Severe maternal morbidity associated with endometriosis: a population-based, retrospective cohort study.

OBJECTIVE: To evaluate the association between endometriosis and the risk of severe maternal morbidity (SMM) as defined by the Centers for Disease Control and Prevention. DESIGN: This was a population-based, retrospective cohort study using the California Office of Statewide Health Planning and Development Linked Birth File with hospital discharge International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnoses between 2007 and 2012. SETTING: Population-based. PATIENT(S): A total of 3,098,578 pregnancies from 2007 to 2012. INTERVENTION(S): Prior diagnosis of endometriosis identified using the ICD-9-CM codes 617.0-617.9. MAIN OUTCOME MEASURE(S): The primary outcome of interest was SMM, which was defined as having been diagnosed with any of the ICD-9-CM codes corresponding to 25 peripartum conditions listed by the Centers for Disease Control and Prevention. The secondary outcomes of interest were each individual condition. RESULT(S): Of the 3,098,578 pregnancies analyzed, 2,910 pregnancies were among women with a prior diagnosis of endometriosis. There were 45,655 pregnancies complicated by at least 1 SMM; 158 pregnancies (54.3 per 1,000 pregnancies) were in women with endometriosis and 45,497 (14.7 per 1,000 pregnancies) were in women without endometriosis. Women with pregnancies complicated by endometriosis were 2.41 times more likely to develop SMM than women who did not have endometriosis (adjusted odds ratio [aOR], 2.41; 95% confidence interval [CI], 2.03-2.87). There was an increased risk of disseminated intravascular coagulation (aOR, 2.46; 95% CI, 1.65-3.66), heart failure during a procedure or surgery (aOR, 2.58; 95% CI, 1.69-3.94), pulmonary edema (aOR, 3.02; 95% CI, 1.11-8.17), blood transfusion (aOR, 2.17; 95% CI, 1.75-2.68), and hysterectomy (aOR, 2.46; 95% CI, 1.58-3.85). When the association was stratified by delivery mode, the risk of SMM was higher for vaginal delivery (aOR, 4.59; 95% CI, 2.73-7.71) than for cesarean delivery (aOR, 1.64; 95% CI, 1.37-1.97) (P-interaction<.0001). CONCLUSION(S): This study demonstrated that endometriosis is a major risk factor for SMM, especially among those who deliver vaginally. Furthermore, precautions should be taken before delivery in anticipation of potential complications.

Maternal obesity increases DNA methylation and decreases RNA methylation in the human placenta.

Maternal obesity is associated with increased risk of adverse pregnancy and birth outcomes. While increasing body of evidence supports that the etiology is related to fetal and placental hypoxia, molecular signaling changes in response to this pathophysiological condition in human placenta have remained elusive. Here by using varied approaches including immunocytochemistry staining, Western blot, RT-qPCR, and ELISA, we aimed to investigate the changes in epigenetic markers in placentas from obese pregnant women following delivery by Caesarean-section at term. Our results revealed that the levels of 5-methylcytosine (5mC), a methylated form commonly occurring in CpG dinucleotides and an important repressor of gene transcription in the genome, were significantly increased coupled with decreased activity of Ten-Eleven Translocation (TETs) enzymes that principally function by oxidizing 5mC in the obese placenta, consistent with hypoxia-induced genome-wide DNA hypermethylation observed in varied types of cells and tissues. N6-methyladenosine (m6A) represents the most abundant and conserved modification of gene transcripts, especially within mRNAs, which is stalled by m6A methyltransferases or "writers" including METTL-3/-14, WTAP, RBM15B, and KIAA1429. We further showed that obese placentas demonstrated significantly down-regulated levels of m6A along with reduced gene expression of WTAP, RBM15B, and KIAA1429. Our data support that maternal obesity-induced hypoxia may play an important role in triggering genome-wide DNA hypermethylation in the human placenta, and in turn leading to transcriptome-wide inhibition of RNA modifications. Our results further suggest that selectively modulating these pathways may facilitate development of novel therapeutic approaches for controlling and managing maternal obesity-associated adverse clinical outcomes.

One shot to control Pain: Decreasing postoperative opioid use in gynecologic oncology patients with intrathecal opioid injection.

OBJECTIVES: To determine whether regional anesthesia with single-shot intrathecal opioid injections (ITO) reduce postoperative pain and intravenous (IV) opioid use after exploratory laparotomy in major gynecologic surgeries. METHODS: A retrospective chart review of 315 consecutive cases of patients who underwent an exploratory laparotomy on the gynecologic oncology service from July 2015 to January 2018 was conducted. Single-shot ITO was offered to all patients undergoing open abdominal surgery. The primary outcomes of interest were IV opioid use in morphine equivalents during the first 48 hours after surgery. Univariate analyses were performed to estimate the effect of ITO on IV opioid use at 0, 6, 12, 24 and 48 hours after surgery. Longitudinal regression analyses were performed to estimate the effect of ITO on changes in outcomes of interest over time, adjusting for potential confounders. RESULTS: 35% (110/315) received ITO preoperatively. There were no differences in patient age, BMI, previous number of abdominal surgeries, history of opioid dependence, type of gynecologic surgery, or total EBL between the ITO and control groups. Preoperative ITO was associated with a significantly lower IV opioid requirement between 0 and 6 hours after surgery (9.7 ± 8.1 vs 14.3 ± 11.5, p < 0.0001) and between 6 and 12 hours after surgery (2.7 ± 3.8 vs 5.4 ± 9.5, p = 0.0054). There was no statistically significant difference in total hospital stay opioid requirement but median length of stay was increased by 1 day. CONCLUSIONS: Preoperative administration of ITO reduced IV opioid requirement in the first 12 hours postoperatively but was associated with median 1 day increase in hospital stay.

When the balloon goes up, blood transfusion goes down: a pilot study of REBOA in placenta accreta spectrum disorders.

BACKGROUND: Patients with placenta accreta spectrum (PAS) disorders often suffer massive hemorrhage during cesarean hysterectomies (CHyst). A novel strategy to decrease blood loss and minimize perioperative morbidity associated with PAS is utilization of ER-REBOA Catheter intraoperatively. In this study, we explore the use of ER-REBOA Catheter during CHyst with the goal of minimizing perioperative morbidity and packed red blood cell (PRBC) transfusions. METHODS: We conducted a retrospective case-control study at a regional referral center of consecutive patients with PAS undergoing CHyst. The primary outcomes were PRBC transfusions of ≥4 units. Secondary outcomes included surgical intensive care unit admissions, postoperative length of stay (LOS), postoperative ileus, and vascular complication rate. We also explored utilization of manual palpation and omission of precesarean fluoroscopy for resuscitative endovascular balloon occlusion of the aorta (REBOA) placement verification in distal aortic zone 3. RESULTS: 90 patients were included in the study. REBOA and non-REBOA cases were similar in clinicodemographic characteristics. 17.7% of REBOA cases received ≥4 units of PRBC compared with 49.3% of non-REBOA cases (p=0.03). Zero REBOA patients developed postoperative ileus, whereas 18 (25%) non-REBOA patients did (p=0.02). LOS was reduced in the REBOA group. Postplacement fluoroscopy was omitted in all REBOA cases. Two postoperative arterial thrombotic events (2 of 19, 11% of REBOA patients) were identified in the REBOA group, one requiring a thrombectomy (1 of 19, 5%). DISCUSSION: Decrease in blood transfusions of ≥4 units of PRBC is demonstrated when ER-REBOA Catheter is placed in distal aortic zone 3 during CHyst performed for severe PAS disorders. The incidence of postoperative ileus and LOS are reduced in the ER-REBOA Catheter group. Placement and utilization of ER-REBOA Catheter during CHyst may be feasible without fluoroscopy when manual placement verification is performed by an experienced operator. Protocol modifications focusing on reducing thrombotic rate are ongoing. LEVEL OF EVIDENCE: IV.

Genetic Carrier Screening in the Twenty-first Century.

Historically, carrier screening for a small number of autosomal recessive disorders has been offered to targeted populations based on ethnicity and family history. These chosen disorders are associated with severe morbidity or mortality, have a well-established carrier frequency in the targeted population, and have an acceptably high detection rate to make screening efficient. With advancing genetic technology, expanded panels rapidly are being designed and offered to the panethnic general population. This article reviews current recommendations for ethnicity-specific carrier screening for common disorders as well as the limitations and counseling complexities associated with expanded panels.