Point-of-Care Ultrasound in Critical Care Obstetrics: A Scoping Review of the Current Evidence.

OBJECTIVES: To synthesize the current evidence of maternal point-of-care ultrasound (POCUS) in obstetrics. A scoping review was conducted using PubMed, Clinicaltrials.gov, and the Cochrane library from inception through October 2023. METHODS: Studies were eligible for inclusion if they described the use of POCUS among obstetric or postpartum patients. Two authors independently screened all abstracts. Quantitative, qualitative, and mixed-methods studies were eligible for inclusion. Case reports of single cases, review articles, and expert opinion articles were excluded. Studies describing detailed maternal nonobstetric sonograms or maternal first trimester sonograms to confirm viability and rule out ectopic pregnancy were also excluded. Data were tabulated using Microsoft Excel and summarized using a narrative review and descriptive statistics. RESULTS: A total of 689 publications were identified through the search strategy and 12 studies met the inclusion criteria. Nine studies evaluated the use of lung POCUS in obstetrics in different clinical scenarios. Lung ultrasound (LUS) findings in preeclampsia showed an excellent ability to detect pulmonary edema (area under the receiver operating characteristic 0.961) and findings were correlated with clinical evidence of respiratory distress (21 of 57 [37%] versus 14 of 109 [13%]; P = .001). Three studies evaluated abdominal POCUS, two of the inferior vena cava (IVC) to predict postspinal anesthesia hypotension (PSAH) and fluid receptivity and one to assess the rate of ascites in patients with preeclampsia. Patients with PSAH had higher IVC collapsibility (area under the curve = 0.950, P < .001) and, in patients with severe preeclampsia, there is a high rate of ascites (52%) associated with increased risk of adverse outcomes. There were no studies on the use of subjective cardiac POCUS. CONCLUSION: POCUS use in the management of high-risk obstetrics has increased. LUS has been the most studied modality and appears to have a potential role in the setting of preeclampsia complicated by pulmonary edema. Cardiac and abdominal POCUS have not been well studied. Trials are needed to evaluate its clinical applicability, reliability, and technique standardization before widespread use.

Neonatal Outcomes among Fetuses with an Abdominal Circumference <3rd %ile and Estimated Fetal Weight 3rd to 9th %ile Compared to Fetuses with an EFW <3rd %ile.

OBJECTIVE: Fetal growth restriction (FGR) is defined as an estimated fetal weight (EFW) or abdominal circumference (AC) <10th percentile (%ile) for gestational age (GA). An EFW <3rd %ile for GA is considered severe FGR (sFGR). It remains unknown if fetuses with isolated AC <3rd %ile should be considered sFGR. Our primary objective was to assess composite neonatal outcomes in fetuses with an AC <3rd %ile and overall EFW 3rd to 9th %ile compared with those with an EFW <3rd %ile. STUDY DESIGN: This retrospective cohort study was undertaken at a tertiary academic center from January 2016 to December 2021. Inclusion criteria were singleton fetuses with an EFW <3rd %ile (Group 1) or AC <3rd %ile with EFW 3rd to 9th %ile (Group 2) at 28 weeks' gestation or greater. Exclusion criteria were multiple gestations, presence of a major fetal anomaly, resolution of FGR, genetic syndrome, or infection. Composite neonatal outcome was defined by any of the following: neonatal intensive care unit admission >48 hours, necrotizing enterocolitis, sepsis, respiratory distress syndrome, mechanical ventilation, retinopathy of prematurity, seizures, intraventricular hemorrhage, stillbirth, or death before discharge. Small for gestational age (SGA) was defined as birth weight <10th %ile for GA. RESULTS: A total of 743 patients fulfilled our study criteria, with 489 in Group 1 and 254 in Group 2. The composite neonatal outcome occurred in 281 (57.5%) neonates in Group 1 and 53 (20.9%) in Group 2 (p < 0.01). The rates of SGA at birth were 94.9 and 75.6% for Group 1 and Group 2, respectively (OR 5.99, 95% confidence interval 3.65-9.82). CONCLUSION: Although AC <3rd %ile with EFW 3rd to 9th %ile is associated with a lower frequency of SGA and neonatal morbidity than EFW <3 %ile, fetuses with AC <3 %ile still exhibited moderate rates of these adverse perinatal outcomes. Consideration should be given to inclusion of an AC <3rd %ile with EFW 3rd to 9th %ile as a criterion for sFGR. However, prospective studies comparing delivery at 37 versus 38 to 39 weeks' gestation are needed to ensure improved outcomes before widespread adaptation in clinical practice. KEY POINTS: · The composite neonatal outcome occurred in 57.5% of fetuses with an overall EFW <3rd %ile and 20.9% of fetuses with an AC <3rd %ile but EFW 3rd to 9th %ile.. · Both groups demonstrated a high positive predictive value for SGA birth weight.. · Consideration should be given to inclusion of an AC <3rd %ile as a criterion for sFGR..

Low-dose aspirin therapy for the prevention of preeclampsia: time to reconsider our recommendations?

The American College of Obstetricians and Gynecologists recommends initiation of 81 mg of aspirin daily for women at risk of preeclampsia between 12 and 28 weeks' gestation, optimally before 16 weeks, with continuation until delivery. The World Health Organization recommends that 75 mg of aspirin should be initiated before 20 weeks of gestation for women at high risk of preeclampsia. Both the Royal College of Obstetricians and Gynaecologists and the National Institute of Health and Care Excellence quality statement on "Antenatal Assessment of Pre-eclampsia Risk" request that healthcare providers prescribe low-dose aspirin to pregnant women at increased risk of preeclampsia daily from 12 weeks of gestation. The Royal College of Obstetricians and Gynaecologists recommends 150 mg of aspirin daily, and the National Institute of Health and Care Excellence guidelines suggest risk stratification with a dosage of 75 mg for those at moderate risk of preeclampsia and 150 mg for those at high risk of preeclampsia. The International Federation of Gynecology and Obstetrics initiative on preeclampsia recommends 150 mg of aspirin to be initiated at 11 to 14+6 week's gestation and also proposes that 2 tablets of 81 mg is an acceptable alternative. Review of the available evidence suggests that both the dosage and timing of aspirin initiation is key to its effectiveness at reducing the risk of preeclampsia. Doses of >100 mg of aspirin daily initiated before 16 weeks' gestation seem to be most effective at reducing the risk of preeclampsia and thus dosages recommended by most major societies and organizations may not be effective. Randomized control trials examining 81 mg vs 162 mg of aspirin daily for the prevention of preeclampsia are required to assess the safety and efficacy of aspirin dosages available in the United States.

Artificial intelligence in obstetric ultrasound: A scoping review.

The objective is to summarize the current use of artificial intelligence (AI) in obstetric ultrasound. PubMed, Cochrane Library, and ClinicalTrials.gov databases were searched using the following keywords "neural networks", OR "artificial intelligence", OR "machine learning", OR "deep learning", AND "obstetrics", OR "obstetrical", OR "fetus", OR "foetus", OR "fetal", OR "foetal", OR "pregnancy", or "pregnant", AND "ultrasound" from inception through May 2022. The search was limited to the English language. Studies were eligible for inclusion if they described the use of AI in obstetric ultrasound. Obstetric ultrasound was defined as the process of obtaining ultrasound images of a fetus, amniotic fluid, or placenta. AI was defined as the use of neural networks, machine learning, or deep learning methods. The authors' search identified a total of 127 papers that fulfilled our inclusion criteria. The current uses of AI in obstetric ultrasound include first trimester pregnancy ultrasound, assessment of placenta, fetal biometry, fetal echocardiography, fetal neurosonography, assessment of fetal anatomy, and other uses including assessment of fetal lung maturity and screening for risk of adverse pregnancy outcomes. AI holds the potential to improve the ultrasound efficiency, pregnancy outcomes in low resource settings, detection of congenital malformations and prediction of adverse pregnancy outcomes.

Economic Analysis of Induction versus Elective Cesarean in Term Nulliparas with Supermorbid Obesity.

OBJECTIVE: We sought to evaluate the economic benefit of the induction of labor compared with elective cesarean delivery in individuals with supermorbid obesity (body mass index 60 kg/m2 or greater) at term. STUDY DESIGN: We developed an economic analysis model to compare induction of labor with elective cesarean delivery in nulliparous individuals with supermorbid obesity at term. The primary outcome was the total cost per strategy from a health system perspective with elective cesarean delivery as a reference group. Pregnancy outcomes for the index and subsequent pregnancies were considered. When available, probabilities of pregnancy outcomes were extracted from our institutions. Rare pregnancy outcomes, relative risks, and costs were derived from the literature. All costs in this analysis were inflated to 2022 USD (U.S. dollar). To determine the robustness of the decision model, we conducted one-way sensitivity analyses by changing point estimates of variables. We then performed a probabilistic sensitivity analysis using Monte Carlo simulation repeating 1,000 times to test the robustness of the results in the setting of simultaneous changes in probabilities, relative risks, and costs. RESULTS: In the base-case analysis, assuming that 72.7% of nulliparous individuals undergoing induction of labor would have a cesarean delivery, induction of labor would cost $41,084 compared with $40,742 for elective cesarean delivery, resulting in a higher cost of $342 per nulliparous individuals with supermorbid obesity. In a sensitivity analysis, we found that induction of labor compared with elective cesarean is less economical if the probability of cesarean delivery after induction of labor exceeds 71%. Monte Carlo simulation suggests that elective cesarean delivery was the preferred cost-beneficial strategy with a frequency of 53.5%. CONCLUSION: Among our patient population, induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals with supermorbid obesity. KEY POINTS: · The prevalence of obesity in the United States continues to rise.. · Morbid obesity compared with normal weight is associated with increased risks of adverse pregnancy outcomes.. · Induction of labor was less economical compared with elective cesarean delivery at term for nulliparous individuals..

Trial of labor after two cesarean sections: A retrospective case-control study.

AIM: The objective of this study was to compare neonatal and maternal outcomes among women with two previous cesarean deliveries who undergo trial of labor after two cesarean section (TOLA2C) versus elective repeat cesarean delivery (ERCD). Our primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes included APGAR score <7 at 5 min, TOLA2C success rate, uterine rupture, postpartum hemorrhage, maternal blood transfusion, maternal bowel and bladder injury, immediate postpartum infection, and maternal mortality. METHODS: This retrospective cohort study was undertaken at a community medical center from January 1, 2008 to December 31, 2018. Inclusion criteria were women with a vertex singleton gestation at term and a history of two prior cesarean sections. Exclusion criteria included a previous successful TOLA2C, prior classical uterine incision or abdominal myomectomy, placenta previa or invasive placentation, multiple gestation, nonvertex presentation, history of uterine rupture or known fetal anomaly. Maternal and neonatal outcomes were assessed using Fisher exact test and Wilcoxon rank sum test. RESULTS: A total of 793 patients fulfilled study criteria. There were no differences in neonatal intensive care unit admissions or 5-min APGAR scores <7 between the two groups. Sixty-eight percent of women who underwent TOLAC (N = 82) had a successful vaginal delivery. The uterine rupture rate was 1.16% (N = 1) in the TOLA2C group with no case of uterine rupture in the ERCD group. No difference in maternal morbidity was noted between the two groups. No maternal or neonatal mortalities occurred in either group. CONCLUSIONS: There was no difference in maternal or neonatal morbidity among patients in our study population with two previous cesarean sections who opted for TOLA2C versus ERCD.

Understanding New Recommendations for Respiratory Syncytial Virus Prevention in Pregnancy.

Respiratory syncytial virus (RSV) is a significant cause of infant morbidity and mortality worldwide with peak hospitalization rates for RSV-mediated illnesses between 2 and 3 months of life. Until very recently, prevention strategies for RSV involved primarily passive immunization of neonates at high risk with monoclonal antibodies and promotion of breastfeeding. The Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices now recommends passive immunization of all neonates with monoclonal antibodies during RSV season, and the American Association of Pediatrics has endorsed this practice. The U.S. Food and Drug Administration (FDA) recently approved a vaccination for RSV in pregnancy. The CDC's Advisory Committee on Immunization Practices has recently recommended RSV vaccination for all pregnant patients between 32 and 36 weeks of gestation who are anticipated to deliver during RSV season if they are not planning nirsevimab for their infants. This recommendation has been endorsed by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. In this clinical perspective, we review the scientific evidence, potential concerns, challenges, and future considerations for RSV vaccination in pregnancy.

Abdominal Fibromyxoid Sarcoma in Pregnancy: An Unusual Cause of Preterm Labor and Sepsis.

Cancer in pregnancy is rare, with incidence less than 1%, and the most common cancers being melanoma, breast, and cervical cancers. Fibromyxoid sarcoma is a soft tissue tumor involving deep soft tissues of the extremities and trunk, rarely located in the abdomen. A low-grade fibromyxoid sarcoma (LGFMS) falls in the family of fibrosarcoma. Only two cases of LGFMS in pregnancy have been reported. We report a case of abdominal LGFMS in pregnancy leading to preterm labor, sepsis, and an acute abdomen requiring surgery in the third trimester. A 19-year-old woman, gravida 1 at 32 weeks and 5 days presented to an outside hospital with preterm contractions and cervical effacement. She had a known abdominal mass, suspected to be accessory liver lobe, measuring 9.0 × 6.4 × 7.7 cm in the right upper quadrant. At 33 weeks of gestation, she developed fever and hypotension. Magnetic resonance imaging confirmed the presence of the mass, which was now on the left side of the abdomen and associated with a suspected abscess. She underwent cesarean delivery, and complete surgical resection of the mass along with a small bowel resection. Final pathology of the mass revealed a LGFMS. This case also highlights the need for a multidisciplinary approach to manage a rare presentation of sepsis and preterm labor in pregnancy.

ChatGPT in maternal-fetal medicine practice: a primer for clinicians.

ChatGPT (Generative Pre-trained Transformer), a language model that was developed by OpenAI and launched in November 2022, generates human-like responses to prompts using deep-learning technology. The integration of large language processing models into healthcare has the potential to improve the accessibility of medical information for both patients and health professionals alike. In this commentary, we demonstrated the ability of ChatGPT to produce patient information sheets. Four board-certified, maternal-fetal medicine attending physicians rated the accuracy and humanness of the information according to 2 predefined scales of accuracy and completeness. The median score for accuracy of information was rated 4.8 on a 6-point scale and the median score for completeness of information was 2.2 on a 3-point scale for the 5 patient information leaflets generated by ChatGPT. Concerns raised included the omission of clinically important information for patient counseling in some patient information leaflets and the inability to verify the source of information because ChatGPT does not provide references. ChatGPT is a powerful tool that has the potential to enhance patient care, but such a tool requires extensive validation and is perhaps best considered as an adjunct to clinical practice rather than as a tool to be used freely by the public for healthcare information.

Continuous Glucose Monitoring in Pregnancy.

Diabetes mellitus in pregnancy is associated with adverse maternal and neonatal outcomes. Optimal glycemic control is associated with improved outcomes. Continuous glucose monitoring is a less invasive alternative to blood glucose measurements. Two types of continuous glucose monitoring are available in the market: real time and intermittently scanned. Continuous glucose monitoring is gaining popularity and is now recommended by some societies for glucose monitoring in pregnant women. In this review, we discuss the differences between the two types of continuous glucose monitoring, optimal treatment goals, and whether there is an improvement in maternal or neonatal outcomes.

Propranolol to decrease time to delivery: a meta-analysis of randomized controlled trials.

OBJECTIVE: To assess the effect of propranolol on time to delivery among patients undergoing induction or augmentation of labor. DATA SOURCES: PubMed, Scopus, Cochrane Library, ClinicalTrials.gov, and CINAHL (EBSCO) were searched from inception to December 2023. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials (RCTs) that examined the impact of propranolol on time to delivery among patients undergoing induction or augmentation of labor were included. RCTs that included stillbirth before randomization, non-randomized trials, observational, cohort, case control, or studies in which the control group included an intervention other than standard care were excluded. STUDY APPRAISAL AND SYNTHESIS METHODS: Primary outcome was time to delivery after administration of propranolol among patients undergoing induction or augmentation of labor. The summary measures were reported as summary mean difference (MD) or relative risk with 95% confidence interval (CI). RESULTS: Nine RCTs including 1,182 patients were included in this meta-analysis. Five studies investigated the effect of propranolol among patients undergoing induction of labor (IOL) and demonstrated a significant decrease in time to delivery (MD, -91.5 minutes, 95% CI -110.6 to -72.4). Four studies investigated the effect of propranolol among patients undergoing augmentation of labor and showed no significant decrease in time to delivery (MD, -2.98 minutes, 95% CI -21.6 to 15.6). Our pooled analysis demonstrated that the use of propranolol in IOL and augmentation was associated with a decrease in time to delivery from administration of propranolol compared to placebo (mean difference, -46.15 minutes, 95% CI -59.48 to -32.81). The meta-analysis found no increased risk of PPH, blood transfusion, cesarean delivery rates, or NICU admission with the use of propranolol during labor. CONCLUSION: The use of propranolol during induction of labor shortens overall time to delivery by about 91 minutes and did not significantly decrease time to delivery in those undergoing augmentation of labor.

Pregnancy outcomes among patients with stage 1 chronic hypertension.

In recent years, the American College of Cardiology and the American Heart Association have reduced the thresholds for a hypertension diagnosis among nonpregnant adults. This change has led to more individuals with reproductive potential to be labeled as being chronically hypertensive, and some were started on antihypertensive medications. When these individuals become pregnant, the obstetrical care provider will have to decide whether to manage them as individuals with chronic hypertensive when only a few years ago they would have been managed as normotensive individuals and when the evidence regarding treatment of these patients during pregnancy is limited. If implemented widely, the management of patients with stage 1 hypertension similar to the traditional chronic hypertension will likely lead to additional maternal and fetal testing, to an increase in hospital admissions, and potentially to unnecessary interventions, such as preterm birth. Our goal was to compile the existing evidence regarding the pregnancy outcomes among patients with stage 1 hypertension to assist providers in their diagnosis and management of this patient group.

Early vs. delayed amniotomy in individuals undergoing pre-induction cervical ripening with transcervical Foley balloon: a meta-analysis.

OBJECTIVES: To systematically review randomized controlled trials (RCTs) and perform a meta-analysis comparing early amniotomy with delayed amniotomy in individuals undergoing pre-induction cervical ripening by Foley balloon. The primary outcome was the rate of cesarean delivery. Understanding the impact of the timing of amniotomy on the rate of cesarean delivery is crucial for obstetricians and healthcare providers when making decisions about the management of labor induction. DATA SOURCES: Data were sourced from electronic databases, including PubMed, OVID, Cochrane Library, Web of Science, and ClinicalTrials.gov through February 2024. The review adhered to Preferred Reporting Item for Systematic Reviews guidelines and registered with PROSPERO (ID CRD42023454520). STUDY ELIGIBILITY CRITERIA: Inclusion criteria comprised RCTs comparing early amniotomy with delayed amniotomy in individuals undergoing cervical ripening by Foley balloon. Early amniotomy was defined as amniotomy soon after cervical ripening. Delayed amniotomy was defined as withholding amniotomy until after the onset of the active phase of labor, until at least 4 hours from either initiation of oxytocin or Foley balloon removal/expulsion, or until achieving >4 cm of dilation. Participants included nulliparous or multiparous individuals with singleton pregnancies undergoing labor induction at 37 weeks or later. STUDY APPRAISAL AND SYNTHESIS: A systematic literature search was conducted using defined search terms including "early amniotomy," "delayed amniotomy," "induction of labor," "cervical ripening," and "Foley balloon," and "Foley catheter." The quality of the included trials was assessed using the Cochrane Risk of Bias Tool for randomized controlled trials. The primary outcome was cesarean delivery. Secondary outcomes included outcomes related to labor duration and neonatal outcomes. Pooled relative risks (RR) and weighted mean differences (WMD) with 95% confidence intervals were calculated. RESULTS: Five trials involving 849 participants undergoing induction and cervical ripening by Foley balloon were included. The rate of cesarean delivery did not differ between individuals randomly assigned to the early amniotomy group compared with those assigned to the delayed amniotomy group (22.9% vs. 23.3%; RR 1.00; 95% CI 0.65-1.55). Early amniotomy compared to delayed amniotomy was associated with a higher proportion of delivery within 24 hours (79.9% vs. 67.1%; RR 1.19; 95% CI 1.04-1.36). Early amniotomy compared with delayed amniotomy was associated with a shorter interval from oxytocin to delivery (WMD -1.5 hours; 95% CI -2.1 to -0.8), from Foley expulsion to vaginal delivery (WMD -2.5 hours; 95% CI -4.8 to -0.1), and from the start of oxytocin to vaginal delivery (WMD -1.8 hours; 95% CI -3.2 to -0.4). Other outcomes were not significantly different. CONCLUSION: Early amniotomy following cervical ripening by Foley balloon in individuals with singleton pregnancies did not impact rates of cesarean delivery compared with delayed amniotomy but led to shorter duration for various labor progress outcomes.

Intrahepatic cholestasis of pregnancy: a comparison of Society for Maternal-Fetal Medicine and the Royal College of Obstetricians and Gynaecologists' guidelines.

This study reviewed the literature regarding the diagnosis, antepartum surveillance, and timing of delivery of pregnancies complicated by intrahepatic cholestasis of pregnancy, comparing the guidelines published by the Society for Maternal-Fetal Medicine in February 2021 and those published by the Royal College of Obstetricians and Gynaecologists in the United Kingdom in June 2022. Several key differences exist in the clinical guidelines between the 2 organizations. With regard to the diagnosis of intrahepatic cholestasis of pregnancy, the Society for Maternal-Fetal Medicine considers any elevation in bile acids above the upper limit of normal in the setting of maternal pruritus diagnostic of intrahepatic cholestasis of pregnancy, whereas the Royal College of Obstetricians and Gynaecologists requires a pregnancy-specific elevated bile acid level of ≥19 mmol/L for diagnosis. Regarding the treatment of intrahepatic cholestasis of pregnancy, the Society for Maternal-Fetal Medicine recommends ursodeoxycholic acid as the first-line treatment of maternal symptoms. In contrast, the Royal College of Obstetricians and Gynaecologists specifically recommends against the routine use of ursodeoxycholic acid for intrahepatic cholestasis of pregnancy because of a lack of evidence regarding both maternal and fetal benefit. The Society for Maternal-Fetal Medicine recommends fetal surveillance at a gestational age when abnormal fetal testing would result in delivery being performed, whereas the Royal College of Obstetricians and Gynaecologists does not recommend any fetal testing beyond fetal kick count assessment. The Society for Maternal-Fetal Medicine recommends delivery at 36 to 39 weeks' gestation for intrahepatic cholestasis of pregnancy with bile acids <100 mmol/L and delivery at 36 weeks for bile acid levels >100 mmol/L. The Royal College of Obstetricians and Gynaecologists recommends serial assessment of bile acids with delivery timing stratified between 35- and 40-weeks' gestation according to bile acid levels.

Pregnancy in a Patient with Idiopathic Pulmonary Fibrosis: A Case Report.

Idiopathic pulmonary fibrosis (IPF) is a progressive restrictive lung disease. Data on the impact of pregnancy on IPF and maternal outcome is extremely limited. We present the case of a 35-year-old woman, gravida 1 para 0 with familial IPF with no oxygen requirement prior to pregnancy. The patient demonstrated significant deterioration in her lung function beginning at 22 weeks' gestation and underwent hospitalization at 27 2/7 weeks gestation due to acute on chronic hypoxic respiratory failure, ultimately requiring delivery at 28 weeks' gestation. The patient has not regained her baseline pulmonary function and remains oxygen dependent at 5 months postpartum. Based on limited available data, significant maternal morbidity and mortality is reported for women with IPF who become pregnant. Key Points Pregnancy outcomes in IPF are more severe than chronic interstitial lung disease due to connective tissue disorders.Deterioration in lung function amongst pregnant women with IPF occurs predominantly in the late second trimester, and lung function does not appear to recover postpartum.Significant maternal morbidity and mortality (40% at 1 year postpartum) is reported for women with IPF who become pregnant.

Implications for Prenatal Genetic Testing in the United States After the Reversal of Roe v Wade.

Prenatal genetic screening and diagnostic testing should be offered to every pregnant individual, with methods varying based on gestational age. Since Roe v Wade was overturned in June 2022, many states have implemented gestational age-based abortion restrictions. It is critical that reproductive health care professionals be aware of the interaction between the timing of genetic screening and diagnostic testing and the availability of legal abortion services in their state. We examined individual state abortion restrictions per publicly available data from The New York Times and the Guttmacher Institute and reviewed which genetic screening and diagnostic tests could be performed to provide results in time for individuals to decide whether to terminate their pregnancies legally in each state. As of December 11, 2022, 14 states have restrictions in which no diagnostic testing could be completed before gestational age-based cutoffs. Gestational age-based abortion restrictions may also influence a patient to favor chorionic villous sampling (CVS) over amniocentesis. There are two states, Florida and Arizona, where CVS would be feasible before the state's gestational age limit on abortion but amniocentesis would not. Both CVS and amniocentesis are feasible in 35 states, with legal challenges pending in 8 of the 35. Seven states specifically prohibit abortion for fetuses with genetic abnormalities. Clinicians may be placed in the suboptimal position of counseling patients with screening results alone before the gestational age-based ban in their state. There are several potential downstream consequences of gestational age-based termination restrictions for current genetic screening and testing paradigms, from adjustments to counseling options to potentially higher CVS procedure rates. Clinicians should be prepared for practice patterns to change to best serve patients in this evolving legal context.

Prophylactic ureteral stent placement for the prevention of genitourinary tract injury during hysterectomy for placenta accreta spectrum: systematic review and meta-analysis.

OBJECTIVE: This study aimed to assess the effectiveness of prophylactic ureteral stent placement for the prevention of genitourinary tract injury at the time of cesarean hysterectomy for placenta accreta spectrum. The secondary objectives were to assess mean blood loss, operative time, number of packed red blood cells transfused, and rates of urinary tract infection among patients undergoing cesarean hysterectomy for placenta accreta spectrum with and without prophylactic ureteral stent placement. DATA SOURCES: The search was performed using PubMed, Cochrane Library, and ClinicalTrials.gov from inception to February 2022 to December 2022. The protocol for this review was registered with the International Prospective Register of Systematic Reviews before data collection (registration number: CRD42022372817). STUDY ELIGIBILITY CRITERIA: All studies that examined differences in the rate of genitourinary tract injury among women undergoing cesarean hysterectomy for prenatally suspected placenta accreta spectrum with and without placement of prophylactic ureteral stents were included. Genitourinary injury was defined as cystotomy, ureteral injury, and/or bladder fistula. Cases of both intentional and unintentional genitourinary injuries were included in the analysis. METHODS: For all studies meeting the inclusion criteria, the following data were extracted: number of included patients, maternal demographic information, obstetrical history, type of invasive placentation, placement of stents (yes or no), type of stent placed, blood loss, operative time, genitourinary tract injury, and urinary tract infection. Pooled data analysis was completed using the Review Manager (version 5.3; Nordic Cochrane Centre, Copenhagen, Denmark; Cochrane Collaboration, 2014). The summary measures were reported as summary relative risk or as summary mean difference. The quality and risk of biases of the included studies were assessed according to the Newcastle-Ottawa Scale. RESULTS: Overall, 9 studies, including 848 patients, fulfilled our inclusion criteria and were included in our analysis. Moreover, 523 patients (61.7%) had prophylactic ureteral stents placed, and 325 patients (38.3%) did not. Genitourinary injury occurred in 138 of 523 patients (26.4%) in the ureteral stent group vs 83 of 325 patients (25.5%) in the no ureteral stent group (relative risk, 0.94; 95% confidence interval, 0.74-1.20). The mean number of packed red blood cells transfused did not differ between the 2 groups. The pooled analysis demonstrated decreased blood loss among patients who received prophylactic ureteral stents, with a mean difference of 392 mL (95% confidence interval, 52.74-738.13). CONCLUSION: Our systematic review and meta-analysis demonstrated no difference in the rates of genitourinary tract injury with the use of prophylactic ureteral stent placement among cases of prenatally suspected placenta accreta spectrum undergoing cesarean hysterectomy.

Mirror syndrome: a systematic literature review.

OBJECTIVE: This study aimed to review the diagnostic criteria for mirror syndrome and describe its clinical presentation. DATA SOURCES: Databases from PubMed, Scopus, Cochrane Library, ClinicalTrials.gov, and CINAHL were inquired for case series containing ≥2 cases of mirror syndrome from inception to February 2022. STUDY ELIGIBILITY CRITERIA: Studies were included if they reported ≥2 cases of mirror syndrome and included case reports, case series, cohort studies, and case-control studies. STUDY APPRAISAL AND SYNTHESIS METHODS: The studies' quality and risk of bias were independently assessed. Data were tabulated using Microsoft Excel and summarized using narrative review and descriptive statistics. This systematic review was conducted according to the Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement. All eligible references were assessed. Screening of records and data extraction were independently performed, and a third author resolved disagreements. RESULTS: Of 13 citations, 12 studies (n=82) reported diagnostic criteria for mirror syndrome: maternal edema (11/12), fetal hydrops (9/12), placental edema (6/12), placentomegaly (5/12), and preeclampsia (2/12); 12 studies (n=82) described the clinical presentation of mirror syndrome as maternal edema (62.2%), hypoalbuminemia (54.9%), anemia (39.0%), and new-onset hypertension (39.0%); 4 studies (n=36) reported that hemodilution was present in all patients; 8 studies (n=36) reported the etiology of fetal hydrops, with the most common being structural cardiac malformations (19.4%), alpha thalassemia (19.4%), Rh isoimmunization (13.9%), and nonimmune hydrops fetalis (13.9%); and 6 studies (n=47) reported maternal complications, 89.4% of which were major: postpartum hemorrhage (44.7%), hemorrhage requiring blood transfusion (19.1%), intensive care unit admission (12.8%), heart failure (10.6%), pulmonary edema (8.5%), and renal dysfunction (8.5%). In 39 cases, the reported fetal outcomes were stillbirth (66.6%) and neonatal or infant death (25.6%). The overall survival rate among continued pregnancies was 7.7%. CONCLUSION: The diagnostic criteria of mirror syndrome differed considerably among studies. Mirror syndrome clinical presentation overlapped with preeclampsia. Only 4 studies discussed hemodilution. Significant maternal morbidity and fetal mortality were associated with mirror syndrome. Further research is warranted to elucidate the pathogenesis of mirror syndrome to better guide clinicians in identifying and managing the condition.

Placenta Accreta Spectrum: Prenatal Diagnosis and Management.

The incidence of placenta accreta spectrum (PAS) is increasing and is now about 3 per 1000 deliveries, largely due to the rising cesarean section rate. Ultrasound is the preferred method for diagnosis of PAS. Ultrasound markers include multiple vascular lacunae, loss of the hypoechoic retroplacental zone, abnormalities of the uterine serosa-bladder interface, retroplacental myometrial thickness less than 1 mm, increased placental vascularity, and observation of bridging vessels linking the placenta and bladder. Patients with PAS should be managed by experienced multidisciplinary teams. Hysterectomy is the accepted management of PAS and conservative or expectant management of PAS should be considered investigational.