Protocolo Clínico - Quirúrgico de Cesárea en la Unidad Técnica de Alto Riesgo Obstétrico / Clinical-Surgical Protocol for Cesarean Section in the Obstetric High Risk Technical Unit

El procedimiento quirúrgico cesárea con miras a la historia es considerada como un avance de suma importancia en la dismi-nución del riesgo de mortalidad materna y perinatal1.Es la intervención más realizada a nivel de especialidad lo que conlleva riesgos inherentes, quirúrgicos y anestésicos2,3.En el año 2015 la incidencia en el Ecuador de terminación del embarazo por cesárea es del 29,3% en el sector público, 49,9% en Seguridad Social y 69,9% en clínicas privadas4. Para la Or-ganización Mundial de la Salud (OMS) en el mismo año refiere que "En ninguna región del mundo se justifica la incidencia de cesárea superior al 10- 15%"5. La variabilidad de indicación de cesárea, hace que sea necesaria la creación de guías y protocolos, para de esta manera unificar los criterios médicos, de acuerdo a la mejor evidencia científica disponible.

The cesarean section surgical procedure is historically considered a very important advance in reducing the risk of maternal and perinatal mortality1.It is the most frequently performed intervention at the specialty level, which entails inherent surgical and anesthetic risks2,3.In 2015, the incidence in Ecuador of termination of pregnancy by cesarean section is 29,3% in the public sector, 49,9% in Social Security and 69,9% in private clinics4. For the World Health Or-ganization (WHO) in the same year, it states that "In no region of the world is the incidence of cesarean section higher than 10-15% justified" 5.The variability of the indication for cesarean section makes it ne-cessary to create guidelines and protocols, in order to unify me-dical criteria, according to the best scientific evidence available.

Assessment of Organ Dysfunction and Underlying Causes in Maternal Near-miss Cases at Health Care Facilities in Doiwala Block of District Dehradun - A Retrospective Study.

INTRODUCTION: The extent of maternal morbidity is a good gauge of a nation's maternal health care system. Maternal near-miss (MNM) cases need to be reviewed because they can indirectly contribute significantly to reducing the maternal mortality ratio in India. MNM cases can provide useful information in this context. Such women who survive these life-threatening conditions arising from complications during pregnancy, childbirth and post partum (42 days) share many commonalities with those who die because of such complications. AIM: To assess the organ dysfunction and the underlying causes, associated/contributory factors associated with "maternal near-miss" cases in pregnant, in labor, post-partum women (upto42 days) in the health care facilities of Doiwala block, district Dehradun. MATERIALS AND METHODS: The present study was conducted over a period of 6 months under the Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh. The cross-sectional study included the medical record files of all pregnant women attending the Department of Obstetrics and Gynecology, in the selected healthcare facilities of Doiwala block, district Dehradun. This study was conducted as per the WHO criteria for "near-miss" by using convenience sampling for the selection of healthcare facilities. The medical record files of all women who were pregnant, in labor, or who had delivered or aborted up to 42 days were included from a period of 01.06.2021 - 31.05.2022. RESULTS: It was found that Out of the women with maternal near-miss (n=91), the majority of women had coagulation /hematological dysfunction (n=45, 49.4%), followed by neurologic dysfunction (n=15, 16.4%), cardio-vascular dysfunction (n=11, 12%). Out of the total women with a maternal near-miss (n = 91), 10 women underwent multiple organ dysfunctions. Of the total 91 maternal near-miss cases, the underlying cause of near-miss was obstetric hemorrhage in almost half the participants (n=45, 49.5%) followed by hypertensive disorders (n=36, 39.5%). Eleven women had a pregnancy with abortive outcomes (12%) and 7 women had pregnancy-related infection. It was also seen that, out of 91 near-miss women, the leading contributory /associated cause was Anemia (n=89, 97.8%) followed by women having a history of previous cesarean section (n=63, 69.2%). Sixteen women had prolonged /obstructed labor (n = 16, 17.58%). CONCLUSION: Pregnancy should be a positive experience for every woman of childbearing age. A better understanding of pregnancy-related conditions enables early detection of complications and prevents the conversion of mild to moderate maternal morbidity outcomes to severe maternal outcomes with long-term health implications or death. There are already effective measures in place to reduce maternal and newborn mortality and morbidity.

Epidural-related maternal fever: incidence, pathophysiology, outcomes, and management.

Epidural-related maternal fever affects 15% to 25% of patients who receive a labor epidural. Two meta-analyses demonstrated that epidural-related maternal fever is a clinical phenomenon, which is unlikely to be caused by selection bias. All commonly used neuraxial techniques, local anesthetics with or without opioids, and maintenance regimens are associated with epidural-related maternal fever, however, the impact of each component is unknown. Two major theories surrounding epidural-related maternal fever development have been proposed. First, labor epidural analgesia may lead to the development of hyperthermia through a sterile (noninfectious) inflammatory process. This process may involve reduced activation of caspase-1 (a protease involved in cell apoptosis and activation of proinflammatory pathways) secondary to bupivacaine, which impairs the release of the antipyrogenic cytokine, interleukin-1-receptor antagonist, from circulating leucocytes. Detailed mechanistic processes of epidural-related maternal fever remain to be determined. Second, thermoregulatory mechanisms secondary to neuraxial blockade have been proposed, which may also contribute to epidural-related maternal fever development. Currently, there is no prophylactic strategy that can safely prevent epidural-related maternal fever from occurring nor can it easily be distinguished clinically from other causes of intrapartum fever, such as chorioamnionitis. Because intrapartum fever (of any etiology) is associated with adverse outcomes for both the mother and baby, it is important that all parturients who develop intrapartum fever are investigated and treated appropriately, irrespective of labor epidural utilization. Institution of treatment with appropriate antimicrobial therapy is recommended if an infectious cause of fever is suspected. There is currently insufficient evidence to warrant a change in recommendations regarding provision of labor epidural analgesia and the benefits of good quality labor analgesia must continue to be reiterated to expectant mothers.

Intervenções psicológicas necessárias: a prática como residente no serviço de medicina fetal / Necessary psychological interventions: the practice as a resident in the fetal medicine service / Intervenciones psicológicas necesarias: la práctica como residente en el servicio de medicina fetal

Com os avanços tecnológicos e o aprimoramento da prática médica via ultrassonografia, já é possível detectar possíveis problemas no feto desde a gestação. O objetivo deste estudo foi analisar a prática do psicólogo no contexto de gestações que envolvem riscos fetais. Trata-se de um estudo qualitativo sob formato de relato de experiência como psicólogo residente no Serviço de Medicina Fetal da Maternidade Escola da Universidade Federal do Rio de Janeiro (UFRJ). Os registros, feitos por observação participante e diário de campo, foram analisados em dois eixos temáticos: 1) intervenções psicológicas no trabalho em equipe em consulta de pré-natal, exame de ultrassonografia e procedimento de amniocentese; e 2) intervenções psicológicas em casos de bebês incompatíveis com a vida. Os resultados indicaram que o psicólogo nesse serviço é essencial para atuar de forma multiprofissional na assistência pré-natal para gravidezes de alto risco fetal. Ademais, a preceptoria do residente é relevante para sua formação e treinamento para atuação profissional no campo da psicologia perinatal.(AU)

Face to the technological advances and the improvement of medical practice via ultrasound, it is already possible to detect possible problems in the fetus since pregnancy. The objective of this study was to analyze the psychologist's practice in the context of pregnancies which involve fetal risks. It is a qualitative study based on an experience report as a psychologist trainee at the Fetal Medicine Service of the Maternity School of UFRJ. The records, based on the participant observation and field diary, were analyzed in two thematic axes: 1) psychological interventions in the teamwork in the prenatal attendance, ultrasound examination and amniocentesis procedure; and 2) psychological interventions in cases of babies incompatible to the life. The results indicated that the psychologist in this service is essential to work in a multidisciplinary way at the prenatal care for high fetal risk pregnancies. Furthermore, the resident's preceptorship is relevant to their education and training for professional performance in the field of Perinatal Psychology.(AU)

Con los avances tecnológicos y la mejora de la práctica médica a través de la ecografía, ya se puede detectar posibles problemas en el feto desde el embarazo. El objetivo de este estudio fue analizar la práctica del psicólogo en el contexto de embarazos de riesgos fetal. Es un estudio cualitativo basado en un relato de experiencia como residente de psicología en el Servicio de Medicina Fetal de la Escuela de Maternidad de la Universidade Federal do Rio de Janeiro (UFRJ). Los registros, realizados en la observación participante y el diario de campo, se analizaron en dos ejes temáticos: 1) intervenciones psicológicas en el trabajo en equipo, en la consulta prenatal, ecografía y los procedimientos de amniocentesis; y 2) intervenciones psicológicas en casos de bebés incompatibles con la vida. Los resultados señalaron como fundamental la presencia del psicólogo en este servicio trabajando de forma multidisciplinar en la atención prenatal en el contexto de embarazos de alto riesgo fetal. Además, la tutela del residente es relevante para su educación y formación para el desempeño profesional en el campo de la Psicología Perinatal.(AU)

Self-assessment of nursing preparedness and knowledge in the care of patients with obstetric anal sphincter injuries and utilization of a computer-based learning module for continued nursing education in the United States.

IMPORTANCE: Perineal injury is the most common complication of vaginal delivery, and labor and delivery (L&D) nurses are crucial in managing and educating women following perineal trauma. OBJECTIVE: The aims of this study were to assess L&D nurse experience, knowledge, and self-perception of preparedness in caring for women with obstetric anal sphincter injuries (OASIS) and to compare pre- and post-test scores using a computer-based learning module (CBL) for OASIS nurse education. STUDY DESIGN: All L&D nurses were invited to complete a voluntary, self-assessment questionnaire inquiring about prior experience, training, and education and current clinical practice in caring for patients with OASIS. They were also asked to answer ten knowledge-based questions about OASIS. The primary outcome was change in pretest and posttest knowledge-based scores after completion of CBL. RESULTS: Forty-one L&D nurses voluntarily responded to the self-assessment survey. Of respondents, 20% answered they were "very comfortable", 48% "comfortable", 23% "neutral," and 8% "uncomfortable" for caring for women with OASIS post-delivery. Fifty-three percent of reported having no formal education in nursing school about OASIS and 35% reported no formal training while at work. The average pretest knowledge test score was 66.3% and 93.5% (p < 0.001) after completion of the CBL. CONCLUSIONS: Most L&D nurses in this study reported having very limited formal nursing education in OASIS. Regardless of this lack of formal training, the majority of L&D nurses in this sample described themselves as comfortable caring for patients with OASIS post-delivery. Completion of a CBL was associated with higher OASIS knowledge scores.

Immediate postpartum assessment of the anal sphincter by endovaginal ultrasound: An experimental study.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injuries are frequently missed and carry a significant risk for the development of anal incontinence. Immediate postpartum endoanal ultrasound increases identification of these injuries but is rarely employed. We hypothesize that endovaginal ultrasound could be a feasible and easily available alternative sonographic tool to improve early diagnosis of anal sphincter tears. METHODS: We conducted a prospective experimental study including 160 primiparous women. Shortly after vaginal delivery, patients underwent clinical and sonographic perineal examinations. We analyzed the feasibility of anal sphincter assessment by endovaginal ultrasound and its potential contribution in the early diagnosis of anal sphincter injuries. RESULTS: Sonographic assessment of the anal sphincter was analyzable for 136 patients (85.0%). Causes of non-analyzability included air artifacts (6.9%), lack of distinction between the external anal sphincter and surrounding tissues (9.4%) and distortion artifacts (9.4%). Patients in the non-analyzable ultrasound subgroup were less likely to have delivered in a dorsal lithotomy position (62.5% vs. 85.3 %) and more likely to have had an episiotomy (33.3% vs. 14.0%), and their risk of sphincter injury was more frequently classified as "improbable" on clinical examination (91.7% vs. 61.0%). Ultrasounds were analyzable for 96.4% of patients clinically reported as having "possible" or "certain" sphincter injuries. The incidence of anal sphincter injury was 16.9% for clinical observation and 20.0% with associated sonographic examination. CONCLUSIONS: Endovaginal ultrasound could be used as a complementary tool in assessment of the anal sphincter in high-risk patients. Its feasibility and easy availability make this technique a promising tool for improving the management of anal sphincter tears.

Prevalence and management of severe intrapartum hypertension in patients with preeclampsia at an urban tertiary care medical center.

OBJECTIVES: Data on management of severe intrapartum hypertension is lacking. The aim of this study is to explore the proportion of timely interventions in severe, persistent intrapartum hypertension treatment by exploring the prevalence and management of intrapartum hypertension trends. STUDY DESIGN: This was a retrospective case-control study of pregnant women who delivered at the University of Chicago between January 2015 and March 2017. Patients with severe preeclampsia who underwent labor (either induced or spontaneous) were stratified into two groups: severe intrapartum hypertension and no severe intrapartum hypertension. MAIN OUTCOME MEASURES: Type of treatment and timing to treatment of severe hypertensive episodes were explored as well as prevalence of maternal adverse outcomes. RESULTS: A total of 95 patients with severe preeclampsia in labor were identified. In patients with persistent severe intrapartum hypertension (n = 52), 15 (28.9%) received treatment. Patients experiencing greater than three episodes of blood pressure elevation were more likely to receive treatment as compared to those with fewer episodes. There was no significant difference in severe maternal morbidity (SMM) between those treated within 60 min compared to those untreated or treated after 60 min (16.7% vs 27.5%; p = 0.71). CONCLUSIONS: Management protocols of intrapartum hypertensive episodes are variable or not universally implemented. Inadequately treated episodes of severe intrapartum hypertension trend towards higher rates of SMM.

Potentially Preventable Primary Cesarean Sections in Future Placenta Accreta Spectrum.

OBJECTIVE: Prior cesarean delivery is a well-known risk factor for placenta accreta spectrum disorders. While primary cesarean section is unavoidable in some patients, in others it may not be clearly indicated. The aim of the study is to determine the proportion of patients with placenta accreta spectrum who had a potentially preventable primary cesarean section and to identify factors associated with preventable placenta accreta spectrum. STUDY DESIGN: This was a single-center retrospective cohort study of women with pathology-confirmed placenta accreta spectrum from 2007 to 2019. Primary cesarean sections were categorized as potentially preventable or unpreventable based on practice consistent with the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine "Safe Prevention of the Primary Cesarean Delivery" recommendations. Fisher's exact test and Mann-Whitney U-test were used for comparison with p <0.05 considered statistically significant. RESULTS: Seventy-two patients had pathology-confirmed placenta accreta spectrum over the course of the study period, 15 (20.8%) of whom required a cesarean hysterectomy at the time of primary cesarean section. Fifty-seven patients had placenta accreta spectrum in a pregnancy following their primary cesarean section. Of these, 29 (50.9%) were considered potentially preventable. Most were performed without clear medical indication (37.9%) or for fetal malpresentation without attempted external cephalic version (37.9%). The remainder were due to arrest of labor not meeting criteria (17.2%) and abnormal or indeterminate fetal heart patterns with documented recovery (6.9%). Of the 11 patients without clear medical indication for primary cesarean section, eight (72.7%) were patient-choice cesarean sections and three (27.3%) were for suspected fetal macrosomia with estimated fetal weights not meeting criteria for cesarean delivery. There was no difference in the incidence of potentially preventable primary cesarean sections before and after the ACOG-SMFM "Safe Prevention of the Primary Cesarean Delivery" publication (48.8 vs. 57.1%, p = 0.59). Privately insured patients were more likely to have a potentially preventable primary cesarean section than those with Medicaid (62.5 vs. 23.5%, p = 0.008) and were more likely to have a primary cesarean section without clear medical indication (81.8 vs. 18.2%, p = 0.004). CONCLUSION: Many patients with placenta accreta spectrum had a potentially preventable primary cesarean section. Most were performed without clear medical indication or for malpresentation without attempted external cephalic version, suggesting that at least a subset of placenta accreta spectrum cases may be preventable. This was particularly true for privately insured patients. These findings call for continued investigation of potentially preventable primary cesarean sections with initiatives to address concerns at the patient, provider, and hospital level. KEY POINTS: · Many patients with placenta accreta spectrum have potentially preventable primary cesarean sections.. · Privately insured patients are more likely to have potentially preventable primary cesarean sections.. · Our findings suggest that at least a subset of placenta accreta spectrum cases may be preventable..

Anal endosonographic assessment of the accuracy of clinical diagnosis of obstetric anal sphincter injury.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injuries (OASIS) are a common cause of maternal morbidity with an overall incidence in the UK of 2.9% (range 0-8%). They can cause a range of physical symptoms and psychological distress. This study aims to assess the accuracy of clinical diagnosis of OASIS using endoanal ultrasound (EAUS) and the correlation between confirmed injury and change to anorectal physiology squeeze pressure and the incidence of bowel symptoms. METHODS AND MATERIALS: Retrospective study of prospectively collected data from 1135 women who attended the Third- and Fourth-Degree Tears Clinic at our institution, 12 weeks post-delivery, between June 2008 and October 2019. RESULTS: OASIS was confirmed in 876 (78.8%) women and 236 (21.3%) had no injury. Of the women who underwent anorectal physiology, 45.6% had a mean maximal resting pressure below the normal range and 68.8% had a mean incremental squeeze pressure below normal. Women with confirmed OASIS had significantly lower pressures (p < 0.001) than those without a confirmed sphincter injury. Three hundred ninety-three (34.8%) women reported bowel symptoms, with those with endosonographic evidence of injury more likely to develop flatus incontinence. CONCLUSION: Of the women in this study with a suspected OASIS, 21.2% could be reassured that they did not have an injury. This information is useful for women considering future mode of delivery. Those with confirmed injury are more likely to complain of flatus incontinence and have reduced anal sphincter pressures.

Prospective assessment of vacuum deliveries from midpelvic station in a tertiary care university hospital: Frequency, failure rates, labor characteristics and maternal and neonatal complications.

BACKGROUND: Midpelvic vacuum extractions are controversial due to reports of increased risk of maternal and perinatal morbidity and high failure rates. Prospective studies of attempted midpelvic vacuum outcomes are scarce. Our main aims were to assess frequency, failure rates, labor characteristics, maternal and neonatal complications of attempted midpelvic vacuum deliveries, and to compare labor characteristics and complications between successful and failed midpelvic vacuum deliveries. STUDY DESIGN: Clinical data were obtained prospectively from all attempted vacuum deliveries (n = 891) over a one-year period with a total of 6903 births (overall cesarean section rate 18.2% (n = 1258). Student's t-test, Mann-Whitney U-test or Chi-square test for group differences were used as appropriate. Odds ratios and 95% confidence intervals are given as indicated. The uni- and multivariable analysis were conducted both as a complete case analysis and with a multiple imputation approach. A p-value of <0.05 was considered statistically significant. RESULTS: Attempted vacuum extractions from midpelvic station constituted 36.7% (n = 319) of all attempted vacuum extractions (12.9% (n = 891) of all births). Of these 319 midpelvic vacuum extractions, 11.3% (n = 36) failed and final delivery mode was cesarean section in 86.1% (n = 31) and forceps in the remaining 13.9% (n = 5). Successful completion of midpelvic vacuum by 3 pulls or fewer was achieved in 67.1%. There were 3.9% third-degree and no fourth-degree perineal tears. Cup detachments were associated with a significantly increased failure rate (adjusted OR 6.13, 95% CI 2.41-15.56, p< 0.001). CONCLUSION: In our study, attempted midpelvic vacuum deliveries had relatively low failure rate, the majority was successfully completed within three pulls and they proved safe to perform as reflected by a low rate of third-degree perineal tears. We provide data for nuanced counseling of women on vacuum extraction as a second stage delivery option in comparable obstetric management settings with relatively high vacuum delivery rates and low cesarean section rates.

Obstetric hemorrhage risk assessment tool predicts composite maternal morbidity.

Obstetric hemorrhage is one of the leading preventable causes of maternal mortality in the United States. Although hemorrhage risk-prediction models exist, there remains a gap in literature describing if these risk-prediction tools can identify composite maternal morbidity. We investigate how well an established obstetric hemorrhage risk-assessment tool predicts composite hemorrhage-associated morbidity. We conducted a retrospective cohort analysis of a multicenter database including women admitted to Labor and Delivery from 2016 to 2018, at centers implementing the Association of Women's Health, Obstetric, and Neonatal Nurses risk assessment tool on admission. A composite morbidity score incorporated factors including obstetric hemorrhage (estimated blood loss ≥ 1000 mL), blood transfusion, or ICU admission. Out of 56,903 women, 14,803 (26%) were categorized as low-risk, 26,163 (46%) as medium-risk and 15,937 (28%) as high-risk for obstetric hemorrhage. Composite morbidity occurred at a rate of 2.2%, 8.0% and 11.9% within these groups, respectively. Medium- and high-risk groups had an increased combined risk of composite morbidity (diagnostic OR 4.58; 4.09-5.13) compared to the low-risk group. This established hemorrhage risk-assessment tool predicts clinically-relevant composite morbidity. Future randomized trials in obstetric hemorrhage can incorporate these tools for screening patients at highest risk for composite morbidity.

Indications and outcomes of emergency obstetric hysterectomy; a 5-year review at the Bafoussam Regional Hospital, Cameroon.

BACKGROUND: Emergency Obstetric Hysterectomy (EOH) is removal of the uterus due to life threatening conditions within the puerperium. This life saving intervention is associated with life threatening complications. In our setting, little is known on EOH. OBJECTIVES: To determine the prevalence, indications and outcomes of emergency obstetric hysterectomy while comparing both postpartum hysterectomy and caesarean hysterectomy. METHODS: A 5-year hospital-based retrospective cohort study involving medical records of patients who underwent emergency obstetric hysterectomies between 1st January 2015 and 31st December 2019, was carried out at the Bafoussam Regional Hospital (BRH) from 1st February 2020 to 30th April 2020. Cases were classified as caesarean hysterectomy (CH) or postpartum hysterectomy (PH). Epidemiological data, indications, and complications of EOH were collected and analyzed in EPI-INFO 7.2.2.1. The chi-squared test was used to compare the two groups, and bivariate analysis was used to identify indicators of adverse outcomes of EOH. Statistical significance was set at p < 0.05. RESULTS: There were 30 cases of emergency obstetric hysterectomy (24 caesarean hysterectomies and 6 postpartum hysterectomies), giving a prevalence rate of 3.75 per 1000 deliveries. The most common indication for CH, was intractable postpartum haemorrhage and uterine rupture (33.33% each), while abnormal placentation (50%) was commonly indicated for PH. Anaemia (both groups) (p = 0.013) and sepsis (PH group only, 33.33%) (p = 0.03) were the most statistically significant complications of EOH respectively. Absence of blood transfusion prior to surgery (p = 0.013) and prolonged surgery lasting 2 or more hours (p = 0.04), were significantly associated with a negative clinical outcome. CONCLUSION: The prevalence of EOH is high. There were no differences in the sociodemographic profile, risk factors and indications of both groups. PH group was more likely to develop sepsis as complication. Lack of blood transfusion prior to surgery and prolonged surgeries were significantly associated to complication. Meticulous care and timely recognition of negative prognostic factors of delivery as well as those of EOH will help improve maternal outcomes of pregnancy.

Comparison of Childbirth Delivery Outcomes and Costs of Care Between Women Experiencing vs Not Experiencing Homelessness.

Importance: Women and families constitute the fastest-growing segments of the homeless population. However, there is limited evidence on whether women experiencing homelessness have poorer childbirth delivery outcomes and higher costs of care compared with women not experiencing homelessness. Objective: To compare childbirth delivery outcomes and costs of care between pregnant women experiencing homelessness vs those not experiencing homelessness. Design, Setting, and Participants: This cross-sectional study included 15 029 pregnant women experiencing homelessness and 308 242 pregnant women not experiencing homelessness who had a delivery hospitalization in 2014. The study used statewide databases that included all hospital admissions in 3 states (ie, Florida, Massachusetts, and New York). Delivery outcomes and delivery-associated costs were compared between pregnant women experiencing homelessness and those not experiencing homelessness cared for at the same hospital (analyzed using the overlap propensity-score weighting method and multivariable regression models with hospital fixed effects). The Benjamini-Hochberg false discovery rate procedure was used to account for multiple comparisons. Data were analyzed from January 2020 through May 2020. Exposure: Housing status at delivery hospitalization. Main Outcomes and Measures: Outcome variables included obstetric complications (ie, antepartum hemorrhage, placental abnormalities, premature rupture of the membranes, preterm labor, and postpartum hemorrhage), neonatal complications (ie, fetal distress, fetal growth restriction, and stillbirth), delivery method (ie, cesarean delivery), and delivery-associated costs. Results: Among 15 029 pregnant women experiencing homelessness (mean [SD] age, 28.5 [5.9] years) compared with 308 242 pregnant women not experiencing homelessness (mean [SD] age, 29.4 [5.8] years) within the same hospital, those experiencing homelessness were more likely to experience preterm labor (adjusted probability, 10.5% vs 6.7%; adjusted risk difference [aRD], 3.8%; 95% CI, 1.2%-6.5%; adjusted P = .03) and had higher delivery-associated costs (adjusted costs, $6306 vs $5888; aRD, $417; 95% CI, $156-$680; adjusted P = .02) compared with women not experiencing homelessness. Those experiencing homelessness also had a higher probability of placental abnormalities (adjusted probability, 4.0% vs 2.0%; aRD, 1.9%; 95% CI, 0.4%-3.5%; adjusted P = .053), although this difference was not statistically significant. Conclusions and Relevance: This study found that women experiencing homelessness, compared with those not experiencing homelessness, who had a delivery and were admitted to the same hospital were more likely to experience preterm labor and incurred higher delivery-associated costs. These findings suggest wide disparities in delivery-associated outcomes between women experiencing homelessness and those not experiencing homelessness in the US. The findings highlight the importance for health care professionals to actively screen pregnant women for homelessness during prenatal care visits and coordinate their care with community health programs and social housing programs to make sure their health care needs are met.

Prevalence and risk factors of severe postpartum hemorrhage: a retrospective cohort study.

BACKGROUND: Although maternal deaths are rare in developed regions, the morbidity associated with severe postpartum hemorrhage (SPPH) remains a major problem. To determine the prevalence and risk factors of SPPH, we analyzed data of women who gave birth in Guangzhou Medical Centre for Critical Pregnant Women, which received a large quantity of critically ill obstetric patients who were transferred from other hospitals in Southern China. METHODS: In this study, we conducted a retrospective case-control study to determine the prevalence and risk factors for SPPH among a cohort of women who gave birth after 28 weeks of gestation between January 2015 and August 2019. SPPH was defined as an estimated blood loss ≥1000 mL and total blood transfusion≥4 units. Logistic regression analysis was used to identify independent risk factors for SPPH. RESULTS: SPPH was observed in 532 mothers (1.56%) among the total population of 34,178 mothers. Placenta-related problems (55.83%) were the major identified causes of SPPH, while uterine atony without associated retention of placental tissues accounted for 38.91%. The risk factors for SPPH were maternal age < 18 years (adjusted OR [aOR] = 11.52, 95% CI: 1.51-87.62), previous cesarean section (aOR = 2.57, 95% CI: 1.90-3.47), history of postpartum hemorrhage (aOR = 4.94, 95% CI: 2.63-9.29), conception through in vitro fertilization (aOR = 1.78, 95% CI: 1.31-2.43), pre-delivery anemia (aOR = 2.37, 95% CI: 1.88-3.00), stillbirth (aOR = 2.61, 95% CI: 1.02-6.69), prolonged labor (aOR = 5.24, 95% CI: 3.10-8.86), placenta previa (aOR = 9.75, 95% CI: 7.45-12.75), placenta abruption (aOR = 3.85, 95% CI: 1.91-7.76), placenta accrete spectrum (aOR = 8.00, 95% CI: 6.20-10.33), and macrosomia (aOR = 2.30, 95% CI: 1.38-3.83). CONCLUSION: Maternal age < 18 years, previous cesarean section, history of PPH, conception through IVF, pre-delivery anemia, stillbirth, prolonged labor, placenta previa, placental abruption, PAS, and macrosomia were risk factors for SPPH. Extra vigilance during the antenatal and peripartum periods is needed to identify women who have risk factors and enable early intervention to prevent SPPH.

Temporal trend of near miss and its regional variations in Brazil from 2010 to 2018 / Tendência temporal do near miss e suas variações regionais no Brasil de 2010 a 2018

Abstract Cases of maternal near miss are those in which women survive severe maternal complications during pregnancy or the puerperium. This ecological study aimed to identify the temporal trend of near-miss cases in different regions of Brazil between 2010 and 2018, using data fromtheHospital Information System(HIS) of theUnified BrazilianHealth System (SUS, in the Portuguese acronym). Hospital admission records of women between 10 and 49 years old with diagnosis included in the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and codes indicating nearmiss events were selected. From 20,891,040 admissions due to obstetric causes, 766,249 (3.66%) near-miss cases were identified, and 31,475 women needed admission to the intensive care unit (ICU). The cases were found to be more predominant in black women over 35 years old from the North and Northeast regions. There was a trend of increase in near-miss rates of ~ 13.5% a year during the period of the study. The trend presented a different behavior depending on the level of development of the region studied. The main causes of near miss were preeclampsia (47%), hemorrhage (24%), and sepsis (18%).

Resumo Casos de near miss materna são aqueles em que as mulheres sobrevivem a graves complicações maternas durante a gravidez ou o puerpério. Este estudo ecológico teve comoobjetivo identificar a tendência temporal de casos de near missemdiferentes regiões do Brasil entre 2010 e 2018, utilizando dados do Sistema de Informações Hospitalares (SIH) do Sistema Único de Saúde (SUS). Foram selecionados registros de internação demulheres entre 10 e 49 anos comdiagnóstico incluído na 10ª revisão daClassificação Internacional de Doenças e Problemas Relacionados à Saúde (CID-10) e códigos indicando eventos de near miss. Das 20.891.040 internações por causas obstétricas, 766.249 (3,66%) casos de near miss foram identificados, e 31.475mulheres necessitaramde internação na unidade de terapia intensive (UTI). Constatou-sequeos casos sãomaispredominantesemmulheres negras commais de 35 anos da região Norte e Nordeste. Houve uma tendência de aumento nas taxas de near miss de aproximadamente 13,5% ao ano durante o período do estudo. A tendência apresentou um comportamento diferente, dependendo do nível de desenvolvimento da região estudada. As principais causas de near miss foram pré-eclâmpsia (47%), hemorragia (24%), e sepse (18%).

Temporal Trend of Near Miss and its Regional Variations in Brazil from 2010 to 2018.

Cases of maternal near miss are those in which women survive severe maternal complications during pregnancy or the puerperium. This ecological study aimed to identify the temporal trend of near-miss cases in different regions of Brazil between 2010 and 2018, using data from the Hospital Information System (HIS) of the Unified Brazilian Health System (SUS, in the Portuguese acronym). Hospital admission records of women between 10 and 49 years old with diagnosis included in the 10th Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and codes indicating near-miss events were selected. From 20,891,040 admissions due to obstetric causes, 766,249 (3.66%) near-miss cases were identified, and 31,475 women needed admission to the intensive care unit (ICU). The cases were found to be more predominant in black women over 35 years old from the North and Northeast regions. There was a trend of increase in near-miss rates of ∼ 13.5% a year during the period of the study. The trend presented a different behavior depending on the level of development of the region studied. The main causes of near miss were preeclampsia (47%), hemorrhage (24%), and sepsis (18%).

Casos de near miss materna são aqueles em que as mulheres sobrevivem a graves complicações maternas durante a gravidez ou o puerpério. Este estudo ecológico teve como objetivo identificar a tendência temporal de casos de near miss em diferentes regiões do Brasil entre 2010 e 2018, utilizando dados do Sistema de Informações Hospitalares (SIH) do Sistema Único de Saúde (SUS). Foram selecionados registros de internação de mulheres entre 10 e 49 anos com diagnóstico incluído na 10ª revisão da Classificação Internacional de Doenças e Problemas Relacionados à Saúde (CID-10) e códigos indicando eventos de near miss. Das 20.891.040 internações por causas obstétricas, 766.249 (3,66%) casos de near miss foram identificados, e 31.475 mulheres necessitaram de internação na unidade de terapia intensive (UTI). Constatou-se que os casos são mais predominantes em mulheres negras com mais de 35 anos da região Norte e Nordeste. Houve uma tendência de aumento nas taxas de near miss de aproximadamente 13,5% ao ano durante o período do estudo. A tendência apresentou um comportamento diferente, dependendo do nível de desenvolvimento da região estudada. As principais causas de near miss foram pré-eclâmpsia (47%), hemorragia (24%), e sepse (18%).

Birth hospital and racial and ethnic differences in severe maternal morbidity in the state of California.

BACKGROUND: Birth hospital has recently emerged as a potential key contributor to disparities in severe maternal morbidity, but investigations on its contribution to racial and ethnic differences remain limited. OBJECTIVE: We leveraged statewide data from California to examine whether birth hospital explained racial and ethnic differences in severe maternal morbidity. STUDY DESIGN: This cohort study used data on all births at ≥20 weeks gestation in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least 1 of the 21 diagnoses and procedures (eg, eclampsia, blood transfusion, hysterectomy). Mixed-effects logistic regression models (ie, women nested within hospitals) were used to compare racial and ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, comorbidities, and hospital characteristics. We also estimated the risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percentage reduction in severe maternal morbidity if each group of racially and ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic white women. RESULTS: Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian and Pacific Islander; 1.1% white; 1.6% American Indian and Alaska Native, and Mixed-race referred to as Other). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, the odds of severe maternal morbidity were greater among nonwhite women than white women in a given hospital (Black: odds ratio, 1.25; 95% confidence interval, 1.19-1.31); US-born Hispanic: odds ratio, 1.25; 95% confidence interval, 1.20-1.29; foreign-born Hispanic: odds ratio, 1.17; 95% confidence interval, 1.11-1.24; Asian and Pacific Islander: odds ratio, 1.26; 95% confidence interval, 1.21-1.32; Other: odds ratio, 1.31; 95% confidence interval, 1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of white women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared with 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and white women and accounted for 16.1% to 24.2% of the differences for all other racial and ethnic groups. CONCLUSION: In California, excess odds of severe maternal morbidity among racially and ethnically minoritized women were not fully explained by birth hospital. Structural causes of racial and ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.

Burden of stillbirths and associated factors in Yirgalem Hospital, Southern Ethiopia: a facility based cross-sectional study.

BACKGROUND: Stillbirth is an adverse pregnancy outcome of public health importance causing considerable psychosocial burden on parents and their family. Studies on stillbirth are scarce in southern Ethiopia. An assessment of stillbirths and associated factors in health care settings helps in devising strategies for tailored interventions. Therefore, we assessed the burden of stillbirths and associated factors in Yirgalem Hospital, southern Ethiopia. METHODS: A facility based cross-sectional study was conducted between 1 and 2015 and 30 July 2016. We randomly selected medical records of pregnant women from a hospital delivery registry. Bivariate analysis was employed to assess the association between independent and dependent variables using chi-square with significant p-value. Multivariate logistic regression was used to identify independent risk factors for stillbirths and to control for confounding variables. RESULTS: Of 374 reviewed records of pregnant women, 370 were included for the study. The magnitude of stillbirths was 92 per 1000 births. Fifteen (44.1%) of fetal deaths occurred after admission to the hospital. In multivariate logistic regression, stillbirths were higher among low birth-weight babies (< 2500grams) (adjusted odds ratio (AOR): 10.70, 95% CI 3.18-35.97) than normal birth-weight babies (2500-<4000). Pregnant women who experienced a prolonged labour for more than 48 hours were 12 times (AOR: 12.15, 95% CI 1.76-84.12) more likely to have stillbirths than pregnant women without a prolonged labour. Pregnant women with obstetric complications were 18.9 times more likely to have stillbirths than pregnant women without obstetric complications. Similarly, pregnant women with at least two pregnancies were more likely to have stillbirths than pregnant women with less than two pregnancies (AOR: 4.39, 95% CI 1.21-15.85). CONCLUSIONS: We found a high burden of stillbirths in the study setting. Modifiable risk factors contributed to a higher risk of stillbirths; therefore, tailored interventions such as early identification and management of prolonged labour and obstetric complication at each level of health system could avert preventable stillbirths.