known history of uterine abnormalities or those having undergone an ECV. Our case also highlights a safe repeat cesarean section after this rare complication and brief narrative review of existing literature on this rare obstetrical emergency.

Cesarean section prior to 28 weeks' gestation: which type of uterine incision is optimal?

OBJECTIVE: The purpose of this study was to determine the factors that influence physician preference for type of hysterotomy incisions in gravidas with a singleton or twin pregnancy undergoing cesarean section under 28 weeks, and to assess factors that result in delivery complications, defined as either intraoperative dystocia or hysterotomy extension. We hypothesized that compared to those with non-cephalic presentations, gravidas with a presenting fetus in cephalic presentation would have higher rates of low-transverse cesarean section, and reduced rates of delivery complications with low-transverse hysterotomy. METHODS: This was a retrospective cohort chart analysis of 128 gravidas between 23 0/7 and 27 6/7 weeks undergoing cesarean section at a single academic institution between August 2010 and December 2022. Data was abstracted for factors that might influence the decision for hysterotomy incision type, as well as for documentation of difficulty with delivery of the fetus or need for hysterotomy extension to affect delivery. RESULTS: There was a total of 128 subjects, 113 with a singleton gestation and 15 with twins. The presenting fetus was in cephalic presentation in 43 (33.6%), breech presentation in 71 (55.5%), transverse/oblique lie in 13 (10.2%), and not documented in 1 (0.8%). Sixty-eight (53.1%) had a low-transverse cesarean section (LTCS), 53 (41.4%) had a Classical, 5 (3.9%) had a low-vertical hysterotomy and 2 (1.6%) had a mid-transverse incision. There was a significantly higher rate of LTCS among gravidas with the presenting fetus in cephalic presentation (30/43, 69.8%) compared to those with breech (31/71, 43.7%) or transverse/oblique presentations (7/13, 53.8%), p = .03. No other significant associations were related to hysterotomy incision, including nulliparity, racially or ethnically minoritized status, plurality, indication for cesarean delivery, or pre-cesarean labor. Twenty (15.6%) subjects experienced either an intraoperative dystocia or hysterotomy extension. For the entire cohort, there was a greater median cervical dilatation in those with delivery complications (4.0 cm, IQR .5 - 10 cm) compared to those without complications (1.5, IQR 0 - 4.0), p = .03, but no significant association between delivery complications and fetal presentation, hysterotomy type, plurality, or other demographic/obstetrical factors. However, among gravidas undergoing low-transverse cesarean section, only 2/30 (6.7%) with cephalic presentations had a delivery complication, compared to 9/31 (29.0%) with breech presentations and 3/7 (42.9%) with a transverse/oblique lie, p = .03. CONCLUSION: In pregnancies under 28 weeks, the performance of a low-transverse cesarean section was significantly associated only with presentation of the presenting fetus. Among those with cephalic presentations, the rate of intrapartum dystocia or hysterotomy extension was low after a low-transverse hysterotomy, suggesting that in this subgroup, a low-transverse cesarean section should be considered.

Advanced repair of recurrent and low-large hysterotomy defects using a myometrial glide flap.

BACKGROUND: The resolution of factors linked to the recurrence of cesarean section defects can be accomplished through a comprehensive technique that effectively addresses the dehiscent area, eliminates associated intraluminal fibrosis, and establishes a vascularized anterior wall by creating a sliding myometrial flap. OBJECTIVE: Propose a comprehensive surgical repair for recurrent and large low hysterotomy defects in women seeking pregnancy or recurrent spotting. STUDY DESIGN: A retrospective cohort analysis included 54 patients aged 25-41 with recurrent large cesarean scar defects treated at Otamendi, CEMIC, and Valle de Lili hospitals. Comprehensive surgical repair was performed by suprapubic laparotomy, involving a wide opening of the vesicouterine space, removal of the dehiscent cesarean scar and all intrauterine abnormal fibrous tissues, using a glide myometrial flap, and intramyometrial injection of autologous platelet-rich plasma. Qualitative variables were determined, and descriptive statistics were employed to analyze the data in absolute frequencies or percentages. The data obtained were processed using the InfostatTM statistic program. RESULTS: Following the repair, all women experienced normal menstrual cycles and demonstrated an adequate lower uterine segment thickness, with no evidence of healing defects. All patients experienced early ambulation and were discharged within 24 h. Uterine hemostasis was achieved at specific points, minimizing the use of electrocautery. The standard duration of the procedure was 60 min (skin-to-skin), and the average bleeding was 80-100 ml. No perioperative complications were recorded. A control T2-weighted MRI was performed six months after surgery. All patients displayed a clean, unobstructed endometrial cavity with a thick anterior wall (Median: 14.98 mm, IQR 13-17). Twelve patients became pregnant again, all delivered by cesarean between 36.1 and 38.0 weeks, with a mean of 37.17 weeks. The thickness of the uterine segment before cesarean ranged between 3 and 7 mm, with a mean of 3.91 mm. No cases of placenta previa, dehiscence, placenta accreta spectrum (PAS), or postpartum hemorrhage were reported. CONCLUSIONS: The comprehensive repair of recurrent low-large defects offers a holistic solution for addressing recurrent hysterotomy defects. Innovative repair concepts effectively address the wound defect and associated fibrosis, ensuring an appropriate myometrial thickness through a gliding myometrial flap.

Cephalad-caudad vs transverse blunt expansion of low transverse hysterotomy during caesarean section and risk of severe postpartum haemorrhage: A prospective comparative study.

BACKGROUND: The global prevalence of caesarean section as a delivery method is increasing worldwide. However, there is notable divergence among countries in their national guidelines regarding the optimal technique for blunt expansion hysterotomy of the low transverse uterine incision during caesarean section (cephalad-caudad or transverse). AIM: To compare the risk of severe postpartum haemorrhage (PPH) between cephalad-caudad and transverse blunt expansion hysterotomy during caesarean section. METHODS: This prospective comparative observational study was conducted in a university maternity hospital. All women who gave birth to one infant by caesarean section after 30 weeks of gestation between November 2020 and November 2021 were included in this study. The exclusion criteria were a coagulation disorder, the presence of placenta previa, multiple pregnancies, or enlargement of the hysterotomy with scissors. The choice between cephalad-caudad or transverse blunt expansion of the low transverse hysterotomy was left to the surgeon's discretion. The primary outcome measure was severe PPH, defined as estimated blood loss ≥ 1000 ml. Univariate and multivariate analyses were employed to assess the risk of severe PPH associated with the two methods of enlarging the low transverse hysterotomy. RESULTS: The study included 850 women, of whom 404 underwent transverse blunt expansion and 446 underwent cephalad-caudad blunt expansion. The overall incidence of severe PPH was 13.3 %. Univariate analysis revealed no significant difference in the frequency of severe PPH between the cephalad-caudad and transverse blunt expansion groups (13.9 % vs 12.6 %; p = 0.61). However, the use of additional surgical sutures (mainly additional haemostatic stitches) was less common with cephalad-caudad blunt expansion (26.7 % vs 36.9 %; p < 0.05). Multivariate analysis showed no significant difference in risk between the two techniques (odds ratio 1.17, 95 % confidence interval 0.77-1.78). CONCLUSION: No significant difference in the risk of severe PPH was found between cephalad-caudad and transverse blunt expansion of the low transverse hysterotomy during caesarean section.

Enhanced recovery after fetal spina bifida surgery: what is our global practice?

OBJECTIVE: Prenatal spina bifida closure results in improved outcomes for the child compared to postnatal surgery but is associated with significant maternal morbidity. Optimization of the perioperative care for women who underwent fetal spina bifida surgery could improve maternal and pregnancy outcomes. Enhanced Recovery After Surgery (ERAS) protocols are multimodal, evidence-based care plans that have been adopted for multiple surgical procedures to promote faster and better patient recovery and shorter hospitalization. This study aims to explore if fetal centers have implemented ERAS principles in this setting. Furthermore, we provide recommendations for the perioperative management of patients undergoing fetal spina bifida surgery. METHODS: Fifty-three fetal therapy centers offering prenatal surgery for open spina bifida were identified and invited to complete a digital questionnaire covering their pre-, intra- and postoperative management. An overall score was calculated per center based on the center's compliance with 20 key ERAS principles, extrapolated from ERAS guidelines for cesarean section, gynecologic oncology and colorectal surgery. Each item was scored 1 or 0 when the center did or did not comply with each principle, with a maximum score of 20. RESULTS: The questionnaire was completed by 46 centers in 17 countries (response rate 87%). Twenty-two centers (48%) exclusively perform open fetal surgery (laparotomy and hysterotomy), whereas 14 (30%) offer both open and fetoscopic procedures and 10 (22%) use fetoscopy only. The perioperative management of patients undergoing fetoscopic and open surgery was highly similar. The median ERAS score was 12 (mean 12.5, SD 2.4, range 8-17). Center compliance was the highest for the use of regional anesthesia (98%), avoidance of bowel preparation (96%), and thromboprophylaxis (96%), while the lowest compliance was achieved for preoperative carbohydrate loading (15%), postoperative nausea and vomiting prevention (33%), avoidance of overnight fasting (33%) and a 2-hour fasting period for clear fluids (20%). ERAS scores were similar in centers with a short (2-5 days), medium (6-10 days) and long (≥11 days) hospital stay (12.8 ± 2.4, 12.1 ± 2.0, and 10.3 ± 3.2, respectively, p=0.15). Furthermore, there was no significant association between ERAS score and surgical technique or center volume. CONCLUSION: The perioperative management of fetal spina bifida surgery is highly variable across fetal therapy centers worldwide. Standardizing protocols according to ERAS principles may improve patient recovery, reduce maternal morbidity, and shorten hospital stay after fetal spina bifida surgery. This article is protected by copyright. All rights reserved.

The association between unintended hysterotomy extensions with cesarean delivery and subsequent preterm birth.

BACKGROUND: An increased risk for preterm birth has been observed among individuals with a previous second stage cesarean delivery when compared with those with a previous vaginal delivery. One mechanism that may contribute to the increased risk for preterm birth following a second stage cesarean delivery is the increased risk for cervical injury because of extension of the uterine incision (hysterotomy) into the cervix. The contribution of hysterotomy extension to the rate of preterm birth in a subsequent pregnancy has not been investigated and may shed light on the mechanism underlying the observed relationship between the mode of delivery and subsequent preterm birth. OBJECTIVE: We aimed to quantify the association between unintended hysterotomy extension and preterm birth in a subsequent delivery. STUDY DESIGN: We performed a retrospective cohort study using electronic perinatal data collected from 2 university-affiliated obstetrical centers. The study included patients with a primary cesarean delivery of a term, singleton live birth and a subsequent singleton birth in the same catchment (2005-2021). The primary outcome was subsequent preterm birth <37 weeks' gestation; secondary outcomes included subsequent preterm birth at <34, <32, and <28 weeks' gestation. We assessed crude and adjusted associations between unintended hysterotomy extensions and subsequent preterm birth with log binomial regression models using rate ratios and 95% confidence intervals. Adjusted models included several characteristics of the primary cesarean delivery such as maternal age, length of active labor, indication for cesarean delivery, chorioamnionitis, and maternal comorbidity. RESULTS: A total 4797 patients met the study inclusion criteria. The overall rate of unintended hysterotomy extension in the primary cesarean delivery was 6.0% and the total rate of preterm birth in the subsequent pregnancy was 4.8%. Patients with an unintended hysterotomy extension were more likely to have a longer duration of active labor, chorioamnionitis, failed vacuum delivery attempt, second stage cesarean delivery, and persistent occiput posterior position of the fetal head in the primary cesarean delivery and higher rates of smoking in the subsequent pregnancy. Multivariable analyses that controlled for several confounders showed that a history of hysterotomy extension was not associated with a higher risk for preterm birth <37 weeks' gestation (adjusted rate ratio, 1.55; 95% confidence interval, 0.98-2.47), but it was associated with preterm birth <34 weeks' gestation (adjusted rate ratio, 2.49; 95% confidence interval, 1.06-5.42). CONCLUSION: Patients with a uterine incision extension have a 2.5 times higher rate of preterm birth <34 weeks' gestation when compared with patients who did not have this injury. This association was not observed for preterm birth <37 weeks' gestation. Future research should aim to replicate our analyses with incorporation of additional data to minimize the potential for residual confounding.

Outcomes of severely injured pregnant trauma patients: a multicenter analysis.

Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS < 15) and compared with bivariate analyses. From 950 patients, 32 (3.4%) had severe injuries. Compared to non-severely injured PTPs, severely injured PTPs were of similar maternal age but had younger gestational age (21 vs 26 weeks, p = 0.009). Penetrating trauma was more common in the severely injured cohort (15.6% vs 1.4%, p < 0.001). The severely injured cohort more often underwent an operation (68.8% vs 3.8%, p < 0.001), including a hysterectomy (6.3% vs 0.3%, p < 0.001). The severely injured group had higher rates of complications (34.4% vs 0.9%, p < 0.001), mortality (15.6% vs 0.1%, p < 0.001), a higher rate of fetal delivery (37.5% vs. 6.0%, p < 0.001) and resuscitative hysterotomy (9.4% vs. 0%, p < 0.001). Only approximately 3% of PTPs were severely injured. However, severely injured PTPs had a nearly 40% rate of fetal delivery as well as increased complications and mortality. This included a resuscitative hysterotomy rate of nearly 10%. Significant vigilance must remain when caring for this population.