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OBJECTIVE: This study aimed to evaluate whether enhanced recovery after cesarean (ERAC) pathways reduces inpatient and outpatient opioid use, pain scores and improves the indicators of postoperative recovery. STUDY DESIGN: This is a prospective, longitudinal, quality improvement study of all patients older than 18 undergoing an uncomplicated cesarean delivery (CD) at an academic medical center. We excluded complicated CD, patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or mothers whose neonate demised before their discharge. Lastly, we excluded non-English- and non-Spanish-speaking patients. Our study compared patient outcomes before (pre-ERAC) and after (post-ERAC) implementation of ERAC pathways. Primary outcomes were inpatient morphine milligram equivalent (MME) use and the patient's delta pain scores. Secondary outcomes were outpatient MME prescriptions and indicators of postoperative recovery (time to feeding, ambulation, and hospital discharge). RESULTS: Of 308 patients undergoing CD from October 2019 to September 2020, 196 were enrolled in the pre-ERAC cohort and 112 in the post-ERAC cohort. Patients in the pre-ERAC cohort were more likely to require opioids in the postoperative period compared with the post-ERAC cohort (81.6 vs. 64.3%, p < 0.001). Likewise, there was a higher use of MME per stay in the pre-ERAC cohort (30 [20-49] vs. 16.8 MME [11.2-33.9], p < 0.001). There was also a higher number of patients who required prescribed opioids at the time of discharge (98 vs. 86.6%, p < 0.001) as well as in the amount of MMEs prescribed (150 [150-225] vs. 150 MME [112-150], p < 0.001; different shape of distribution). Furthermore, the patients in the pre-ERAC cohort had higher delta pain scores (3.3 [2.3-4.7] vs. 2.2 [1.3-3.7], p < 0.001). CONCLUSION: Our study has illustrated that our ERAC pathways were associated with reduced inpatient opioid use, outpatient opioid use, patient-reported pain scores, and improved indicators of postoperative recovery. KEY POINTS: · Implementation of ERAC pathways is associated with a higher percentage of no postpartum opioid use.. · Implementation of ERAC pathways is associated with lower delta (reported - expected) pain scores.. · The results of ERAC pathways implementation are increased by adopting a patient-centered approach..
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Analgésicos Opioides , Endrin/análogos & derivados , Transtornos Relacionados ao Uso de Opioides , Gravidez , Feminino , Recém-Nascido , Humanos , Analgésicos Opioides/uso terapêutico , Estudos Prospectivos , Dor Pós-Operatória/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estudos Retrospectivos , Padrões de Prática MédicaRESUMO
OBJECTIVES: The objective of the study was to determine any identifiable clinical utility of the practice of universal maternal and infant tetrahydrocannabinol (THC) testing at the time of birth. METHODS: This was cross-sectional, retrospective cohort study comparing the following birth outcomes in relation to maternal and infant tetrahydrocannabinol (THC): APGAR scores, cord gases, NICU admission and need for immediate resuscitation. All births at the University of Maryland Medical Center between January 1, 2018 and December 31, 2020 were reviewed. Those that had either maternal or infant test results missing were excluded. Statistical analysis was performed using STATA v27. Birth outcomes were adjusted for gestational age at delivery and tobacco use. Infant resuscitation was considered the need for any respiratory support. RESULTS: A total of 4260 maternal/infant pairs were included. Of these, 314 (7.4%) birthing parents and 161 (3.8%) of infants tested positive for THC. Of the birth parents who tested positive for THC, 51.3% of their infants also tested positive for THC. Maternal/infant pairs that both tested positive for THC had the lowest need for immediate resuscitation and Neonatal Intensive Care Unit admission. Cord gases and APGAR scores were similar between the groups. Birth parents who tested positive for THC delivered infants at an earlier gestational age (37w6d v 38w5d, p = 0.001) and lower mean birth weight (2690gm v 3061gm, p = 0.001) than those who tested negative even after adjusting for confounders. When limited to only term births and broken down by weeks completed gestation, the mean birth weights were lower for every week in those who tested positive for THC versus those who tested negative. CONCLUSIONS: Our study shows that maternal and neonatal testing for THC at the time of birth is not predictive of important neonatal outcome parameters. Therefore, even though it is likely that there are some effects of in utero THC exposure on the neonate, we did not find any clinical benefits that would justify routine maternal and/or infant testing for THC at the time of birth.
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Cannabis , Recém-Nascido , Lactente , Humanos , Estudos Retrospectivos , Dronabinol , Estudos Transversais , Peso ao Nascer , GasesRESUMO
OBJECTIVE: Current recommendations for individuals with risk factors for gestational diabetes mellitus (GDM) call for screening in early pregnancy. However, there is currently no clear consensus on a specific screening modality. This study evaluates whether a hemoglobin A1c (HbA1c) screening in individuals with risk factors for gestational diabetes (GDM) could be used instead of an early 1-hour glucose challenge test (GCT). We hypothesized that the HbA1c could replace 1-hour GCT in early pregnancy evaluation STUDY DESIGN: This is a prospective observational trial at a single tertiary referral center of women with at least one risk factor for GDM who were screened at <16 weeks of gestation with both 1-hour GCT or HbA1c. Exclusion criteria include: previous diagnosis of diabetes mellitus, multiple gestation, miscarriage, or missing delivery information. The diagnosis of GDM was made by a 3-hour 100-g glucose tolerance test, using the Carpenter-Coustan criteria (at least two results >94, 179, 154, and 139 mg/dL for fasting, 1-, 2-, and 3-hour values, respectively), 1-hour GCT > 200 mg/dL, or HbA1c > 6.5%. RESULTS: A total of 758 patients met inclusion criteria. A total of 566 completed a 1-hour GCT and 729 had an HbA1c collected. The median gestational age at testing was 91/7 weeks (range: 40/7-156/7 weeks]. Twenty-one participants were diagnosed with GDM at <16 weeks' GA. The receiver operating characteristic (ROC) curves identified the optimal valves for a positive screen for an HbA1c > 5.6%. The HbA1c had a sensitivity of 84.2%, a specificity of 83.3%, and a false positive rate of 16.7% (p < 0.001). The area under the ROC curve for the HbA1c was 0.898. Gestational age of delivery was slightly earlier with individuals with an elevated HbA1c but no other changes in delivery or neonatal outcomes. Contingent screening improved specificity (97.7%) and decreased false positive rate to 4.4%. CONCLUSION: HbA1c may be a good assessment in early pregnancy for gestational diabetes. KEY POINTS: · HbA1c is a rational assessment in early pregnancy.. · An HbA1c > 5.6% is associated with gestational diabetes.. · Contingent screening limits the need for additional testing..
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OBJECTIVE: In obstetric emergencies, care coordination is critical in achieving a "decision-to-delivery" time of 30 minutes. Reliable communication is essential to optimize coordinated care of mother and baby. Clinical mobility (CM) platforms have been shown to improve communication during medical emergencies; however, their impact on improving decision-to-delivery times has not been shown. This study aimed to determine the impact of a new CM platform on decision-to-delivery time. STUDY DESIGN: A multidisciplinary team designed a CM platform that employs a wall-mounted panel paired with mobile technology to alert all relevant clinical staff. This new platform uses in-room preprogrammed messages that alert predetermined responders matching the emergency. For example, the "STAT section" button summons doctors (obstetrics, anesthesiology, and neonatology), obstetric nurses, and newborn resuscitation staff via smartphones. Impact of this platform was assessed with process and outcome data: cord artery pH, 5-minute Apgar's score; and decision for cesarean section to time of: skin incision, uterine incision, and delivery. This pre- and postimplementation study (October-September 2018 vs. January-December 2019) centered on the opening of our new Obstetric Care Unit. Data were analyzed with Chi-square and Mann-Whitney U-test. RESULTS: Emergent cesarean delivery was performed in 172 women pre- and 124 postimplementation of the new CM platform. In postimplementation, we observed a 7.4-minute reduction in time from decision-to-delivery (26 pre- vs. 18.6 minutes postimplementation, p = 0.001). Delivery within 30 minutes improved by 15.2% (p = 0.018). Times to skin and uterine incision were also significantly reduced. The two groups had similar neonatal outcomes: birth weight, Apgar's score at 5 minutes, and cord artery pH did not differ, but the study was underpowered to compare these outcomes. CONCLUSION: This new CM platform significantly reduced decision-to-delivery time, in turn improving compliance with the "30-minute rule." All relevant personnel were contacted specifically, while avoiding overhead paging and other unnecessary messages. KEY POINTS: · Obstetric communication via a clinical mobility platform shortens the delivery to delivery interval. · Obstetric communication systems via an information technology (IT)-system results in a higher frequency of deliveries within 30 minutes.. · Communication systems may be a useful tools to synchronously call multiple services to respond..
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Cesárea , Obstetrícia , Cesárea/métodos , Comunicação , Parto Obstétrico , Emergências , Feminino , Humanos , Recém-Nascido , Gravidez , Fatores de TempoRESUMO
OBJECTIVE: The objective of our study was to investigate the effect of impaired glucose metabolism (IGM) and ultrasound (US) findings consistent with hyperglycemia on maternal and neonatal outcomes. STUDY DESIGN: This was a retrospective case-control study of singleton, nonanomalous pregnancies with an elevated 1-hour glucose screening test (GST) completed after 23 weeks of gestation. IGM was defined as a 1-hour GST of >130, but less than two abnormal values on 3-hour glucose tolerance test (GTT). Gestational diabetes was defined as two or more abnormal values on 3-hour GTT. Ultrasound evidence of hyperglycemia was defined as abdominal circumference >95th centile and/or polyhydramnios. Individuals with IGM were divided into those with ultrasound evidence of hyperglycemia (impaired glucose metabolism consistent with ultrasound findings [IGM-US]) and those without IGM. Maternal demographics, delivery outcomes (gestational age at delivery, delivery mode, shoulder dystocia, lacerations), postpartum hemorrhage, and neonatal outcome (birth weight centile [BW%], neonatal intensive care unit admission, hypoglycemia, and glucose) were recorded. Composite morbidity was tabulated. Delivery and neonatal outcome variables were compared in individuals with IGM-US, IGM, and gestational diabetes mellitus (GDM). Odds ratios were calculated and adjusted for maternal age, BMI, and gestational weight gain. RESULTS: A total of 637 individuals with an abnormal 1-hour GST were included (122 with IGM-US, 280 with IGM, and 235 with GDM). When compared to the IGM group, IGM-US had higher rates of cesarean delivery and BW% > 90th centile at delivery (adjusted odds ratio [aOR]: 1.7 [1.1-2.8] and aOR: 5.9 [2.7-13.0], respectively). Individuals with GDM also demonstrated similar rates with BW% > 90% but not cesarean section(aOR: 3.9 [1.8-8.5] and aOR: 1.4 [0.9-2.1], respectively). The remaining maternal and fetal outcomes were similar. CONCLUSION: Women with impaired glucose tolerance should have a third-trimester ultrasound to identify an increased risk of perinatal complications. KEY POINTS: · Women with elevated blood glucose screening should be evaluated with third-trimester ultrasound to identify risks for perinatal morbidity.. · The third-trimester ultrasound identifies individuals at risk for cesarean section.. · Counseling should be completed with individuals with polyhydramnios or accelerated growth..
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BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS: Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS: Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24-31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS: Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.
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Oxigenação por Membrana Extracorpórea , Complicações Cardiovasculares na Gravidez/terapia , Transtornos Puerperais/terapia , Insuficiência Respiratória/terapia , Choque/terapia , Adulto , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Recém-Nascido , Nascido Vivo , Período Pós-Parto , Gravidez , Complicações Cardiovasculares na Gravidez/mortalidade , Complicações Cardiovasculares na Gravidez/fisiopatologia , Transtornos Puerperais/mortalidade , Transtornos Puerperais/fisiopatologia , Insuficiência Respiratória/mortalidade , Insuficiência Respiratória/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Choque/mortalidade , Choque/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
OBJECTIVE: To evaluate current opioid prescription practices following a cesarean delivery. METHODS: Women were asked to participate in a prospective observational cohort study following a cesarean delivery. Participants were asked about their opioid use after discharge, amount leftover, subjective pain score, and satisfaction. RESULTS: A total of 344 women had cesarean deliveries during the study period, 242 were approached, 171 met eligibility criteria, and 109 were included in the analysis. Women in our study were predominantly African American (66.1%), high school graduates (32.1%), publicly insured (65.1%), single (55%) working mothers (68.8%). Most had been previously prescribed opioids (70.6%), of which 58.4% had a prior cesarean delivery. Only 78.8% of study participants took their opioid prescriptions, and 89.6% had an average of 17 pills leftover. The number of pills taken correlated with those prescribed in the study. Improved satisfaction in pain control with opioid and non-opioid alternatives was associated with a decrease in opioids used. Similarly, the participants' perception of their abundant prescription quantity was associated with a decrease in prescription taken. CONCLUSION: Women were prescribed excess opioids. Excess opioids accounted for 63.3% of all pills filled, a total of 1670 pills leftover, most of which were stored in an unlocked location (75.6%). Our data showed a discrepancy of pills prescribed (24) compared to those used (10), which was also perceived as enough or too many by our participants. Our study demonstrates that women would benefit from fewer opioid pills and a discussion based on their pain perception.
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Analgésicos Opioides , Dor Pós-Operatória , Estudos de Coortes , Feminino , Humanos , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Gravidez , Prescrições , Estudos ProspectivosRESUMO
OBJECTIVE: This study aimed to identify the optimal gestational age for delivery of pregnancies complicated by fetal growth restriction (FGR) without Doppler abnormalities. STUDY DESIGN: Cases of FGR (ultrasound-estimated fetal weight less than the 10th or abdominal circumference less than the 5th percentile for gestational age) without fetal Doppler abnormalities were identified from a fetal ultrasound database. The primary outcome was a composite of perinatal mortality and morbidity. The risk of the primary outcome for each gestational age was compared with pregnancies delivered at 390/7 to 406/7 weeks. Odds ratios were adjusted for potential confounders. RESULTS: The analysis included 1,024 pregnancies. FGR was identified at a median of 235/7 weeks (range: 20-42 weeks). Four cases of fetal death (234/7-376/7 weeks) and no neonatal deaths were included. The primary outcome occurred in 209 patients (20.4%). This was greater for patients delivered at less than 37 weeks' gestation than for those delivered at or after 39 weeks' gestation, with no increased risk after 40 weeks. CONCLUSION: Among pregnancies complicated by suspected FGR without Doppler abnormalities, delivery at 39 weeks is safe with no difference in perinatal outcomes from 37 to 42 weeks.
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Parto Obstétrico , Retardo do Crescimento Fetal , Idade Gestacional , Ultrassonografia Pré-Natal , Adulto , Índice de Apgar , Feminino , Retardo do Crescimento Fetal/diagnóstico por imagem , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Unidades de Terapia Intensiva Neonatal , Modelos Logísticos , Masculino , Gravidez , Estudos Retrospectivos , Natimorto , Fatores de Tempo , Ultrassonografia Doppler , Adulto JovemRESUMO
Pregnant women with diabetes are at higher risk of adverse outcomes. Prevention of such outcomes depends on strict glycemic control, which is difficult to achieve and maintain. A variety of technologies exist to aid in diabetes management for nonpregnant patients. However, adapting such tools to meet the demands of pregnancy presents multiple challenges. This article reviews the key attributes digital technologies must offer to best support diabetes management during pregnancy, as well as some digital tools developed specifically to meet this need. Despite the opportunities digital health tools present to improve the care of people with diabetes, in the absence of robust data and large research studies, the ability to apply such technologies to diabetes in pregnancy will remain imperfect.
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Hospital noise is associated with adverse effects on patients and staff. Communication through overhead paging is a major contributor to hospital noise. Replacing overhead paging with smartphones through a clinical mobility platform has the potential to reduce transitory noises in the hospital setting, though this result has not been described. The current study evaluated the impact of replacing overhead paging with a smartphone-based clinical mobility platform on transitory noise levels in a labor and delivery unit. Transitory noises were defined as sound levels greater than 10 dB above baseline, as recorded by a sound level meter. Prior to smartphone implementation, 77% of all sound levels at or above 60 dB were generated by overhead paging. Overhead pages occurred at an average rate of 3.17 per hour. Following smartphone implementation, overhead pages were eliminated and transitory noises decreased by two-thirds (P < 0.001). The highest recorded sound level decreased from 76.54 to 57.34 dB following implementation. The percent of sounds that exceeded the thresholds recommended by the Environmental Protection Agency and International Noise Council decreased from 31.2% to 0.2% following implementation (P < 0.001). Replacement of overhead paging with a clinical mobility platform that utilized smartphones was associated with a significant reduction in transitory noise. Clinical mobility implementation, as part of a noise reduction strategy, may be effective in other inpatient settings.
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Sistemas de Comunicação no Hospital , Smartphone , Hospitais , Humanos , RuídoRESUMO
OBJECTIVE: This study aims to investigate the perinatal outcome of fetuses with polyhydramnios and/or accelerated growth among women with a normal oral glucose challenge test (oGCT). METHODS: Singleton, nonanomalous pregnancies with an oGCT(< 130 mg/dL) at 24 to 28 weeks, who subsequently demonstrate polyhydramnios (amniotic fluid index > 24 cm or maximum vertical pocket > 8 cm) and/or accelerated growth (abdominal circumference > 95th percentile) on two-third trimester examinations were studied. Maternal demographics, delivery, and neonatal information were recorded. Cases were compared with a reference group (normal oGCT with neither abnormal third-trimester growth nor polyhydramnios). RESULTS: A total of 282 pregnancies were in the study group, and 663 were in the reference group. Deliveries in the study group were at a higher risk for birth weight (BW)% > 90%, standard deviation, and postpartum hemorrhage when compared with the reference group (adjusted odds ratio: 2.3-5.6). Pregnancies complicated by both polyhydramnios and accelerated fetal growth were significantly more likely to result in a BW% > 90% (odds ratio [OR]: 18.5; 95% confidence interval [CI]: 8.9-38.6) and PPH (OR: 4.2; 95% CI: 2.4-7.6). CONCLUSION: Pregnancies with normal oGCT that develop polyhydramnios and accelerated growth are at higher risk for maternal and neonatal complications. Isolated polyhydramnios without accelerated growth increases the risk for delivery complications but not neonatal morbidity.
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Desenvolvimento Fetal , Complicações do Trabalho de Parto/diagnóstico por imagem , Poli-Hidrâmnios/diagnóstico por imagem , Complicações na Gravidez/diagnóstico por imagem , Resultado da Gravidez , Adolescente , Adulto , Líquido Amniótico , Índice de Apgar , Feminino , Macrossomia Fetal/etiologia , Teste de Tolerância a Glucose , Humanos , Recém-Nascido , Maryland/epidemiologia , Pessoa de Meia-Idade , Complicações do Trabalho de Parto/epidemiologia , Poli-Hidrâmnios/epidemiologia , Hemorragia Pós-Parto/etiologia , Gravidez , Complicações na Gravidez/epidemiologia , Terceiro Trimestre da Gravidez , Estudos Retrospectivos , Ultrassonografia Pré-Natal , Adulto JovemRESUMO
OBJECTIVE: To evaluate whether fetal epicardial fat thickness (EFT) differs in diabetic and nondiabetic pregnant women. METHODS: Retrospective case-control study of pregnancies between 24 and 36 weeks complicated by preexisting (PDM) or gestational (GDM) diabetes mellitus, matched one to one with controls for body mass index and gestational age (GA). Epicardial fat was identified as the hypoechogenic area between myocardium and visceral pericardium over the right ventricle and its thickness was measured by a single observer blinded to clinical condition and outcomes. A linear regression analysis was performed to assess the relationship between GA and EFT, and regression lines were compared between diabetics and controls. RESULTS: 53 PDM and 53 GDM pregnant women were matched with controls. With the exception of maternal age, the demographics were similar among groups. EFT increased significantly with advancing gestation in both diabetics and controls (P < 0.0001) and was significantly greater in diabetics than in controls (P < 0.0001). The best fit lines were different between diabetics (EFT = 0.05 × GA + 0.07 mm; R2 = 0.70) and controls (EFT = 0.07 × GA + 0.04 mm; R2 = 0.93) (P < 0.0001). CONCLUSION: Fetal EFT was greater in diabetics than in nondiabetics, and even greater in pregestational diabetics. EFT maybe an additional and/or earlier marker to identify early changes in fetal metabolism before accelerated fetal growth and polyhydramnios is apparent.
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Tecido Adiposo/diagnóstico por imagem , Tecido Adiposo/metabolismo , Diabetes Mellitus/fisiopatologia , Pericárdio/diagnóstico por imagem , Pericárdio/embriologia , Complicações na Gravidez/fisiopatologia , Ultrassonografia Pré-Natal/métodos , Tecido Adiposo/embriologia , Adulto , Estudos de Casos e Controles , Feminino , Coração Fetal/diagnóstico por imagem , Coração Fetal/metabolismo , Coração Fetal/fisiopatologia , Humanos , Pericárdio/metabolismo , Gravidez , Estudos RetrospectivosRESUMO
OBJECTIVES: To determine reference values for sonography-based estimated fetal weight (EFW) in twin gestations in one single tertiary medical center in the United States. METHODS: A retrospective longitudinal analysis of EFW evaluations of fetuses of twin gestations between November 2006 and June 2016. Fetuses with major congenital anomalies or chromosomal abnormalities were excluded. Estimated fetal weight was calculated using the Hadlock 1985 formula. Linear mixed models were used to allow for multiple but inconsistent observations among individuals, and to account for intertwin differences as well as for gender. Reference values were constructed using a best-fit regression model for estimation of mean and standard deviation at each gestational age after normalization of variables. Chorionicity-specific curves were constructed. RESULTS: A total of 5515 ultrasound examinations were performed in 2115 twin pregnancies between 24 and 38 weeks of gestation (2.6 ± 4.0 scans/pregnancy). Values corresponding to the 5th, 10th, 50th, 90th, and 95th percentiles for EFW are presented for every gestational age. At 28, 32, and 36 weeks, values were as follows: 855, 1109, and 1363 g; 1351, 1732, and 2294 g; and 1363, 2112, and 2881 g for the 10th, 50th, and 90th percentiles, respectively. Chorionicity-specific curves are presented for comparison with previously published references. CONCLUSIONS: Reference values for sonographic-based fetal growth are presented for clinical and research use.
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Córion/diagnóstico por imagem , Peso Fetal , Gravidez de Gêmeos , Ultrassonografia Pré-Natal/métodos , Adolescente , Adulto , Feminino , Humanos , Estudos Longitudinais , Pessoa de Meia-Idade , Gravidez , Valores de Referência , Estudos Retrospectivos , Adulto JovemRESUMO
A 27-week fetus evaluated for bradycardia and hydrops was found to have anti-SSA-negative 2° atrioventricular block and ventricular tachycardia. A presumptive diagnosis of fetal long QT syndrome was made. Transplacental pharmacotherapy with intravenous magnesium and lidocaine restored sinus rhythm. At 30 6/7 weeks, the infant was delivered due to premature labor. Despite postnatal treatment with mexiletine and propranolol, she developed torsades de pointes. Ultimately, a de novo KCNH2 G628S mutation was diagnosed. She received an implantable cardiac defibrillator at 5 months of age. Early diagnosis and a multidisciplinary approach allowed successful in utero treatment and anticipatory postnatal management. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:168-170, 2017.
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Síndrome do QT Longo/diagnóstico , Síndrome do QT Longo/terapia , Diagnóstico Pré-Natal/métodos , Adulto , Eletrocardiografia , Feminino , Determinação da Frequência Cardíaca/métodos , Humanos , Lidocaína/uso terapêutico , Síndrome do QT Longo/embriologia , Magnésio/uso terapêutico , Monitorização Fisiológica/métodos , Gravidez , Ultrassonografia Pré-Natal , Adulto JovemRESUMO
OBJECTIVE: The purpose of this study was to evaluate the surveillance characteristics that precede stillbirth in growth-restricted fetuses that receive integrated Doppler and biophysical profile scoring (BPS). STUDY DESIGN: Nine hundred eighty-seven singleton pregnancies that were complicated by fetal growth restriction had multivessel Doppler scans (umbilical and middle cerebral arteries [MCA], ductus venosus, and umbilical vein) and BPS. Surveillance findings were compared between live births and stillbirths. RESULTS: Forty-seven stillbirths occurred in 2 clusters, 37 at <34 weeks of gestation and 10 thereafter. Before 34 weeks of gestation, stillbirths had parallel escalation of umbilical artery and ductus venosus Doppler findings followed by abnormal BPS. At ≥34 weeks of gestation, only a decline in MCA pulsatility index was observed, and 75% of stillbirths were unanticipated by the BPS. CONCLUSION: Before 34 weeks of gestation, multivessel Doppler abnormality anticipates an abnormal BPS and subsequent stillbirth. After 34 weeks of gestation, stillbirths occur after MCA brain-sparing in a shorter interval than predicted by a normal BPS. Recognition of these differences in clinical behavior requires consideration for the planning of monitoring intervals in preterm and term fetal growth restriction.
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Retardo do Crescimento Fetal/diagnóstico por imagem , Nascido Vivo , Artéria Cerebral Média/diagnóstico por imagem , Natimorto , Artérias Umbilicais/diagnóstico por imagem , Veias Umbilicais/diagnóstico por imagem , Adolescente , Adulto , Velocidade do Fluxo Sanguíneo , Cardiotocografia , Estudos de Coortes , Feminino , Retardo do Crescimento Fetal/fisiopatologia , Idade Gestacional , Humanos , Pessoa de Meia-Idade , Gravidez , Estudos Retrospectivos , Ultrassonografia Doppler , Ultrassonografia Pré-Natal , Adulto JovemRESUMO
OBJECTIVE: This study aimed to systematically investigate a wide range of obstetrical and neonatal outcomes with respect to 2 types of prepregnancy bariatric surgery, Roux-en-Y gastric bypass and sleeve gastrectomy, through: (1) providing a meta-analysis of the effect of bariatric surgery (Roux-en-Y gastric bypass vs no surgery and, separately, sleeve gastrectomy vs no surgery) on adverse obstetrical and neonatal outcomes, and (2) comparing the relative benefit of Roux-en-Y gastric bypass vs sleeve gastrectomy using both conventional and network meta-analysis. DATA SOURCES: We searched PubMed, Scopus, and Embase systematically from inception up to April 30, 2021. ELIGIBILITY CRITERIA: Studies reporting on pregnancies' obstetrical and neonatal outcomes with respect to 2 types of prepregnancy bariatric surgery-Roux-en-Y gastric bypass and sleeve gastrectomy-were included. The included studies either indirectly compared between the procedure and controls or directly compared between the 2 procedures. METHODS: We performed a systematic review followed by pairwise and network meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In the pairwise analysis, multiple obstetrical and neonatal outcomes were tabulated and compared between 3 groups: (1) Roux-en-Y gastric bypass vs controls, (2) sleeve gastrectomy vs controls, and (3) Roux-en-Y gastric bypass vs sleeve gastrectomy. Primary outcomes included small for gestational age, large for gestational age, gestational hypertension/preeclampsia, and gestational diabetes mellitus. Secondary outcomes included preterm birth, anemia, cesarean delivery, and biochemical profile. The random-effects model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. The Newcastle-Ottawa scale was used to assess individual study quality. To resolve inconclusive findings and to rank current treatments, network meta-analysis was conducted for the primary outcomes. Quality of evidence was assessed with the Confidence in Network Meta-Analysis approach and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) tool within the summary of findings table. RESULTS: A total of 20 studies were included, reporting on 40,108 pregnancies, of which 5194 underwent Roux-en-Y gastric bypass, 405 underwent sleeve gastrectomy, and 34,509 were controls. Compared with controls, Roux-en-Y gastric bypass increased the risk of small for gestational age infants (odds ratio, 2.56; 95% confidence interval, 1.77-3.70; I2, 29.1%; P<.00001), decreased the risk of large for gestational age infants (odds ratio, 0.25; 95% confidence interval, 0.18-0.35; I2, 0%; P<.00001), decreased gestational hypertension/preeclampsia (odds ratio, 0.54; 95% confidence interval, 0.30-0.97; I2, 26.8%; P=.04), decreased gestational diabetes mellitus (odds ratio, 0.43; 95% confidence interval, 0.23-0.81; I2, 32%; P=.008), increased maternal anemia (odds ratio, 2.70; 95% confidence interval, 1.53-4.79; I2, 40.5%; P<.001), increased neonatal intensive care unit admission (odds ratio, 1.36; 95% confidence interval, 1.04-1.77; I2, 0%; P=.02), and decreased mean gestational weight gain (mean difference, -3.37 kg; 95% confidence interval, -5.62 to -1.11; I2, 65.3%; P=.003). Only 3 studies compared sleeve gastrectomy with controls, and found no significant differences in primary outcomes or in mean gestational weight gain. The network meta-analysis showed that Roux-en-Y gastric bypass (malabsorptive procedure) resulted in greater decrease of large for gestational age, gestational hypertension/preeclampsia, and gestational diabetes mellitus, and a greater increase in small for gestational age infants when compared with sleeve gastrectomy (restrictive procedure). However, the small number of studies, small number of sleeve gastrectomy patients, limited outcomes, and data heterogeneity resulted in low-to-moderate network GRADE of evidence. CONCLUSION: This network meta-analysis showed that Roux-en-Y gastric bypass, compared with sleeve gastrectomy, resulted in greater decrease in large for gestational age, gestational hypertension/preeclampsia, and gestational diabetes mellitus, but in greater increase in small for gestational age infants. Certainty of evidence in the network meta-analysis was of a low-to-moderate GRADE. Evidence is still lacking for periconception biochemical profile, congenital malformations, and reproductive health outcomes for both interventions; thus, future well-designed prospective studies are needed to further characterize these outcomes.
Assuntos
Anemia , Diabetes Gestacional , Derivação Gástrica , Ganho de Peso na Gestação , Hipertensão Induzida pela Gravidez , Obesidade Mórbida , Pré-Eclâmpsia , Nascimento Prematuro , Gravidez , Feminino , Humanos , Recém-Nascido , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Obesidade Mórbida/diagnóstico , Obesidade Mórbida/epidemiologia , Obesidade Mórbida/cirurgia , Hipertensão Induzida pela Gravidez/etiologia , Hipertensão Induzida pela Gravidez/cirurgia , Diabetes Gestacional/diagnóstico , Diabetes Gestacional/epidemiologia , Diabetes Gestacional/etiologia , Metanálise em Rede , Nascimento Prematuro/epidemiologia , Nascimento Prematuro/etiologia , Anemia/complicações , Anemia/cirurgia , Gastrectomia/efeitos adversos , Gastrectomia/métodosRESUMO
OBJECTIVE: The objectives of this study were (1) to estimate the association between marginal placental cord insertion (PCI) and small for gestational age (SGA) and other adverse perinatal outcomes and (2) to determine if pregnancy-associated plasma protein A (PAPP-A) levels was altered in these patients. METHODS: It was a retrospective cohort study of singleton pregnancies undergoing ultrasound between 2016 and 2018. Marginal PCI was defined as a distance of ≤2 cm from placental edge to PCI site, visualized in both sagittal and transverse planes, and diagnosed between 16 and 32 weeks. Velamentous PCI were excluded. The primary outcome was SGA, defined as birthweight below 10th percentile for gestational age. Pregnancies with marginal PCI were compared to those with normal PCI with respect to maternal characteristics, PAPP-A levels and adverse perinatal and delivery outcomes. RESULTS: The incidence of marginal PCI was 4.2% (76/1819). Compared to those with a normal PCI, patients with a marginal PCI were more likely to be nulliparous and less likely to be African American or morbidly obese (p < .05). SGA rate was similar between the groups (17.6% vs. 18.1%). There was a trend toward an increased incidence of oligohydramnios, polyhydramnios and breech presentation in patients with marginal PCI; however, these did not reach statistical significance. The incidence of low PAPP-A level was comparable between the groups (18.4% vs. 14.3%, p > .05). CONCLUSION: Our study did not demonstrate any increase in adverse pregnancy outcomes in the presence of marginal PCI. These findings may provide reassurance for counseling patients with this sonographic finding.
Assuntos
Obesidade Mórbida , Placenta , Feminino , Seguimentos , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Gravidez , Resultado da Gravidez/epidemiologia , Estudos RetrospectivosRESUMO
OBJECTIVE: Surgical site infections (SSIs) are a major source of morbidity and mortality for women who undergo cesarean section (c-section). SSIs following c-section include wound infection, infection of the endometrium (endometritis) and intra-abdominal infections. Perioperative interventions to prevent these infections continue to be studied, including the use of vaginal preparation prior to c-section. Although literature has shown that the use of vaginal preparation prior to c-section decreases the rate of SSI, real-world clinical data regarding effective implementation of these policies are lacking. The objectives of this study were to determine (1) if a vaginal preparation policy could be implemented in a real-world setting with a high compliance rate and (2) to identify factors led to differences in compliance with policy. STUDY DESIGN: This was a secondary analysis of a retrospective cohort study designed to examine the incidence of SSI after c-section before and after the implementation of vaginal preparation policy. The primary outcomes included implementation rates of the vaginal preparation for the post policy cohort. Secondary outcomes included subgroup analysis of policy adherence based on time of day, urgency of delivery, membrane status, labor status, and maternal factors. RESULTS: Overall adherence to the vaginal preparation policy was 87.2% of patients. Maternal factors did not impact the rate of policy adherence. 81.4% of patients undergoing c-section at night had vaginal prep completed compared to 89.9% of patients undergoing c-section during the day (p = .016). 63.8% of patients undergoing emergent c-section had vaginal prep completed, compared to 90.1% of patients undergoing non-emergent c-section (p < .001). Laboring patients were more likely to have vaginal preparation completed (143 (95.3%) vs. 225 (82.7%), p = .009). CONCLUSIONS: Compliance with vaginal preparation policy was high. Patients who are undergoing evening deliveries and emergent deliveries are less likely to have vaginal preparation completed. Some of these differences are likely attributable to perceived urgency of the c-section. It is important that interventions are identified such as staff education and standardization of documentation to improve rates of policy adherence.
Assuntos
Cesárea , Endometrite , Humanos , Feminino , Gravidez , Estudos Retrospectivos , Endometrite/prevenção & controle , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle , PolíticasRESUMO
INTRODUCTION: Prone positioning has been widely utilized in ARDS management before and during the COVID-19 pandemic due to its demonstrated mortality benefits. In pregnancy, proning requires careful attention to often overlooked physiologic changes in pregnancy and additional technical challenges accompanying a gravid abdomen. The purpose of this manuscript is to demonstrate a proning technique that was successfully used at our institution to avoid premature delivery of the fetus while improving maternal outcomes. All technical challenges are addressed in the instructional videos using a pregnant model with twin gestation at 32 weeks. METHODS: We reviewed all the patients' charts with positive SARS-CoV-2 from March 2020 until July 2020 and identified those who developed ARDS. Subsequently, we identified four patients that were proned during the antepartum period. We described their clinical course, including the change in ventilatory parameters in relationship with proning timing. Stepwise instructions for self-proning and proning in mechanically ventilated patients are illustrated in video format. RESULTS: During the study period, we identified 100 pregnant patients with SARS-CoV-2 infection. Mechanical ventilation was required in 8 of these patients. In four cases, proning was performed during the antepartum period. We were able to improve the P/F ratio while decreasing FiO2 and avoiding iatrogenic preterm delivery. Except for one case, where the patient self-extubated and required emergent delivery, all patients were successfully extubated, followed for prenatal care, and delivered for usual obstetric indications. CONCLUSION: Proning remains a well-proven intervention in ARDS and should be considered in pregnant women when indicated. We recognize that proning might not be effective in all cases. However, proning positioning is an option to improve oxygenation in patients with severe hypoxemia when the next consideration is delivery of a premature infant or maternal cannulation for extracorporeal membrane oxygenation.
Assuntos
COVID-19 , Síndrome do Desconforto Respiratório , Recém-Nascido , Humanos , Feminino , Gravidez , COVID-19/complicações , Pandemias , SARS-CoV-2 , Decúbito Ventral/fisiologia , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/terapia , Respiração ArtificialRESUMO
BACKGROUND: Although obesity is a known risk factor for cesarean delivery, there is a paucity of data on the course of induction of labor in these patients. OBJECTIVE: With emerging data on the safety of 39-week inductions, we aimed to: (1) determine if Class III obesity, including morbid obesity, is an independent risk factor for nonachievement of complete dilation and vaginal delivery after induction of labor, (2) evaluate the characteristics of the induction of labor course and immediate complications, and (3) evaluate the number of induction agents necessary to be associated with vaginal deliveries. We hypothesized that as body mass index increased, it would take longer to achieve complete cervical dilation, more induction agents would be required, and there would be a higher rate of cesarean delivery. STUDY DESIGN: This was a retrospective cohort study of singleton gestations undergoing induction of labor from 2013 to 2020 at a single center. Study groups were defined as nonobese (body mass index <30 kg/m2), non-Class III obesity (body mass index of 30-39.9 kg/m2), and Class III obesity (body mass index ≥40 kg/m2). The primary outcome was achievement of complete cervical dilation. Secondary outcomes included time from start of induction to complete dilation, cesarean delivery rates, doses of misoprostol used, combination of induction agents used, and incidence of chorioamnionitis and postpartum hemorrhage. Univariate and multivariate logistic regression analyses were used to estimate risks. A secondary analysis was performed on nulliparous patients. RESULTS: A total of 3046 individuals met the inclusion criteria. As body mass index increased, the indications for induction were more likely to be maternal. Rate of achievement of complete dilation decreased with increasing body mass index (973 [88.5%] in the body mass index <30 group vs 455 [70.8%] in the body mass index ≥40 group; adjusted odds ratio, 0.3; 95% confidence interval, 0.2-0.4). The rate of cesarean delivery also increased (149 [13.5%] in the body mass index <30 group vs 207 [30.9%] in the body mass index ≥40 group; adjusted odds ratio, 3.2; 95% confidence interval, 2.5-4.2), as did the time to complete dilation (15.3 hours in the body mass index <30 group vs 18.8 hours in the body mass index ≥40 group; P<.001). Morbidly obese patients required higher doses and more types of induction agents. Misoprostol was used as the sole induction agent in 362 (35.1%) of patients in the body mass index <30 group vs 160 (25.4%) of patients in the body mass index ≥40 group (adjusted odds ratio, 0.6; 95% confidence interval, 0.5-0.8). In the body mass index ≥40 group, a greater number required a combination of misoprostol, mechanical ripening, and oxytocin for induction (147 [14.3%] in the body mass index <30 group vs 158 [25.0%] in the body mass index ≥40 group; adjusted odds ratio, 1.7; 95% confidence interval, 1.3-2.3). For nulliparous patients, the rate of cesarean delivery was significantly higher with increasing body mass index (118 [18.3%] in the body mass index <30 group and 157 [48.2%] in the body mass index ≥40 group; P<.001), with 5 more hours spent in labor (18.3 hours in the body mass index <30 group vs 23.3 hours in the body mass index ≥40 group; P<.001). Nulliparous patients were also more likely to require multiple induction agents (122 [20.3%] for body mass index <30 vs 108 [33.6%] for body mass index ≥40; P<.001). CONCLUSION: Class III obesity is an independent risk factor for nonachievement of complete dilation and vaginal delivery following induction of labor. Furthermore, inductions in these patients require more time and are more likely to require multiple agents.