Interactive video module and simulated model for uterine manipulation during laparoscopic hysterectomy.

BACKGROUND: Hysterectomy is one of the most common gynecologic surgeries, with an increasing proportion of hysterectomies performed by a laparoscopic approach. Uterine manipulation is critical for patient safety and surgical efficiency; however, the most junior member of the surgical team assumes the responsibility of uterine manipulation, commonly without preparation. The objective of our study was to determine whether kinesthetic learning using a low-cost simulated pelvic model while learning the uterine manipulation maneuvers of a laparoscopic hysterectomy improves learning efficacy and application efficiency compared to an interactive video module alone. METHODS: Our randomized control trial at an academic medical center included forty first-year and second-year medical students. Participants were randomized to the intervention group that used a low-cost simulated pelvic model for kinesthetic learning during the video module or the control group who only had the interactive video module to learn the uterine manipulation maneuvers of a laparoscopic hysterectomy. RESULTS: Participants in the intervention group were less likely to make unnecessary movements with demonstration of both pelvic side walls (right wall: control 78.9%, intervention 42.9%, p < 0.027; left wall: control 94.7%, intervention 66.7%, p < 0.046), and this was more pronounced in novice first-year participants (p < 0.009). Additionally, participants in the intervention group reported higher perceived preparedness (100% versus 71.4% in control group, p < 0.037). However, there was no difference in verbal or physical cues required, time per task, or force used between the groups. CONCLUSION: Kinesthetic practice may not be required for learning the uterine manipulation maneuvers of a laparoscopic hysterectomy, but it may be beneficial for more novice learners and to increase learners' perceived preparedness. Our novel interactive video module alone may be sufficient to prepare learners to perform uterine manipulation maneuvers prior to the operating room.

Laryngeal reinnervation for paediatric vocal cord palsy: a systematic review.

OBJECTIVE: This systematic review aims to provide an overview of the current evidence-base for paediatric surgical reinnervation in unilateral and bilateral vocal fold palsies in clinical practice. We aim to assess patient demographics, surgical technique and pre- and post-operative outcome measures. METHODS: A systematic literature review was performed and reported according to international PRISMA recommendations. A comprehensive search of PubMed, Embase, and Cochrane CENTRAL databases for relevant publications for all available dates with appropriate MESH search criteria was performed. Articles were categorised by four authors independently. A pooled summative analysis was carried out to allow review of demographic and outcome data. RESULTS: Our systematic PRISMA approach resulted in 19 papers being selected for inclusion and analysis with 179 patients undergoing reinnervation (153 unilateral, 26 bilateral). The youngest patient was 1.9 years. Iatrogenic injury to recurrent laryngeal nerve most common aetiology (65.4% and 19.2% of unilateral and bilateral vocal fold palsies, respectively). Patent ductus arteriosus ligation was the single most common procedure resulting in unilateral vocal fold palsies (43.1% of cases). Statistically significant improvements in subjective and objective outcomes for both voice and swallowing were seen. Meta-analysis was able to be performed on the particularly evident improvements in GRBAS score and Maximum Phonation Time (MPT). GRBAS scores improved by 3.64 (p < 0.01, 95% CI 2.65 to 4.63). MPT showed a statistically significant improvement of 5.26 s (p < 0.05, 95% CI 4.28 to 6.24). No major complications were reported. CONCLUSION: The current published evidence on one-hundred and seventy-nine paediatric surgical reinnervation procedures demonstrates its role as a safe and effective treatment for both unilateral and bilateral vocal fold palsies. Anatomically it has been shown to improve vocal fold tone, bulk and position. Both post-operative voice and swallowing outcomes show improvement as well as associated quality of life measures.

Sequential Minimally Invasive Fetal Interventions for Two Life-Threatening Conditions: A Novel Approach.

INTRODUCTION: In utero interventions are performed in fetuses with "isolated" major congenital anomalies to improve neonatal outcomes and quality of life. Sequential in utero interventions to treat 2 anomalies in 1 fetus have not yet been described. CASE PRESENTATION: Here, we report a fetus with a large left-sided intralobar bronchopulmonary sequestration (BPS) causing mediastinal shift, a small extralobar BPS, and concomitant severe left-sided congenital diaphragmatic hernia (CDH). At 26-week gestation, the BPS was noted to be increasing in size with a significant reduction in right lung volume and progression to fetal hydrops. The fetus underwent ultrasound-guided ablation of the BPS feeding vessel leading to complete tumor regression. However, lung development remained poor (O/E-LHR: 0.22) due to the left-sided CDH, prompting fetal endoscopic tracheal occlusion therapy at 28-week gestation to allow increased lung growth. After vaginal delivery, the newborn underwent diaphragmatic repair with resection of the extralobar sequestration. He was discharged home with tracheostomy on room air at 9 months. DISCUSSION/CONCLUSION: Sequential in utero interventions to treat 2 severe major anomalies in the same fetus have not been previously described. This approach may be a useful alternative in select cases with otherwise high morbidity/mortality. Further studies are required to confirm our hypothesis.

Paediatric tonsillectomy in England: A cohort study of clinical practice and outcomes using Hospital Episode Statistics data (2008-2019).

OBJECTIVES: To assess the safety of paediatric tonsillectomy procedures conducted in NHS hospitals in England between 2008 and 2019. DESIGN: Retrospective observational cohort study using Hospital Episode Statistics (HES) data. SETTING: Acute NHS trusts in England conducting paediatric tonsillectomy procedures. PARTICIPANTS: Children (≤16 years old) undergoing bilateral tonsillectomy. MAIN OUTCOME MEASURES: Number of tonsillectomies performed per year by procedural method. In-hospital complications including return to theatre for arrest of haemorrhage. Readmission within 28 days, including those for pain, haemorrhage and surgical arrest of haemorrhage. Long-term outcomes: all-cause mortality, revision tonsillectomy. RESULTS: A total of 318 453 paediatric tonsillectomies were performed from 2008 to 2019:278,772 dissection (87.5%) and 39 681 coblation (12.5%). The proportion of tonsillectomy performed using coblation increased from 7% in 2008/9 to 27% in 2018/9. Five patients died in hospital (including 4 due to respiratory complications). In-hospital complications occurred in 4202 children (1.3%), with the most frequent being haemorrhage. Within 28 days of tonsillectomy, 28 170 patients (8.8%) were readmitted and 7 deaths occurred. Readmission rates for haemorrhage and pain have increased since 2008. The proportion of children undergoing revision tonsillectomy procedures within 5 years following coblation tonsillectomy (1.4%) was approximately double that of dissection (0.6%). CONCLUSIONS: Clinical practice of paediatric tonsillectomy has changed in England over the past 11 years. The overall mortality rate associated with the procedure is 0.0037%. Differences in outcomes have been identified for different procedural methods. However, routine administrative data are limited in differentiating procedural detail (eg we are unable to differentiate intra or extra-capsular techniques from current clinical coding of tonsillectomy procedures). Therefore, prospective national data collection or more granular clinical coding is essential to capture relative outcomes of the different tonsillectomy methods and techniques being used in the NHS.

Balloon dilatation for paediatric airway stenosis: Evidence from the UK Airway Intervention Registry.

OBJECTIVES: To assess the safety and efficacy in routine clinical practice of balloon dilatation procedures in the treatment of paediatric airway stenosis. DESIGN: Observational data collection in prospective online research database. SETTING: Acute NHS Trusts with ENT department undertaking complex paediatric airway work. PARTICIPANTS: Children (<18) undergoing balloon dilatation treatment for airway stenosis. MAIN OUTCOME MEASURES: Airway diameter, complications, hospital resource usage. RESULTS: Fifty-nine patients had 133 balloon procedures during 128 visits to 10 hospitals. Sixty-nine (52%) of balloon procedures were conducted with a tracheostomy. Intra-operative Cotton-Myer grade decreased in 43 (57%). The mean pre-balloon subglottic diameter was 4.2 [95% CI: 3.8 to 4.5] mm, and its rate of increase was 0.8 [0.5 to 1.2] mm per year modelled on 30 patients' long-term data. As the primary treatment of stenosis, the procedural success rate of balloon dilatation (n = 52) was 65% (22% with tracheostomy, 88% without tracheostomy), and 71% as an adjunct to open reconstructive surgery (n = 7). In the 64 hospital visits where a balloon procedure was conducted with a tracheostomy in place, only one in-hospital complication (lower respiratory tract infection) occurred. For those without a tracheostomy in place, in-hospital complications occurred in seven of 64 balloon hospital visits, all related to ongoing or worsening stenosis. Six out-of-hospital complications were deemed related to ongoing or worsening stenosis following the procedure, and two complications were a combination of lower respiratory infection and ongoing or worsening stenosis. CONCLUSIONS: Balloon dilation increases the size of the airway intraoperatively and is associated with long-term increase in airway diameter. Safety outcomes mostly relate to ongoing or worsening stenosis and are more common in patients without a tracheostomy.

Standardizing Second-Trimester Medical Termination: Effects on Clinical Outcomes.

OBJECTIVE: The objective of this study was to evaluate length of induction and postdelivery complications before and after implementation of a standardized approach to second-trimester medical termination of pregnancy. STUDY DESIGN: This was a retrospective cohort study of all women undergoing medical termination of pregnancy between 130/7 and 266/7 weeks of gestation at a single, academic institution from July 1, 2012, through June 30, 2015. The primary outcome was the time from the start of induction of labor to delivery of the fetus. Postdelivery complications including the need for dilation and curettage (D&C), blood transfusion, and readmission to the hospital were secondary outcomes of interest. RESULTS: A total of 62 women met inclusion criteria; 38 before and 24 after the intervention. There were no differences in measured baseline characteristics (p > 0.05). There was a significant decrease in induction time after the intervention (12.3 compared with 8.6 hours, p = 0.031). There was no significant difference in rates of D&C or other measured complications (p > 0.05). CONCLUSION: Implementation of a standardized clinical guideline for second-trimester medical termination was associated with a decrease in length of induction. There was no significant difference in need for D&C or postdelivery complications; however, we were underpowered for these secondary outcomes.

The Effect of Midface Advancement Surgery on Obstructive Sleep Apnoea in Syndromic Craniosynostosis.

BACKGROUND: Children with syndromic craniosynostosis frequently suffer from obstructive sleep apnoea (OSA). The aim of the authors' study was to investigate if midface advancement surgery for patients with SC improved the severity of OSA by examining the results of sleep studies before and after surgery. METHODS: A retrospective comparison of the pre and postoperative sleep study data of children undergoing midface advancement surgery at Great Ormond Street Hospital between 2007 and 2016. RESULTS: A total of 65 children underwent midface advancement surgery between 2007 and 2016 at Great Ormond Street Hospital and had recorded pre- and postoperative sleep studies. Thirteen patients were excluded from the analysis as their sleep study techniques before and after surgery were not comparable (e.g., different conditions with prong/continuous positive airway pressure use). Fifty-six percent of the patients were treated by monobloc surgery and the remainder with bipartition surgery. A greater proportion of patients had a normal OSA grading following midface advancement (42.3% postoperatively vs. 23.1% preoperatively, P = 0.059) although no statistically significant categorical changes in OSA grade were observed. Seventy-one percent of the patients had a decrease in Apnoea-Hypopnoea Index after surgery (21 patients 2011 onward). Similarly, there was no significant change in median oxygen desaturation index or in oxygen saturation nadir following surgery. CONCLUSION: The authors report one of the largest reviews of the effects of midface advancement surgery on sleep study parameters. Most patients showed improvements in Apnoea-Hypopnoea Index and OSA grading, although measures of oxygenation showed no consistent change.

The Management of Obstructive Sleep Apnea in Syndromic Craniosynostosis.

Syndromic craniosynostosis comprises a group of rare conditions often associated with fibroblast growth factor receptor gene mutations. Premature fusion of cranial sutures leads to facial and cranial dysmorphism, which is associated with upper airway compromise and a high incidence of obstructive sleep apnea. The authors performed a literature search to determine the evidence base for interventions used to treat obstructive sleep apnea in this patient group.A search strategy identified 503 papers of which 23 were included. There was evidence for craniofacial surgery, adenotonsillectomy and palatal surgery, and the use of continuous positive airway pressure and nasopharyngeal airways. The level of evidence was low in all studies, but this is likely to be a manifestation of a rare, heterogenous disease in a pediatric population. The largest volume of evidence supports craniofacial surgery; however, patients undergoing this surgery are commonly older, and there is evidence for alternative treatment strategies in younger patients.

Revisiting the Great Ormond Street Hospital protocol for ward decannulation of children with tracheostomy.

INTRODUCTION: Tracheostomy decannulation is an important and final step in managing patients once the underlying issue requiring a tracheostomy resolves. However, no consensus exists on the optimal method to decannulate a paediatric patient. We revisit the Great Ormond Street Hospital (GOSH) tracheostomy decannulation protocol, a 5-day process involving downsizing the tracheostomy tube, capping, and observation, to evaluate its effectiveness and assess if changes to the protocol are required. METHOD: This is a retrospective study, reviewing patient records between April 2018 and April 2023 from a single quaternary care centre. Data extracted include comorbidities, age at the time of decannulation, duration of tracheostomy, reason for tracheostomy insertion, whether a decannulation attempt was successful or not, and the timings of decannulation failure. RESULTS: 66 patients that met the selection criteria underwent a decannulation trial between April 2018 and April 2023. 32 patients were male, and 34 patients were female. Age at attempted decannulations ranged from 1 year to 18 years, with an average age of 6.1 years. There were a total of 93 attempts at decannulation, with 51 (54.8%) successful attempts, 35 (56.5%) first decannulation attempt successes, and 42 (45.2%) unsuccessful attempts. 17 patients had 2 attempts at decannulation, and 4 patients had 3 or more attempts at decannulation. Of the unsuccessful attempts, patients mostly failed on capping of the tracheostomy tube with 33 failures (35.5%). CONCLUSION: The GOSH protocol achieved similar success rates to comparable protocols. The protocol's multi-step approach provides thorough evaluation and support for patients during the decannulation process, and its success on a complex patient cohort supports its continued use.

Evaluation of the maternal systemic immune system during frozen euploid embryo transfer according to cycle outcome.

Infertility affects 15 % of couples in the US, and many turn to assisted reproductive technologies, including in vitro fertilization and subsequent frozen embryo transfer (FET) to become pregnant. This study aimed to perform a broad assessment of the maternal immune system to determine if there are systemic differences on the day of FET in cycles that result in a live birth compared to those that do not. Women undergoing FET of euploid embryos were recruited and blood was collected on the day of FET as well as at early timepoints in pregnancy. Sixty immune and angiogenic proteins were measured in plasma, and gene expression of 92 immune-response related genes were evaluated in peripheral blood mononuclear cells (PBMCs). We found plasma concentrations of interleukin-13 (IL-13) and macrophage derived chemokine (MDC) were significantly lower on the day of FET in cycles that resulted in a live birth. We also found genes encoding C-C chemokine receptor type 5 (CCR5), CD8 subunit alpha (CD8A) and SMAD family member 3 (SMAD3) were upregulated in PBMCs on the day of FET in cycles that resulted in live birth. Measurements of immune mediators from maternal blood could serve as prognostic markers during FET to guide clinical decision making and further our understanding of implantation failure.

International pediatric otolaryngology group (IPOG) consensus on approach to aspiration.

OBJECTIVE: To provide recommendations for a comprehensive management approach for infants and children presenting with symptoms or signs of aspiration. METHODS: Three rounds of surveys were sent to authors from 23 institutions worldwide. The threshold for the critical level of agreement among respondents was set at 80 %. To develop the definition of "intractable aspiration," each author was first asked to define the condition. Second, each author was asked to complete a 5-point Likert scale to specify the level of agreement with the definition derived in the first step. RESULTS: Recommendations by the authors regarding the clinical presentation, diagnostic considerations, and medical and surgical management options for aspiration in children. CONCLUSION: Approach to pediatric aspiration is best achieved by implementing a multidisciplinary approach with a comprehensive investigation strategy and different treatment options.

Laryngotracheal anomalies in children with syndromic craniosynostosis undergoing tracheostomy.

Children with syndromic craniosynostosis may present with airway anomalies. We reviewed a cohort of such individuals who underwent tracheostomy at the Great Ormond Street Hospital for Children (London, UK) between 1999 and 2012 from a prospectively collated database. A case note review was undertaken in 11 patients. We evaluated the indication for tracheostomy in these children and the presence of laryngotracheal anomalies. The most common indication for tracheostomy was upper airway obstruction refractory to medical and first-line surgical management. Laryngotracheal anomalies were detected both at diagnostic microlaryngoscopy and bronchoscopy and at the time of tracheostomy. The commonest anomaly was a tracheal cartilaginous sleeve, but we also describe the figure-of-eight trachea that, to the best of our knowledge, has not been described before in this group of patients. A mutation of a fibroblast growth factor gene was found in 71% of our patients with a laryngotracheal anomaly. We present the largest cohort of children with syndromic craniosynostosis and confirmed anatomical anomalies of the airway and uniquely describe the figure-of-eight appearance of the trachea. These findings highlight the importance of thorough airway evaluation and the special care needed in airway management for children with syndromic craniosynostosis.

Novel approach to prenatal predictors of outcomes for fetuses with severe Ebstein anomaly.

OBJECTIVE: Ebstein anomaly (EA) is a cardiac malformation with highly variable presentation and severity with limited perinatal management options. We present incorporation of fetal lung measurements into a multidisciplinary evaluation for counseling and predicting postnatal outcomes in patients with severe EA. METHODS: Five fetuses with severe fetal EA were reviewed. Third trimester sonographic observed/expected total lung area (O/E TLA) and lung to head ratio (O/E LHR), fetal MRI total fetal lung volume ratio (O/E-TFLV), echocardiographic cardio-thoracic ratio (CT ratio), sonographic estimated fetal weight (EFW) by Hadlock formula and presence of hydrops, were used to guide perinatal management. RESULTS: Three of five had appropriate fetal growth, were delivered at term in a cardiac operative suite, and underwent immediate intervention with good neonatal outcomes. Two had severe fetal growth restriction (FGR), CT ratios > 0.8 and O/E LHR and TLA < 25%. One of which delivered prematurely with neonatal demise and one suffered in utero demise at 34 weeks. CONCLUSIONS: FGR, hydrops, increased CT ratio and reduced O/E LHR and TFLV are potential prognosticators of poor outcomes in severe EA, and should be validated in larger cohorts that would allow for a statistical analysis of the predictive utility of these measurements.

Pulmonary hypoplasia is associated with severe morbidityThere are limited prognosticating tools to risk stratify and guide management in cases of severe prenatal Ebstein anomaliesFetal MRI may improve prognostication for fetuses with EA.

Comprehensive management of anterior drooling: An International Pediatric Otolaryngology Group (IPOG) consensus statement.

OBJECTIVE: To provide guidance for the comprehensive management of children referred for anterior drooling. The mission of the International Pediatric Otolaryngology Group (IPOG) is to develop expertise-based recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. METHODS: Survey of expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The recommendations are derived from current expert consensus and critical review of the literature. RESULTS: Consensus recommendations include initial care and approach recommendations for health care providers who commonly evaluate children with drooling. This includes evaluation and treatment considerations for commonly debated issues in drooling management, initial work-up of children referred for anterior drooling, treatment recommendations, indications and contra-indications for rehabilitation, medical, and surgical management, as well as pros and cons of different surgical procedures in the hands of drooling management experts. CONCLUSION: Anterior drooling consensus recommendations are aimed at improving patient-centered care in children referred for sialorrhea.

Association of an Obstetric Surgical Closing Protocol With Infection After Cesarean Delivery.

OBJECTIVE: To examine surgical site infection rates before and after the addition of a closing protocol to an existing surgical site infection risk-reduction bundle used during cesarean delivery. METHODS: We conducted a single-center retrospective cohort study to review the association of a closing protocol with rates of surgical site infection after cesarean delivery. The closing protocol included fresh surgical instruments and physician and scrub nurse glove change before fascia closure. Surgical site infections were defined using Centers for Disease Control and Prevention criteria. Eligible patients underwent cesarean delivery at our institution from July 1, 2013, through December 31, 2015 (n=1,708; preimplementation group), or from June 1, 2016, through April 30, 2018 (n=1,228; postimplementation group). RESULTS: The surgical site infection rate was 2.3% preimplementation and 2.7% postimplementation (difference 0.4%, 95% CI -1.6 to 0.7%]. The mean [SD] duration of the surgical procedure was longer postimplementation (59.6 [23.7] vs 55.6 [21.5] minutes; P<.001). CONCLUSION: Addition of a closing tray and glove change to our existing surgical site infection risk-reduction bundle was not associated with a reduction in the frequency of postcesarean surgical site infection but was associated with longer operating times.

Impact of long-term nasopharyngeal airway on health-related quality of life of children with obstructive sleep apnea caused by syndromic craniosynostosis.

Obstructive sleep apnea in children with syndromic craniosynostosis is a well-documented entity, and airway management in these group of children is difficult, with well-documented cardiorespiratory and neurodevelopment consequences. Numerous well-documented techniques are available for airway management in this group of children. In our center, the nasopharyngeal airway (NPA) is the first-line treatment. This study aimed to evaluate the improvement in health-related quality of life in this group of children using the Glasgow Children's Benefit Inventory. We conducted a retrospective postal study of 24 patients with craniofacial disorders who had an NPA inserted as part of their airway management. A 79.2% (n = 19) response rate was obtained. Mean (SD) age was 5.8 (4.1) years. Patients were classified into 3 main groups: Crouzon (n = 11), Apert (n = 6), and Pfeiffer (n = 2) syndromes. There was improvement in 3 of the 4 domains, namely, learning (P = 0.006), vitality (P = 0.003), physical (range, -3 to 8; mean, 2; P = 0.005). There was significant improvement in the sleep study parameters; however, no correlation was found between this and the Glasgow Children's Benefit Inventory findings. Parents also preferred an NPA as opposed to a tracheostomy when given a choice. Our study shows that NPA confers significant improvement not only in health-related quality of life but also in severity of obstructive sleep apnea as judged by sleep study parameters. The NPA is also well tolerated by patients and is much preferred by parents for airway management for their children as opposed to having a tracheostomy. We think that this should be considered in other centers as first-line management in children with syndromic craniosynostosis.

Bilobed tongue base associated with multiple branchial anomalies.

A bilobed tongue base was identified in an infant with multiple other head, neck and cardiac congenital anomalies. This anatomical variation of the posterior tongue is rare, with only two other cases identified in the literature. We report a case of a 5-month-old boy with a bilobed posterior tongue incidentally identified during workup for cardiac surgery.

Dysphonia and dysphagia consequences of paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS).

IMPORTANCE: Paediatric inflammatory multisystem syndrome, temporally associated with SARS-CoV-2 (PIMS-TS) is a novel disease first identified in 2020. Recent cohort studies have described the complex presentation and symptomatology. This paper provides detailed description of the dysphagia and dysphonia symptoms, management, and outcome. OBJECTIVE: To describe dysphagia and dysphonia in PIMS-TS. DESIGN: Retrospective cohort study. SETTING: Single tertiary and quaternary children's hospital. PARTICIPANTS: All 50 children treated for paediatric multisystem inflammatory disease between April and June 2020 were included in this study. MAIN OUTCOME(S) AND MEASURE(S): Dysphonia: GRBAS Perceptual Severity Scores, Vocal Handicap Index scores and the Vocal Tract Discomfort Scale. Dysphagia: Functional Oral Intake Scale. RESULTS: Fifty children met the diagnostic criteria for PIMS-TS. 33 (66%) were male. Median age was 10 years (range: 1-17). 36 (72%) were of Black, Asian or minority ethnic background. Nine (18%) required specialist assessment and management of dysphagia and/or dysphonia. Five (55%) were male with a median age of 9 years 7 months (range: 1-15 years). Symptoms typically resolved within three months. Two children presented with persisting dysphonia three months post-presentation. Neurological, inflammatory, and iatrogenic causes of dysphagia and dysphonia were identified. CONCLUSIONS AND RELEVANCE: Dysphonia and dysphagia are present in children with PIMS-TS. Further data is required to understand pathophysiology, estimate incidence, and determine prognostic factors. This preliminary data highlights the need for dysphagia and dysphonia screening and timely referral for specialist, multidisciplinary assessment and treatment to ensure short-term aspiration risk is managed and long-term, functional outcomes are optimised.

Timing of delivery with coronavirus disease 2019 pneumonia requiring intensive care unit admission.

Approximately 4% of pregnant patients with coronavirus disease 2019 require intensive care unit admission. Given the practical implications of advanced ventilatory and circulatory support techniques, urgent or emergent delivery for nonreassuring fetal status frequently presents a logistical impossibility. This article proposes a protocol for obstetrical management of patients in these situations, emphasizing coordinated preparation among obstetrical, anesthesiology, and intensivist teams for planned preterm delivery at gestational ages when neonatal outcomes are likely to be favorable.