Placenta Accreta Spectrum Disorders: A National Survey.

OBJECTIVES: Describe the current practice of Canadian obstetricians-gynaecologists in managing placenta accreta spectrum (PAS) disorders from suspicion of diagnosis to delivery planning and explore the impact of the latest national practice guidelines on this topic. METHODS: We distributed a cross-sectional bilingual electronic survey to Canadian obstetricians-gynaecologists in March-April 2021. Demographic data and information on screening, diagnosis, and management were collected using a 39-item questionnaire. The survey was validated and pretested among a sample population. Descriptive statistics were used to present the results. RESULTS: We received 142 responses. Almost 60% of respondents said they had read the latest Society of Obstetricians and Gynaecologists of Canada clinical practice guideline on PAS disorders, published in July 2019. Nearly 1 in 3 respondents changed their practice following this guideline. Respondents highlighted the importance of 4 key points: (1) limiting travel to thereby remain close to a regional care centre, (2) preoperative anemia optimization, (3) performance of cesarean-hysterectomy leaving the placenta in situ (83%), (4) access via midline laparotomy (65%). Most respondents recognized the importance of perioperative blood loss reduction strategies such as tranexamic acid and perioperative thromboprophylaxis via sequential compression devices and low-molecular-weight heparin until full mobilization. CONCLUSIONS: This study demonstrates the impact of the Society of Obstetricians and Gynaecologists of Canada's PAS clinical practice guideline on management choices made by Canadian clinicians. Our study highlights the value of a multidisciplinary approach to reducing maternal morbidity in individuals facing surgery for a PAS disorder and the importance of regionalized care that is resourced to provide maternal-fetal medicine and surgical expertise, transfusion medicine, and critical care support.

Arterial Health After Preeclampsia: Role of Chronic Hypertension in the Early Vascular Aging (EVA) Study.

BACKGROUND: Preeclampsia (PE) is associated with increased cardiovascular risk. Recent data have shown worse left ventricular remodeling and diastolic function in women with PE and persistent hypertension (HTN). We performed a comprehensive arterial hemodynamic assessment to evaluate the contribution of persistent HTN on arterial health after PE. METHODS: We recruited 40 women with PE history and 40 age-matched controls (6 months to 6 years postpartum). We evaluated arterial hemodynamics with validated techniques combining applanation tonometry and transthoracic echocardiography, comparing three groups: previous PE with persistent HTN (PE-HTN), previous PE with normalized blood pressure (PE-noHTN) and controls, using multivariable linear regression adjusted for age, body surface area, heart rate, diabetes, smoking history, creatinine, and gravidity. RESULTS: Eight (20%) of the post-PE women had persistent HTN. Mean age was 35.8 ±â€…3.9 years, median number of pregnancies was 2 (range 1-7), and time since last pregnancy 2.1 (range 0.5-5.7) years (not different between groups, P > 0.05). Compared to controls and to PE-noHTN, PE-HTN had higher aortic stiffness, wave reflections, pulsatile, and steady arterial load (P < 0.05 for each). Among PE-noHTN, aortic stiffness, wave reflections and steady arterial load were worse than controls (P < 0.05 for each), with smaller effect sizes. CONCLUSIONS: This is the most comprehensive assessment of arterial hemodynamics and first to demonstrate the contribution of persistent HTN on worse arterial health following PE. Since measures of arterial health are associated with cardiovascular events in the population, the combination of previous PE and chronic HTN may represent a higher risk subgroup who could benefit from targeted prevention strategies.

Delayed-Interval Delivery in Multiple Pregnancy: A Single-Center Experience of Five Cases.

Objectives To describe the obstetric management and perinatal outcomes in multiple pregnancies with delayed-interval delivery (DID) of the cotwin in a tertiary hospital. Methods This is a retrospective chart review of all cases of DID between December 2021 and 2022 at The Ottawa Hospital. Five cases of DID were identified and reviewed to obtain information on obstetric management and maternal-neonatal outcomes. We included eligible twins and triplets. No multiples were excluded. We obtained ethics approval for this case series. Results Four sets of dichorionic diamniotic twins and one trichorionic triamniotic triplet were included. Our patients were admitted between 17 3/7 and 21 5/7 weeks of gestation. We achieved an interval delivery range between 1 and 36 days. Four out of six multiples did not survive in DID. The two surviving newborns were born at 23 0/7 and 23 2/7 , stayed in the neonatal intensive care unit (NICU) for 111 and 131 days, discharged with a weight of 3,594 and 2,743 g, respectively. All DID cases were delivered spontaneously except for two patients that required augmentation due to maternal sepsis. Conclusion Despite the high risk of maternal, fetal, and neonatal morbidity and mortality, if delivery of the first twin occurs before 20 gestational weeks, DID could be considered in selected cases to improve outcomes for the cotwin.

The EVA (Early Vascular Aging) Study: Association of Central Obesity With Worse Arterial Health After Preeclampsia.

Background Women with preeclampsia have a higher risk of cardiovascular disease. This is partly explained by the worse arterial health after preeclampsia. Central obesity (CO) is a risk factor for both preeclampsia and cardiovascular disease. Whether CO contributes to further worsening of arterial health after preeclampsia remains unclear. Our objective was to evaluate the effect of CO and previous preeclampsia on arterial hemodynamics. Methods and Results We studied 40 women with previous preeclampsia (<6 years) and 40 age-matched controls with previous normotensive pregnancy in the same timeframe. We estimated arterial hemodynamics with validated techniques combining applanation tonometry and echocardiography. CO was defined as a waist-to-hip ratio ≥0.85. Differences in arterial hemodynamics across the 3 groups (preeclampsia with CO, preeclampsia without CO, and controls) were assessed with multivariable linear regression models adjusted for potential confounders. Twenty-six (65%) of the participants with preeclampsia had CO compared with 18 (45%) controls. Mean waist-to-hip ratio in patients with preeclampsia with CO, those with preeclampsia and no CO, and controls was 0.94±0.05, 0.80±0.04, and 0.83±0.07, respectively. In multivariable analyses, women with preeclampsia and CO had higher central blood pressure, arterial stiffness (carotid-femoral pulse wave velocity), steady arterial load (systemic vascular resistance), and wave reflections (reflected pressure wave amplitude, augmentation index) compared with controls (P<0.05 for each). Fewer hemodynamic domains were altered in the preeclampsia with no CO group, with higher central diastolic blood pressure, systemic vascular resistance, and wave reflections than controls (P<0.05). Conclusions Women with previous preeclampsia who also experience CO have the greatest alterations in arterial health and hemodynamics. Patients with preeclampsia with CO may represent a higher-risk subgroup who could be targeted for risk stratification and primary prevention of cardiovascular disease.

The EVA Study: Early Vascular Aging in Women With History of Preeclampsia.

Background Early vascular aging (EVA) is associated with higher risk of adverse cardiovascular events and can be estimated noninvasively by assessing arterial hemodynamics. Women with a history of preeclampsia have increased risk of cardiovascular disease, but underlying mechanisms are incompletely understood. We hypothesized that women with a history of preeclampsia display persistent arterial abnormalities and EVA in the postpartum period. Methods and Results We performed a comprehensive, noninvasive arterial hemodynamic evaluation in women with a history of preeclampsia (n=40) and age-matched controls with previous normotensive pregnancies (n=40). We used validated methods integrating applanation tonometry with transthoracic echocardiography to obtain measures of aortic stiffness, steady and pulsatile arterial load, central blood pressure, and arterial wave reflections. Presence of EVA was defined as aortic stiffness higher than that predicted from reference values based on the participant's age and blood pressure. The association of preeclampsia with arterial hemodynamic variables was assessed with multivariable linear regression, and the association of severe preeclampsia with EVA was assessed with multivariable logistic regression, adjusted for confounders. We found that women with a history of preeclampsia had greater aortic stiffness, steady arterial load, central blood pressure, and arterial wave reflections when compared with controls. We observed a dose-response relationship, with the greatest abnormalities observed in subgroups with severe, preterm, or recurrent preeclampsia. Women with severe preeclampsia had 9.23 times greater odds of having EVA as compared with controls (95% CI, 1.67-51.06, P=0.011) and 7.87 greater odds of EVA as compared with women with nonsevere preeclampsia (95% CI, 1.29-47.77, P=0.025). Conclusions Our study comprehensively characterizes arterial hemodynamic abnormalities after preeclampsia and suggests that specific subgroups of women with a history of preeclampsia exhibit greater alterations in arterial hemodynamics related to arterial health. Our findings have important implications for understanding potential links between preeclampsia and cardiovascular events, and suggest women with severe, preterm, or recurrent preeclampsia as subgroups who may deserve intensification of efforts for prevention and early detection of cardiovascular disease.

Association between Levels of Total Cell-Free DNA and Development of Preeclampsia-A Literature Review.

Objectives The aim of the study is to synthesize the evidence and evaluate the total cell-free deoxyribonucleic (cfDNA) associated with the prediction of preeclampsia (PE). Total cfDNA is constituted by both cell-free fetal DNA (cffDNA) originated mainly from the placenta, and maternal cfDNA derived from maternal leukocytes. Methods A systematic review was conducted by searching PubMed and Medline. Literature reporting levels of total cfDNA in the development of PE was included. Studies that only reported cffDNA, but no cfDNA concentrations were not included in this review. Results Eight studies were included. Seven reported values of cfDNA in PE patients, regardless of early or late onset PE, six of which demonstrated a significant increase of cfDNA in patients who subsequently developed PE. Seven studies evaluated cfDNA levels in the first trimester, six of which showed significant increase of cfDNA concentrations in women who later developed PE. Five studies investigated cfDNA levels in the second trimester, all presenting increased total cfDNA levels in the PE group compared with normal controls. Conclusion Total cfDNA may play a role as a biochemical marker of PE, compared with fetal cfDNA. Large prospective studies with homogeneous populations and standardized methodology are needed to further confirm its predictive value.

Myasthenia gravis e gestação: relato de caso e discussão sobre manejo durante gravidez, parto e puerpério / Myasthenia gravis and gestation: a case report and discussion on its management during pregnancy, delivery and puerperium

Embora relativamente incomum, a myasthenia gravis é a desordem autoimune mais prevalente da transmissão neuromuscular. Sua evolução em longo prazo não é afetada pela gestação, mas seu curso durante a gravidez é imprevisível. O quadro mais comum é de astenia e fadiga muscular, e o momento do parto é o ponto crítico da gestação. Os autores relatam o caso de uma paciente com myasthenia gravis, admitida no Hospital Universitário de Brasília, que teve parto vaginal com analgesia. Também apresentam revisão bibliográfica sobre o manejo dessa condição clínica durante os períodos de gestação, parto e puerpério.

Although relatively uncommon, myasthenia gravis is the most prevalent autoimmune disorder of neuromuscular transmission. The long-term outcomes of myasthenia gravis are not affected by pregnancy; however, the course of the disease is unpredictable during pregnancy. The cardinal features of myasthenia gravis are weakness and fatigability of skeletal muscles, and labor is the critical moment of pregnancy in myasthenic women. The authors report the case of a patient with myasthenia gravis admitted to the University Hospital of Brasilia, who had a vaginal delivery with analgesia. The management of this disorder through pregnancy, labor and pospartum is to be discussed in this review.