Intraoperative Multivessel Embolization Reduces Blood Loss and Transfusion Requirements Compared to Internal Iliac Artery Balloon Placement during Cesarean Hysterectomy for Placenta Accreta Spectrum.

PURPOSE: To evaluate the effectiveness and safety of prophylactic multivessel selective embolization (MVSE) compared to those of internal iliac artery occlusion balloon (IIABO) placement in patients undergoing cesarean hysterectomy for placenta accreta spectrum (PAS). MATERIALS AND METHODS: An institutional review board-approved retrospective series was conducted with consecutive patients with PAS at a single institution between 2010 and 2021. MVSE was performed in a hybrid operating room after cesarean section prior to hysterectomy. IIABO was performed with balloons placed into the bilateral internal iliac arteries, which were inflated during hysterectomy. Median blood loss, transfusion requirements, percentage of cases requiring transfusion, and adverse events were recorded. RESULTS: A total of 20 patients treated with embolization and 34 patients with balloon placement were included. Placenta percreta and previa were seen in 60% and 90% of patients, respectively. Median blood loss in the MVSE group was 713 mL (interquartile range [IQR], 475-1,000 mL) compared to 2,000 mL (IQR, 1,500-2,425 mL) in the IIABO group (P < .0001). The median total number of units of packed red blood cell transfusions (0 vs 2.5) and percentage of cases requiring a transfusion (20% vs 65%) were less in the MVSE group (P < .01). A median of 4 vessels (IQR, 3-9) were embolized during MVSE. No major adverse events or nontarget embolization consequences were observed. CONCLUSIONS: Prophylactic MVSE is a safe procedure that reduces operative blood loss and transfusion requirements compared to those of IIABO in patients undergoing cesarean hysterectomy for presumed higher-degree PAS.

FundAl Retroflexion (FAR) Angle is a Novel Sonographic Marker Associated With Cesarean Scar Pregnancies in the First Trimester: A Case-Control Study.

OBJECTIVES: Early diagnosis of Cesarean scar pregnancies (CSP) remains difficult. This study describes a novel sonographic marker, the FundAl Retroflexion (FAR) angle, that may be used in the first trimester. The objective of the study is to compare the FAR angle between CSP and normal pregnancies. METHODS: For this case-control study, we reviewed images from our institution's database that were acquired from January 2016 to December 2019. All cases of CSP and randomly selected controls, defined as patients with history of Cesarean delivery and normal implantation, that underwent ultrasound evaluation at <14 weeks were included. The FAR angle, defined as the acute angle created between the endometrial echo and cervical canal, was measured. The mean FAR angle was then compared between the two groups and a receiver operating characteristic (ROC) curve was generated. RESULTS: We identified 15 cases of CSP during the study period and were able to measure the FAR angle in 14 of the cases. The mean FAR angle was larger in CSP than in normal control pregnancies (45° versus 27°, respectively, P < 0.001). Using an ROC curve, a FAR angle cut off of 40° maximizes the ability to distinguish between CSP from normal pregnancies. CONCLUSIONS: The FAR angle provides an easily obtainable and numerical measurement. CSP have larger FAR angle compared to normal controls with a distinguishing cut off of 40°. Larger studies are needed to determine if using the FAR angle can improve first trimester diagnosis for CSP.

Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization: the PASTIME protocol.

BACKGROUND: Multidisciplinary care of placenta accreta spectrum cases improves pregnancy outcomes, but the specific components of such a multidisciplinary collaboration varies between institutions. As experience with placenta accreta spectrum increases, it is crucial to assess new surgical techniques and protocols to help improve maternal outcomes and to advocate for hospital resources. OBJECTIVE: This study aimed to assess a novel multidisciplinary protocol for the treatment of placenta accreta spectrum that comprises cesarean delivery, multivessel uterine embolization, and hysterectomy in a single procedure within a hybrid operative suite. STUDY DESIGN: This was a matched prepost study of placenta accreta spectrum cases managed before (2010-2017) and after implementation of the Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol (2018-2021) at a tertiary medical center. Historical cases were managed with internal iliac artery balloon placement in selected cases with the decision to inflate the balloons intraoperatively at the discretion of the primary surgeon. Intraoperative Embolization cases were compared with historical cases in a 1:2 ratio matched on the basis of placenta accreta spectrum severity and surgical urgency. The primary outcome was a requirement for transfusion with packed red blood cells. Secondary outcomes included estimated surgical blood loss, operative and postoperative complications, procedural time, length of stay, and neonatal outcomes. RESULTS: A total of 15 Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization cases and 30 matched historical cases were included in the analysis. There were no demographic differences noted between the groups. A median (interquartile range) of 0 units (0-2 units) of packed red blood cells were transfused in the Intraoperative Embolization group compared with 2 units (0-4.5 units) in the historical group (P=.045); 5 of 15 (33.3%) Intraoperative Embolization cases required blood transfusions compared with 19 of 30 (63.3%) cases in the historical group (P=.11). The estimated blood loss was significantly less in the Intraoperative Embolization group with a median (interquartile range) of 750 mL (450-1050 mL) compared with 1750 mL (1050-2500 mL) in the historical group (P=.003). There were no cases requiring massive transfusion (≥10 red blood cell units in 24 hours) in the Intraoperative Embolization group compared with 5 of 30 (16.7%) cases in the historical group (P=.15). There were no intraoperative deaths from hemorrhagic shock using the Intraoperative Embolization protocol, whereas this occurred in 2 of the historical cases. The mean duration of the interventional radiology procedure was longer in the Intraoperative Embolization group (67.8 vs 34.1 minutes; P=.002). Intensive care unit admission and postpartum length of stay were similar, and surgical and postoperative complications were not significantly different between the groups. The gestational age and neonatal birthweights were similar; however, the neonatal length of stay was longer in the Intraoperative Embolization group (median duration, 32 days vs 15 days; P=.02) with a trend toward low Apgar scores. Incidence of arterial umbilical cord blood pH <7.2 and respiratory distress syndrome and intubation rates were not statistically different between the groups. CONCLUSION: A multidisciplinary pathway including a single-surgery protocol with multivessel uterine embolization is associated with a decrease in blood transfusion requirements and estimated blood loss with no increase in operative complications. The Placenta Accreta Spectrum Treatment With Intraoperative Multivessel Embolization protocol provides a definitive surgical method that warrants consideration by other centers specializing in placenta accreta spectrum treatment.

Association of alcohol and other substance-related diagnoses with severe maternal morbidity.

BACKGROUND: Pregnant women with a substance-related diagnosis, such as an alcohol use disorder, are a vulnerable population that may experience higher rates of severe maternal morbidity, such as hemorrhage and eclampsia, than pregnant women with no substance-related diagnosis. METHODS: This retrospective cross-sectional study reviewed electronic health record data on women (aged 18-44 years) who delivered a single live birth or stillbirth at ≥ 20 weeks of gestation from March 1, 2016, to August 30, 2019. Women with and without a substance-related diagnosis were matched on key demographic characteristics, such as age, at a 1:1 ratio. Adjusting for these covariates, odds ratios and 95% confidence intervals were calculated. RESULTS: A total of 10,125 deliveries met the eligibility criteria for this study. In the matched cohort of 1,346 deliveries, 673 (50.0%) had a substance-related diagnosis, and 94 (7.0%) had severe maternal morbidity. The most common indicators in women with a substance-related diagnosis included hysterectomy (17.7%), eclampsia (15.8%), air and thrombotic embolism (11.1%), and conversion of cardiac rhythm (11.1%). Having a substance-related diagnosis was associated with severe maternal morbidity (adjusted odds ratio = 1.81 [95% CI, 1.14-2.88], p-value = 0.0126). In the independent matched cohorts by substance type, an alcohol-related diagnosis was significantly associated with severe maternal morbidity (adjusted odds ratio = 3.07 [95% CI, 1.58-5.95], p-value = 0.0009), while the patterns for stimulant- and nicotine-related diagnoses were not as well resolved with severe maternal morbidity and opioid- and cannabis-related diagnoses were not associated with severe maternal morbidity. CONCLUSION: We found that an alcohol-related diagnosis, although lowest in prevalence of the substance-related diagnoses, had the highest odds of severe maternal morbidity of any substance-related diagnosis assessed in this study. These findings reinforce the need to identify alcohol-related diagnoses in pregnant women early to minimize potential harm through intervention and treatment.

Obstetrical Unit Response to the COVID-19 Pandemic: OUR Study.

OBJECTIVE: This study aimed to describe the response of labor and delivery (L&D) units in the United States to the novel coronavirus disease 2019 (COVID-19) pandemic and determine how institutional characteristics and regional disease prevalence affect viral testing and personal protective equipment (PPE). STUDY DESIGN: A cross-sectional survey was distributed electronically through the Society for Maternal-Fetal Medicine e-mail database (n = 584 distinct practices) and social media between April 14 and 23, 2020. Participants were recruited through "snowballing." A single representative was asked to respond on behalf of each L&D unit. Data were analyzed using Chi-square and Fisher's exact tests. Multivariable regression was performed to explore characteristics associated with universal testing and PPE usage. RESULTS: A total of 301 surveys (estimated 51.5% response rate) was analyzed representing 48 states and two territories. Obstetrical units included academic (31%), community teaching (45%) and nonteaching hospitals (24%). Sixteen percent of respondents were from states with high prevalence, defined as higher "deaths per million" rates compared with the national average. Universal laboratory testing for admissions was reported for 40% (119/297) of units. After adjusting for covariates, universal testing was more common in academic institutions (adjusted odds ratio [aOR] = 1.73, 95% confidence interval [CI]: 1.23-2.42) and high prevalence states (aOR = 2.68, 95% CI: 1.37-5.28). When delivering asymptomatic patients, full PPE (including N95 mask) was recommended for vaginal deliveries in 33% and for cesarean delivery in 38% of responding institutions. N95 mask use during asymptomatic vaginal deliveries remained more likely in high prevalence states (aOR = 2.56, 95% CI: 1.29-5.09) and less likely in hospitals with universal testing (aOR = 0.42, 95% CI: 0.24-0.73). CONCLUSION: Universal laboratory testing for COVID-19 is more common at academic institutions and in states with high disease prevalence. Centers with universal testing were less likely to recommend N95 masks for asymptomatic vaginal deliveries, suggesting that viral testing can play a role in guiding efficient PPE use. KEY POINTS: · Heterogeneity is seen in institutional recommendations for viral testing and PPE.. · Universal laboratory testing for COVID-19 is more common at academic centers.. · N95 mask use during vaginal deliveries is less likely in places with universal testing..

Preterm birth and its associations with residence and ambient vehicular traffic exposure.

BACKGROUND: Preterm birth (PTB) is a multifactorial disorder, and air pollution has been suggested to increase the risk of occurrence. However, large population studies controlling for multiple exposure measures in high-density settings with established commuter patterns are lacking. OBJECTIVE: We performed a geospatial analysis with the use of a publicly available database to identify whether residence during pregnancy, specifically with regard to exposure to traffic density and mobility in urban and suburban neighborhoods, may be a contributing risk factor for premature delivery. STUDY DESIGN: In our cohort study, we analyzed 9004 pregnancies with as many as 4900 distinct clinical and demographic variables from Harris County, Texas. On the basis of primary residency and occupational zip code information, geospatial analysis was conducted. Data on vehicle miles traveled (VMT) and percentages of inhabitants traveling to work were collected at the zip code level and additionally grouped by the three recognized regional commuter loop high-density thoroughfares resulting from two interstate/highway belts (inner, middle, and outer loops). PTB was categorized as late (34 1/7 to 36 6/7 weeks) and early PTB (22 1/7 to 33 6/7 weeks), and unadjusted odds ratios (OR) and adjusted ORs were ascribed. RESULTS: PTB prevalence in our study population was 10.1% (6.8% late and 3.3% early preterm), which is in accordance with our study and other previous studies. Prevalence of early PTB varied significantly between the regional commuter loop thoroughfares [OR for inner vs outer loop: 0.58 (95% confidence interval, 0.39-0.87), OR for middle vs outer loop, 0.74 (0.57-0.96)]. The ORs for PTB and early PTB were shown to be lower in gravidae from neighborhoods with the highest VMT/acre [OR for PTB, 0.82 (0.68-0.98), OR for early PTB, 0.78 (0.62-0.98)]. Conversely, risk of PTB and early PTB among subjects living in neighborhoods with a high percentage of inhabitants traveling to work over a greater distance demonstrated a contrary tendency [OR for PTB, 1.18 (1.03-1.35), OR for early PTB, 1.48 (1.17-1.86)]. In logistic regression models, the described association between PTB and residence withstood and could not be explained by differences in maternal age, gravidity or ethnicity, tobacco use, or history of PTB. CONCLUSION: While PTB is of multifactorial origin, the present study shows that community-based risk factors (namely urban/suburban location, differences in traffic density exposure, and need for traveling to work along high-vehicle density thoroughfares) may influence risk for PTB. Further research focusing on previously unrecognized community-based risk factors may lead to innovative future prevention measures.

Geospatial analysis of food environment demonstrates associations with gestational diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM) is one of most common complications of pregnancy, with incidence rates varying by maternal age, race/ethnicity, obesity, parity, and family history. Given its increasing prevalence in recent decades, covariant environmental and sociodemographic factors may be additional determinants of GDM occurrence. OBJECTIVE: We hypothesized that environmental risk factors, in particular measures of the food environment, may be a diabetes contributor. We employed geospatial modeling in a populous US county to characterize the association of the relative availability of fast food restaurants and supermarkets to GDM. STUDY DESIGN: Utilizing a perinatal database with >4900 encoded antenatal and outcome variables inclusive of ZIP code data, 8912 consecutive pregnancies were analyzed for correlations between GDM and food environment based on countywide food permit registration data. Linkage between pregnancies and food environment was achieved on the basis of validated 5-digit ZIP code data. The prevalence of supermarkets and fast food restaurants per 100,000 inhabitants for each ZIP code were gathered from publicly available food permit sources. To independently authenticate our findings with objective data, we measured hemoglobin A1c levels as a function of geospatial distribution of food environment in a matched subset (n = 80). RESULTS: Residence in neighborhoods with a high prevalence of fast food restaurants (fourth quartile) was significantly associated with an increased risk of developing GDM (relative to first quartile: adjusted odds ratio, 1.63; 95% confidence interval, 1.21-2.19). In multivariate analysis, this association held true after controlling for potential confounders (P = .002). Measurement of hemoglobin A1c levels in a matched subset were significantly increased in association with residence in a ZIP code with a higher fast food/supermarket ratio (n = 80, r = 0.251 P < .05). CONCLUSION: As demonstrated by geospatial analysis, a relationship of food environment and risk for gestational diabetes was identified.

A validation study of electrical cardiometry in pregnant patients using transthoracic echocardiography as the reference standard.

To validate electrical cardiometry (EC) in pregnant patients using transthoracic echocardiography (TTE) as the reference standard. To improve EC accuracy via a one-time, measurement of left ventricular outflow tract (LVOT) diameter. 44 non-laboring, resting women with singleton, viable pregnancies underwent simultaneous EC and TTE measurements. Data were analyzed using Bland-Altman analysis. Entry multiple regression with stepwise elimination was used to develop a model for improved prediction of stroke volume by TTE (SVTTE) using EC. Bootstrapping and an 11-fold cross validation were used to test the model. Heart rate by TTE and EC had a mean bias of 3.3 beats/min and mean percentage error of 10.7 %. Envelope time and left ventricular ejection time had a mean bias of -4.9 ms and mean percentage error 12.7 %. Stroke volumes by the two techniques had a mean bias of 15.6 mL and mean percentage error of 43.7 %. A model, SVEC_Modified, predicting SVTTE was developed using LVOT area, stroke volume by electrical cardiometry and weight. SVTTE and SVEC_Modified had a mean bias of -0.83 mL and mean percentage error of 22 %. EC accurately measures heart rate and duration of systole when compared with TTE. Stroke volume measurements correlate but have a high bias and percentage error. Knowledge of LVOT area, by a one-time, measurement with TTE, could improve prediction of stroke volume by EC.

Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach.

OBJECTIVE: The purpose of this study was to test the hypothesis that a standardized multidisciplinary treatment approach in patients with morbidly adherent placenta, which includes accreta, increta, and percreta, is associated with less maternal morbidity than when such an approach is not used (nonmultidisciplinary approach). STUDY DESIGN: A retrospective cohort study was conducted with patients from 3 tertiary care hospitals from July 2000 to September 2013. Patients with histologically confirmed placenta accreta, increta, and percreta were included in this study. A formal program that used a standardized multidisciplinary management approach was introduced in 2011. Before 2011, patients were treated on a case-by-case basis by individual physicians without a specific protocol (nonmultidisciplinary group). Estimated blood loss, transfusion of packed red blood cells, intraoperative complications (eg, vascular, bladder, ureteral, and bowel injury), neonatal outcome, and maternal postoperative length of hospital stay were compared between the 2 groups. RESULTS: Of 90 patients with placenta accreta, 57 women (63%) were in the multidisciplinary group, and 33 women (37%) were in the nonmultidisciplinary group. The multidisciplinary group had more cases with percreta (P = .008) but experienced less estimated blood loss (P = .025), with a trend to fewer blood transfusions (P = .06), and were less likely to be delivered emergently (P = .001) compared with the nonmultidisciplinary group. Despite an approach of indicated preterm delivery at 34-35 weeks of gestation, neonatal outcomes were similar between the 2 groups. CONCLUSION: The institution of a standardized approach for patients with morbidly adherent placentation by a specific multidisciplinary team was associated with improved maternal outcomes, particularly in cases with more aggressive placental invasion (increta or percreta), compared with a historic nonmultidisciplinary approach. Our standardized approach was associated with fewer emergency deliveries.

Substance-related diagnosis type predicts the likelihood and co-occurrence of preterm and cesarean delivery.

This article aimed to evaluate whether a substance-related diagnosis (SRD; i.e., alcohol, opioids, cannabis, stimulants, nicotine) predicts the likelihood and co-occurrence of preterm (20-37 weeks' gestation) and cesarean delivery.This study reviewed electronic health record data on women (aged 18-44 years) who delivered a single live or stillbirth at ≥ 20 weeks of gestation from 2012 to 2019. Women with and without an SRD were matched on key demographic characteristics at a 1:1 ratio. Adjusting for covariates, odds ratios and 95% confidence intervals were calculated.Of the 19,346 deliveries, a matched cohort of 2,158 deliveries was identified. Of these, 1,079 (50%) had an SRD, 280 (13%) had a preterm delivery, 833 (39%) had a cesarean delivery, and 166 (8%) had a co-occurring preterm and cesarean delivery. An SRD was significantly associated with preterm and cesarean delivery (AOR = 1.84 [95% CI, 1.41-2.39], p-value= <0.0001; AOR = 1.51 [95% CI, 1.23-1.85], p-value= <0.0001). An alcohol-related diagnosis (AOR = 1.82 [95% CI, 1.01-3.28], p-value= 0.0471), opioid-related diagnosis (AOR = 1.94 [95% CI, 1.26-2.98], p-value= 0.0027), stimulant-related diagnosis (AOR = 1.65 [95% CI, 1.11-2.45], p-value= 0.0142), and nicotine-related diagnosis (AOR = 1.54 [95% CI, 1.05-2.26], p-value= 0.0278) were associated with co-occurring preterm and cesarean delivery.Pregnant women with an SRD experienced disproportionally higher odds of preterm and cesarean delivery compared to pregnant women without an SRD. Substance-type predicts the type of delivery outcome. An SRD in pregnant women should be identified early to reduce potential harm through intervention and treatment.

Management of diabetes in pregnancy.

The link between diabetes and poor pregnancy outcomes is well established. As in the non-pregnant population, pregnant women with diabetes can experience profound effects on multiple maternal organ systems. In the fetus, morbidities arising from exposure to diabetes in utero include not only increased congenital anomalies, fetal overgrowth, and stillbirth, but metabolic abnormalities that appear to carry on into early life, adolescence, and beyond. This article emphasizes the newest guidelines for diabetes screening in pregnancy while reviewing their potential impact on maternal and neonatal complications that arise in the setting of hyperglycemia in pregnancy.

Preoperative intravascular balloon catheters and surgical outcomes in pregnancies complicated by placenta accreta: a management paradox.

OBJECTIVE: The objective of the study was to compare outcomes between patients who did and did not receive preoperative uterine artery balloon catheters in the setting placenta accreta. STUDY DESIGN: This was a retrospective case-control study of patients with placenta accreta from 1990 to 2011. RESULTS: Records from 117 patients with pathology-proven accreta were reviewed. Fifty-nine patients (50.4%) had uterine artery balloons (UABs) placed preoperatively. The mean estimated blood loss (EBL) was lower (2165 mL vs 2837 mL; P = .02) for the group that had UABs compared with the group that did not. There were more cases with an EBL greater than 2500 mL and massive transfusions of packed red blood cells (>6 units) in the group that did not have UABs. Percreta was diagnosed more often on final pathology in the group with UABs. Surgical times did not differ between the 2 groups. Two patients (3.3%) had complications related to the UABs. CONCLUSION: Preoperative placement of UABs is relatively safe and is associated with a reduced EBL and fewer massive transfusions compared with a group without UABs.

Identifying sonographic markers for placenta accreta in the first trimester.

Our study attempted to identify whether sonographic markers for placenta accreta may be present as early as the first trimester. We reviewed 10 cases with pathologically proven accreta and retrospectively analyzed their first-trimester images. The gestational ages ranged from 8 weeks 4 days to 14 weeks 2 days. Sonographic findings included anechoic placental areas (9 of 10), low implantation of the gestational sac (9 of 10), an irregular placental-myometrial interface (9 of 10), and placenta previa (7 of 10). Nine patients had at least 1 prior cesarean delivery; 3 had additional uterine surgical procedures. One patient underwent hysteroscopic myomectomy. Our case series suggests that signs of placenta accreta may be present in the first trimester.

Diagnosis of fetal limb abnormalities before 15 weeks: cause for concern.

OBJECTIVES: The purposes of this study were (1) to identify cases of limb abnormalities identified before 15 weeks and correlate with outcomes and (2) to assess first-trimester nuchal translucency examinations to determine how frequently the upper and lower limbs were identified. METHODS: A retrospective review was conducted of sonographic studies up to 15 weeks' gestational age from 2003 to 2010 at our high-risk fetal center. Data were collected regarding fetal gestational age, limb abnormalities, associated anatomic abnormalities, pregnancy outcomes, karyotypes, autopsy results, and the utility of transabdominal sonography, transvaginal sonography, and 3-dimensional sonography. A retrospective analysis of 100 consecutive first-trimester examinations was also conducted to assess the sensitivity of transabdominal sonography in visualization of limb buds. RESULTS: A total of 15 cases were identified with a mean gestational age of 12 weeks 6 days. Club hand was the most common abnormality seen (8 cases), followed by absence of long bones (5 cases), a missing limb (5 cases), club foot (5 cases), shortening of long bones (2 cases), abnormal hands (2 cases), clenched hands (2 cases), and overlapping digits (1 case). Trisomy 18 was present in 9 cases. Transabdominal sonography allowed for detection of all limb buds in 100 consecutive nuchal translucency examinations and 9 of 15 cases of limb abnormalities. Four of the cases resulted in fetal death, and the remaining 11 cases were terminated. CONCLUSIONS: Fetal limb abnormalities can be detected on sonography before 15 weeks' gestational age and are often associated with serious congenital conditions, especially trisomy 18. Transabdominal sonography alone can show most of these abnormalities, although transvaginal and 3-dimensional sonography can provide additional information. Targeted evaluation of fetal limbs during sonography before 15 weeks should be considered in high-risk populations.

Education in Trauma-Informed Care in Maternity Settings Can Promote Mental Health During the COVID-19 Pandemic.

Globally, the pandemic has adversely affected many people's mental health, including pregnant women and clinicians who provide maternity care, and threatens to develop into a mental health pandemic. Trauma-informed care is a framework that takes into account the effect that past trauma can have on current behavior and the ability to cope and can help to minimize retraumatization during health care encounters. The purpose of this article is to highlight the pressing need for perinatal clinicians, including nurses, midwives, physicians, doulas, nurse leaders, and nurse administrators, to be educated about the principles of trauma-informed care so that they can support the mental health of pregnant women, themselves, and members of the care team during the pandemic.

Assessing the multidisciplinary team approaches to placenta accreta spectrum across five institutions within the University of California fetal Consortium (UCfC).

PURPOSE: To describe the multidisciplinary approaches to placenta accreta spectrum (PAS) across five tertiary care centers that comprise the University of California fetal Consortium (UCfC) and to identify potential best practices. MATERIALS AND METHODS: Retrospective review of all cases of pathologically confirmed invasive placenta delivered from 2009 to 2014 at UCfC. Differences in intraoperative management and outcomes based on prenatal suspicion were compared. Interventions assessed included ureteral stent use, intravascular balloon use, anesthetic type, gynecologic oncology (Gyn Onc) involvement, and cell saver use. Intervention variation by institution was also assessed. Analyses were adjusted for final pathologic diagnosis. Chi-square, Fisher's exact, Student's t-test, and Mann-Whitney's U-test were used as appropriate. Binary logistic regression and multivariable linear regression were used to adjust for confounders. RESULTS: One hundred and fifty-one cases of pathologically confirmed invasive placenta were identified, of which 82% (123) were suspected prenatally. There was no correlation between the degree of invasion on prenatal imaging and use of each intervention. Ureteral stents were placed in 33% (41) of cases and did not reduce GU injury. Intravascular balloons were placed in 29% (36) of cases and were associated with shorter OR time (161 versus 236 min, p < .01) and lower estimated blood loss (EBL) (1800 versus 2500 ml, p < .01). General endotracheal anesthesia (GETA) was used in 70% (86). EBL did not differ between GETA and regional anesthesia. Gyn Onc was involved in 58% (71) of cases and EBL adjusted for final pathology was reduced with their involvement (2200 versus 2250 ml, p = .02) while OR time and intraoperative complications did not differ. Cell saver was used in 20% (24) and was associated with longer OR time (296 versus 200 min, p < .01). Use of cell saver was not associated with a difference in EBL or number of units of packed red cells transfused. All analyses were adjusted for pathologic severity of invasion. CONCLUSIONS: Intravascular interventions such as uterine artery balloons and the inclusion of Gynecologic Oncologists as part of a multidisciplinary approach to treating PAS reduce EBL. Additionally, the placement of intravascular balloons may reduce OR time. No significant differences were seen in outcomes when comparing the use of ureteral stents, general anesthesia, or institutions. A team of experienced operators with a standard approach may be more significant than specific practices.

A national survey evaluating obstetric providers' attitudes and regional trends of trial of labor after cesarean.

Objective: To evaluate trends amongst residency programs offering trial of labor after cesarean delivery (TOLAC).Methods: An electronic survey was sent to Program Directors of every obstetrics and gynecology residency program accredited by the Accreditation Council for Graduate Medical Education (ACGME) in the USA and Puerto Rico via publicly available e-mail address for 249 of the 249 programs. The Program Directors were asked to forward the e-mail to all of the current residents in their respective program to complete a similar version of the survey.Results: Seventy-nine Program Directors (33%) and 243 residents responded. All programs offered TOLAC to patients with one prior cesarean. University programs were more likely to offer TOLAC to women with two prior cesareans compared to non-university programs (85 versus 65%; p < .01). Overall, Program Directors and residents were comfortable counseling and managing TOLACs (99 and 95%, respectively). This confidence was associated with advancing years in residency. Residents attending university programs report they are more likely to offer TOLAC to women with 1 prior cesarean (98.1 versus 91.2%, p = .02) and willing to induce TOLAC with favorable cervix (95.2 versus 88.2%; p = .03) post-residency when compared to non-university trained residents. There is an association between region and whether TOLAC is offered to women with two or more prior cesareans, without prior vaginal delivery, and women with twins. Specifically, those in the Mid-Atlantic region are less likely to offer TOLAC to women with two prior cesareans (68 versus 86%; p < .01) and those with unknown type of previous uterine incision (51 versus 74%; p < .01).Conclusion: Offering TOLAC to women with one prior cesarean appears universally acceptable amongst residency programs in the USA. Significant differences arise between types of programs and region of the country in regards to offering TOLAC to women with more complicated obstetrical histories.

Outcomes of Planned Compared With Urgent Deliveries Using a Multidisciplinary Team Approach for Morbidly Adherent Placenta.

OBJECTIVE: To compare outcomes between planned and urgent cesarean hysterectomy for morbidly adherent placenta managed by a multidisciplinary team. METHODS: This is a retrospective case-control study of women with singleton pregnancies with antenatally suspected and pathologically confirmed morbidly adherent placenta who underwent cesarean hysterectomy between January 1, 2011, and February 30, 2017. Timing of delivery was classified as either planned (delivery at 34-35 weeks of gestation) or urgent (need for urgent delivery as a result of uterine contractions, bleeding, or both). The primary outcome variable was composite maternal morbidity. Logistic regression analysis was used to evaluate risk factors for urgent delivery. RESULTS: One hundred thirty patients underwent hysterectomy. Sixty (46.2%) required urgent delivery. Composite maternal morbidity was identified in 34 (56.7%) of the urgent and 26 (37.1%) of the planned deliveries (P=.03). Fewer units of red blood cells and fresh frozen plasma were transfused in the planned delivery group (red blood cells, median interquartile range 3 [0-8] versus 1 [0-4], P=.02; fresh frozen plasma, median interquartile range 1 [0-2] versus 0 [0-0], P=.001). Rates of low Apgar score and respiratory distress syndrome were higher in the urgent compared with the planned delivery group (5-minute Apgar score less than 7, 34 [59.6%] versus 14 [23.3%], P<.01; respiratory distress syndrome, 34 [61.8%] versus 16 [27.1%], P<.01). A history of two or more prior cesarean deliveries was an independent predictor of urgent delivery (adjusted odds ratio 11.4, 95% CI 1.8-71.1). CONCLUSION: Women with morbidly adherent placenta requiring urgent delivery have a worse outcome than women with planned delivery. Women with morbidly adherent placenta and two or more prior cesarean deliveries are at increased risk for urgent delivery. In such women, scheduling delivery before the standard 34- to 35-week timeframe may be reasonable.

Placental Sonolucencies in the First Trimester: Incidence and Clinical Significance.

OBJECTIVES: The aims of this study were to determine the incidence of placental sonolucencies on first-trimester screening sonograms in a general obstetric population and assess whether these findings are associated with adverse obstetric outcomes. METHODS: A retrospective cohort analysis of 201 pregnant patients screened at a high-risk prenatal diagnostic center was conducted with first-trimester cine clips reviewed by 2 radiologists. Placental sonolucencies were defined as intraplacental anechoic or heterogeneous areas 0.7 cm or greater. Obstetric and neonatal outcomes were collected by chart review. RESULTS: Placental sonolucencies 0.7 cm or greater were seen in 45 (22.4%) of first-trimester ultrasound examinations. The ultrasonographic presence of a placenta previa, marginal sinus, and subchorionic hemorrhage was not more common in those with placental sonolucencies 0.7 cm or greater (P > 0.05). Sonolucencies were not associated with prior cesarean deliveries (P > 0.05). Both the groups with and without sonolucencies 0.7 cm or greater had similar rates of antepartum hemorrhage, preeclampsia, preterm delivery, cesarean delivery, postpartum hemorrhage, and delivery of small-for-gestational-age infants. One placenta accreta and no fetal demises occurred in the study population. CONCLUSIONS: Placental sonolucencies detected on first-trimester screening sonograms in the general obstetric population are not predictive of poor obstetric outcomes.

Diagnostic performance of serial haematocrit measurements in identifying major injury in adult trauma patients.

UNLABELLED: Determination of occult haemorrhage is an essential part of trauma assessment. We evaluated the diagnostic utility of decreasing haematocrit (DeltaHct) in detecting major injury. Additionally, we tested the correlation between the volume of infused intravenous fluid (IVF) and DeltaHct. METHODS: Prospective observational study at a level one trauma centre. INCLUSION CRITERIA: Patients with suspected major injury. exclusion criteria: Patients who received blood transfusion in the first 4 h, and those who deceased or were transferred to other units before the completion of the observation period (4 h). We measured IVF and DeltaHct at 4 h after triage. We classified patients as having minor or major injury on the basis of injury severity score > or =15. Receiver Operating Characteristic (ROC) curve was used to test the diagnostic performance of DeltaHct in identifying major injury. We tested the operating characteristics of DeltaHct cut-off values of 5 and 10 in detecting major injury. We also measured the correlation of IVF and DeltaHct in a subgroup of patients with low potential for blood loss (ISS<3) to account for possibility of haemodilution. RESULTS: Four hundred and ninety-four patients (convenience sample) were enrolled (age 36+/-17 years, 82% male, 57% blunt trauma). Sixty-three patients (13%) had major injury. The area under the ROC curve for DeltaHct was not significantly different from the unity line (p=0.20). DeltaHct-4 h>5 points had a sensitivity of 40% (95% CI, 29-52%), specificity of 94% (95% CI, 92-96%), likelihood ratio for a positive test (LR+) of 7.1 (95% CI, 4.4-11.7), and likelihood ratio for a negative test (-LR) of 0.64 (95% CI, 0.52-0.78) in identifying major trauma. DeltaHct-4 h>10 points had sensitivity of 16% (95% CI, 9-27%), specificity of 95% (95% CI, 92-0.96%), +LR of 3.0 (95% CI, 1.5-5.9), and -LR of 0.89 (95% CI, 0.80-0.99). In our subgroup analysis, we detected no significant correlation (p=0.09) between the IVF and DeltaHct-4 h. CONCLUSIONS: DeltaHct-4 h>5 or 10 points is suggestive of major injury (high specificity and +LR). However, the failure to drop the Hct cannot be used to rule out major injury (low sensitivity and -LR).