Delivery outcomes in the subsequent pregnancy following the conservative management of placenta accreta spectrum disorder: a systematic review and meta-analysis.

OBJECTIVE: Cesarean hysterectomy is generally presumed to decrease maternal morbidity and mortality secondary to placenta accreta spectrum disorder. Recently, uterine-sparing techniques have been introduced in conservative management of placenta accreta spectrum disorder to preserve fertility and potentially reduce surgical complications. However, despite patients often expressing the intention for future conception, few data are available regarding the subsequent pregnancy outcomes after conservative management of placenta accreta spectrum disorder. Thus, we aimed to perform a systematic review and meta-analysis to assess these outcomes. DATA SOURCES: PubMed, Scopus, and Web of Science databases were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA: We included all studies, with the exception of case studies, that reported the first subsequent pregnancy outcomes in individuals with a history of placenta accreta spectrum disorder who underwent any type of conservative management. METHODS: The R programming language with the "meta" package was used. The random-effects model and inverse variance method were used to pool the proportion of pregnancy outcomes. RESULTS: We identified 5 studies involving 1458 participants that were eligible for quantitative synthesis. The type of conservative management included placenta left in situ (n=1) and resection surgery (n=1), and was not reported in 3 studies. The rate of placenta accreta spectrum disorder recurrence in the subsequent pregnancy was 11.8% (95% confidence interval, 1.1-60.3; I2=86.4%), and 1.9% (95% confidence interval, 0.0-34.1; I2=82.4%) of participants underwent cesarean hysterectomy. Postpartum hemorrhage occurred in 10.3% (95% confidence interval, 0.3-81.4; I2=96.7%). A composite adverse maternal outcome was reported in 22.7% of participants (95% confidence interval, 0.0-99.4; I2=56.3%). CONCLUSION: Favorable pregnancy outcome is possible following successful conservation of the uterus in a placenta accreta spectrum disorder pregnancy. Approximately 1 out of 4 subsequent pregnancies following conservative management of placenta accreta spectrum disorder had considerable adverse maternal outcomes. Given such high incidence of adverse outcomes and morbidity, patient and provider preparation is vital when managing this population.

When blood is not an option: Optimal bloodless management of severe anemia in pregnancy.

Standard treatment for severe anemia in pregnancy is allogeneic blood transfusion, but this is not acceptable to all patients. Options for alternative anemia treatment are available. In this case report, a 32-year-old G2P1 woman who was a Jehovah's Witness presented at 27 weeks gestation with dyspnea, palpitations, and severe anemia (hemoglobin 2.8 g/dL) related to chronic rectal bleeding. She declined blood transfusion. An anemia management protocol (high-dose erythropoietin-stimulating agent, iron, vitamin D, vitamin C, folate, vitamin B12) rapidly increased endogenous erythropoiesis. After 12 days, hemoglobin increased to 8 g/dL. A bovine hemoglobin-based oxygen carrier was available for acute bleeding but was not used. This case highlights that early initiation of multimodal therapy can adequately increase endogenous erythropoiesis to treat life-threatening anemia in antepartum patients who do not accept blood transfusion.

External Validation of Postpartum Hemorrhage Prediction Models Using Electronic Health Record Data.

OBJECTIVE: A recent study leveraging machine learning methods found that postpartum hemorrhage (PPH) can be predicted accurately at the time of labor admission in the U.S. Consortium for Safe Labor (CSL) dataset, with a C-statistic as high as 0.93. These CSL models were developed in older data (2002-2008) and used an estimated blood loss (EBL) of ≥1,000 mL to define PPH. We sought to externally validate these models using a more recent cohort of births where blood loss was measured using quantitative blood loss (QBL) methods. STUDY DESIGN: Using data from 5,261 deliveries between February 1, 2019 and May 11, 2020 at a single tertiary hospital, we mapped our electronic health record (EHR) data to the 55 predictors described in previously published CSL models. PPH was defined as QBL ≥1,000 mL within 24 hours after delivery. Model discrimination and calibration of the four CSL models were measured using our cohort. In a secondary analysis, we fit new models in our study cohort using the same predictors and algorithms as the original CSL models. RESULTS: The original study cohort had a substantially lower rate of PPH, 4.8% (7,279/228,438) versus 25% (1,321/5,261), possibly due to differences in measurement. The CSL models had lower discrimination in our study cohort, with a C-statistic as high as 0.57 (logistic regression). Models refit in our study cohort achieved better discrimination, with a C-statistic as high as 0.64 (random forest). Calibration improved in the refit models as compared with the original models. CONCLUSION: The CSL models' accuracy was lower in a contemporary EHR where PPH is assessed using QBL. As institutions continue to adopt QBL methods, further data are needed to understand the differences between EBL and QBL to enable accurate prediction of PPH. KEY POINTS: · Machine learning methods may help predict PPH.. · EBL models do not generalize when QBL is used.. · Blood loss estimation alters model accuracy..

Use of a Novel Electronic Maternal Surveillance System and the Maternal Early Warning Criteria to Detect Severe Postpartum Hemorrhage.

BACKGROUND: A leading cause of preventable maternal death is related to delayed response to clinical warning signs. Electronic surveillance systems may improve detection of maternal morbidity with automated notifications. This retrospective observational study evaluates the ability of an automated surveillance system and the Maternal Early Warning Criteria (MEWC) to detect severely morbid postpartum hemorrhage (sPPH) after delivery. METHODS: The electronic health records of adult obstetric patients of any gestational age delivering between April 1, 2017 and December 1, 2018 were queried to identify scheduled or unscheduled vaginal or cesarean deliveries. Deliveries complicated by sPPH were identified and defined by operative management of postpartum hemorrhage, transfusion of ≥4 units of packed red blood cells (pRBCs), ≥2 units of pRBCs and ≥2 units of fresh-frozen plasma, transfusion with >1 dose of furosemide, or transfer to the intensive care unit. The test characteristics of automated pages and the MEWC for identification of sPPH 24 hours after delivery were determined and compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) and their 95% confidence intervals (CIs). McNemar test was used to compare these estimates for both early warning systems. RESULTS: The average age at admission was 30.7 years (standard deviation [SD] = 5.1 years), mean gestational age 38 weeks 4 days, and cesarean delivery accounted for 30.0% of deliveries. Of 7853 deliveries, 120 (1.5%) were complicated by sPPH. The sensitivity of automated pages for sPPH within 24 hours of delivery was 60.8% (95% CI, 52.1-69.6), specificity 82.5% (95% CI, 81.7-83.4), PPV 5.1% (95% CI, 4.0-6.3), and NPV 99.3% (95% CI, 99.1-99.5). The test characteristics of the MEWC for sPPH were sensitivity 75.0% (95% CI, 67.3-82.7), specificity 66.3% (95% CI, 65.2-67.3), PPV 3.3% (95% CI, 2.7-4.0), and NPV 99.4% (95% CI, 99.2-99.6). There were 10 sPPH cases identified by automated pages, but not by the MEWC. Six of these cases were identified by a page for anemia, and 4 cases were the result of vital signs detected by the bedside monitor, but not recorded in the patient's medical record by the bedside nurse. Therefore, the combined sensitivity of the 2 systems was 83.3% (95% CI, 75.4-89.5). CONCLUSIONS: The automated system identified 10 of 120 deliveries complicated by sPPH not identified by the MEWC. Using an automated alerting system in combination with a labor and delivery unit's existing nursing-driven early warning system may improve detection of sPPH.

Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care.

The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.

Monochorionic diamniotic twin pregnancy: timing and duration of sonographic surveillance for detection of twin-twin transfusion syndrome.

OBJECTIVE: Twin-twin transfusion syndrome complicates up to 15% of monochorionic diamniotic gestations. Current recommendations for sonographic surveillance in monochorionic diamniotic pregnancies for detection of twin-twin transfusion syndrome vary. Our objective was to determine an appropriate frequency of sonographic surveillance to optimize detection of twin-twin transfusion syndrome in monochorionic diamniotic gestations. METHODS: A retrospective cohort analysis of all nonanomalous monochorionic diamniotic twins delivered at the University of North Carolina over a 9-year period was performed. The rate and gestational age of twin-twin transfusion syndrome onset were calculated. The time to the diagnosis of twin-twin transfusion syndrome was evaluated by a Kaplan-Meier survival curve; clinical factors at initial sonography were examined for their use in prediction of twin-twin transfusion syndrome. RESULTS: Of the 577 twin deliveries, 145 (25%) were monochorionic diamniotic and included for analysis. The rate of twin-twin transfusion syndrome was 17.93% (n = 26). The mean frequency of surveillance ± SD before diagnosis of twin-twin transfusion syndrome was 3.1 ± 2.1 weeks. The mean gestational age at diagnosis of twin-twin transfusion syndrome was 21.3 ± 3.4 weeks (range, 15-29 weeks). Both a discordant maximum vertical amniotic fluid pocket (>65% difference) and a discordant estimated fetal weight (>25% difference) at initial sonography showed a significantly shorter time to diagnosis of twin-twin transfusion syndrome (P < .0001). CONCLUSIONS: Evaluation for twin-twin transfusion syndrome should begin in the second trimester. Weekly surveillance for those pregnancies with estimated fetal weight or maximum vertical pocket discordance is recommended. For those with a concordant estimated fetal weight and maximum vertical pocket, sonographic evaluation every 2 weeks is warranted to 28 to 30 weeks. After that, development of twin-twin transfusion syndrome is less likely, and a different paradigm of antenatal testing may be reasonable.

Evaluation of Implementation and Unit Impact of a Hypertensive Disorder of Pregnancy Guideline: A Model-Based Approach.

BACKGROUND: Hypertensive disorders of pregnancy are a leading cause of maternal mortality and morbidity. To address this, a large Midwestern hospital initiated a practice guideline. Practice guidelines should improve outcomes, but implementation of these remains challenging. At the time of initiation of the guideline, no implementation or evaluation plan was conceived. OBJECTIVE: Evaluate the implementation and unit impact of a guideline for the management of hypertensive disorders of pregnancy in a large academic health system in the Midwest. METHODS: Six objectives, guided by the constructs of the Ottawa Model of Research Utilization, were operationalized to evaluate the implementation and unit impact of the guideline. RESULTS: The guideline implemented was consistent with national recommendations. Intervention education was inconsistent across provider types. A survey of staff revealed insight into a unit in the midst of practice change. A chart review revealed below-target management of patients with severe range blood pressures. Not following the guideline was associated with hospital readmission. CONCLUSIONS: Guideline implementation can be efficiently and holistically evaluated with a model-based framework, even in projects that were not initiated with such an approach. IMPLICATIONS FOR NURSING PRACTICE: Nurses provide expertise in model-based approaches that result in comprehensive evaluations of quality improvement processes.

Conjoined twins: an obstetrician's guide to prenatal care and delivery management.

OBJECTIVE: Obstetricians infrequently encounter conjoined twins. Much of the clinical care literature focuses on postnatal management from a neonatology and pediatric surgery perspective; guidance on obstetrical management is limited. We outline steps for prenatal evaluation, obstetrical care, and delivery planning. STUDY DESIGN: Experiences with two cases of conjoined twins. RESULTS: We identified several points throughout the planning, delivery, and postnatal process that are important to highlight for optimizing clinical outcome, patient safety, and parental satisfaction. CONCLUSION: After diagnosis, patients should be referred to a center experienced in the management of conjoined twins. Specialists in fields including maternal fetal medicine, pediatric surgery, neonatology, and radiology play a vital role in the management of these patients. Early referral allows for timely family counseling and decision-making. Prenatal evaluation beyond the first trimester should include a detailed ultrasound, fetal echocardiogram, and fetal MRI. 3D printed life-sized models can improve delivery planning and patient understanding.

Fetal hemoglobin levels in premature newborns. Should we reconsider transfusion of adult donor blood?

PURPOSE: The aim of this study was to assess the percent decrease in fetal hemoglobin (HbF) after transfusion of adult-derived donor packed red blood cell (pRBC) units in extremely low gestational age newborns (ELGANs). METHODS: Control percent fetal hemoglobin (%HbF) levels were measured in newborn cord blood or peripheral blood samples in non-transfused patients prior to elective surgery. ELGANs were followed prospectively and %HbF was measured on residual post-test complete blood count (CBC) specimens. ELGAN %HbF values were compared to the control population and transfusions were recorded. RESULTS: Initial mean %HbF in ELGANs (n=16) was 92.2±1.3% (range 90.2-95.1%), which is similar to the control group (n=25). Mean levels dropped to 61.1±11.1% (range 34.2-73.2%) after a single pRBC transfusion (n=9) and to a mean of 35.6±6.3% after an additional transfusion (n=5). %HbF levels trended upwards if no additional transfusions were given, but levels still remained lower than expected for gestational age through discharge (n=85 samples). CONCLUSIONS: Percent fetal hemoglobin concentrations in ELGANs decrease precipitously after transfusion with adult donor pRBCs. Further studies are needed to evaluate the benefit of maintaining higher fetal hemoglobin concentrations in these patients and whether administration of HbF rather than adult donor pRBCs would improve patient outcomes.

User Perceptions of an Electronic Maternal Alerting System.

This survey study evaluates the user experience of an electronic maternal early warning system that generates automated pages. Survey domains included the system's effect on patient care, alarm fatigue, and continued use of the system. The response rate was 47.7% (273 of 572). A majority, 83%, felt that the system should remain in use, and 64.5% felt it improved patient safety. Of those who believed that they had received a page, 51.4% felt that they received pages "too frequently." Although alarm fatigue was not fully evaluated, providers on our unit support the continued use of this automated maternal electronic surveillance system.

The scope of duty hour-associated residency structure modifications.

OBJECTIVE: The purpose of this study was to characterize the duty hours-associated modifications made to the educational and patient care structure of obstetrics and gynecology residency programs, and the relationship of these modifications to residency program setting and size. STUDY DESIGN: A survey of accredited obstetrics and gynecology residency programs in the United States (excluding New York State) was performed between June 21st and July 16th, 2004. Program representatives were queried on the difficulty encountered in complying with each of the 6 components of the ACGME common duty hour requirements and the prevalence of residency modifications affecting the educational and patient care structure. RESULTS: Fifty-eight percent (123/211) of the study population completed the questionnaire. Ensuring a minimum 10-hour rest period between shifts was rated the most difficult requirement. Ninety-eight percent of respondents reported various types of modifications to program structure, including modification of on-call structure (94%), redistribution of responsibilities among resident levels (85%), modification of resident participation in patient care processes (80%), and modification of resident assignments to clinical services (75%). A minimum of 38% of programs reported reductions in resident participation in patient care, regardless of clinical service type or care setting. The prevalence of hiring attending physicians was significantly higher among non-university-based programs (18%), compared to university-based programs (3%, P = .007). CONCLUSION: Duty hour-related changes have resulted in near universal program modifications. One third of programs have made modifications that have resulted in a decrease in the available clinical experiences for residents.

The perceived impact of duty hour restrictions on the residency environment: a survey of residency program directors.

OBJECTIVE: The purpose of this study was to characterize residency program director baseline perceptions regarding the effect of resident duty hour limitations on key components of the graduate medical education environment. STUDY DESIGN: This was a survey of directors of accredited obstetrics and gynecology residency programs in the United States (excluding New York State) between June 21st and July 16th, 2004. Participants were queried on views regarding the need for duty hour limitations, and the perceived effect of these changes on various issues related to the residency environment. RESULTS: Fifty-eight percent (123/211) of the study population completed the questionnaire. Seventy-one percent of respondents supported duty hour restrictions, 19% opposed restrictions, and 10% were undecided. Forty-one percent of respondents preferred a maximum duty hour limitation of 80 hrs/wk or less, 55% preferred one at least 90 hrs/wk, and 4% preferred no upper limit. A significantly greater proportion of female program directors supported limits > 80 hrs/wk than males (73% vs 53%, P = .04). A majority of participants believed resident education, surgical skills, and work ethic have been negatively impacted by the limitations, while patient safety and the overall quality of patient care have remained unchanged or declined, and resident well-being has improved. Opposition to duty hour regulations and a preference for higher limits was associated with a higher prevalence of negative impressions regarding the impact of duty hour regulations on the residency environment. CONCLUSION: Variations in current opinions regarding the impact of residency duty hour restrictions reflect ongoing bias in those most influential to resident education.

Misoprostol for labor induction in women with term premature rupture of membranes: a meta-analysis.

OBJECTIVE: To systematically review published data evaluating the comparative use of misoprostol with placebo/expectant management or oxytocin for labor induction in women with term (> or = 36 weeks of gestation) premature rupture of membranes. DATA SOURCES: PubMed (1966-2005), Ovid (1966-2005), CINAHL, The Cochrane Library, ACP Journal Club, OCLC, abstracts from scientific forums, and bibliographies of published articles were searched using the following keywords: premature rupture of membranes, misoprostol, labor induction, and cervical ripening. Primary authors were contacted directly if the data sought were unavailable or only published in abstract form. METHODS OF STUDY SELECTION: Only randomized controlled trials evaluating the efficacy and safety of misoprostol in comparison with placebo or expectant management (n = 6) and oxytocin (n = 9) published in either article or abstract form were analyzed and included in the meta-analysis. TABULATION, INTEGRATION, AND RESULTS: Studies were reviewed independently by all authors. Meta-analysis was performed, and the relative risks (RRs) were calculated and pooled for each study outcome. Misoprostol, compared with placebo, significantly increased vaginal delivery less than 12 hours (RR 2.71, 95% confidence interval [CI] 1.87-3.92, P < .001). Misoprostol was similar to oxytocin with respect to vaginal delivery less than 24 hours (RR 1.07, 95% CI 0.88-1.31, P = .50) and less than 12 hours (RR 0.98, 95% CI 0.71-1.35, P = .90). Misoprostol was not associated with an increased risk of tachysystole, hypertonus, or hyperstimulation syndrome when compared with oxytocin and had similar risks for adverse neonatal and maternal outcomes. CONCLUSION: Misoprostol is an effective and safe agent for induction of labor in women with term premature rupture of membranes. When compared with oxytocin, the risk of contraction abnormalities and the rate of maternal and neonatal complications were similar among the 2 groups.

The effect of maternal pravastatin therapy on adverse sensorimotor outcomes of the offspring in a murine model of preeclampsia.

Animal and human studies show that in-utero exposure to preeclampsia alters fetal programming and results in long-term adverse cardiovascular outcomes in the offspring. Human epidemiologic data also suggest that offspring born to preeclamptic mothers are also at risk of adverse long term neurodevelopmental outcomes. Pravastatin, a hydrophilic lipid-lowering drug with pleiotropic properties, was found to prevent the altered cardiovascular phenotype of preeclampsia and restore fetal growth in animal models, providing biological plausibility for its use as a preventive agent for preeclampsia. In this study, we used a murine model of preeclampsia based on adenovirus over-expression of the anti-angiogenic factor soluble Fms-like tyrosine kinase 1, and demonstrated that adult offspring born to preeclamptic dams perform poorly on assays testing vestibular function, balance, and coordination, and that prenatal pravastatin treatment prevents impairment of fetal programming.

Maternal pravastatin prevents altered fetal brain development in a preeclamptic CD-1 mouse model.

OBJECTIVE: Using an animal model, we have previously shown that preeclampsia results in long-term adverse neuromotor outcomes in the offspring, and this phenotype was prevented by antenatal treatment with pravastatin. This study aims to localize the altered neuromotor programming in this animal model and to evaluate the role of pravastatin in its prevention. MATERIALS AND METHODS: For the preeclampsia model, pregnant CD-1 mice were randomly allocated to injection of adenovirus carrying sFlt-1 or its control virus carrying mFc into the tail vein. Thereafter they received pravastatin (sFlt-1-pra "experimental group") or water (sFlt-1 "positive control") until weaning. The mFc group ("negative control") received water. Offspring at 6 months of age were sacrificed, and whole brains underwent magnetic resonance imaging (MRI). MRIs were performed using an 11.7 Tesla vertical bore MRI scanner. T2 weighted images were acquired to evaluate the volumes of 28 regions of interest, including areas involved in adaptation and motor, spatial and sensory function. Cytochemistry and cell quantification was performed using neuron-specific Nissl stain. One-way ANOVA with multiple comparison testing was used for statistical analysis. RESULTS: Compared with control offspring, male sFlt-1 offspring have decreased volumes in the fimbria, periaquaductal gray, stria medullaris, and ventricles and increased volumes in the lateral globus pallidus and neocortex; however, female sFlt-1 offspring showed increased volumes in the ventricles, stria medullaris, and fasciculus retroflexus and decreased volumes in the inferior colliculus, thalamus, and lateral globus pallidus. Neuronal quantification via Nissl staining exhibited decreased cell counts in sFlt-1 offspring neocortex, more pronounced in males. Prenatal pravastatin treatment prevented these changes. CONCLUSION: Preeclampsia alters brain development in sex-specific patterns, and prenatal pravastatin therapy prevents altered neuroanatomic programming in this animal model.

Vaginal birth after cesarean and trial of labor after cesarean: what should we be recommending relative to maternal risk:benefit?

Trial of labor after cesarean (TOLAC) delivery is currently a hot obstetrical topic owing to the acute rise in the rate of cesarean deliveries, both primary and repeat. When the physician and patient are considering TOLAC, several factors should be considered: risk of uterine rupture, contraindications, minimizing risk and morbidity, choosing the appropriate candidate and whether or not to induce. Each patient has her own set of individual risk factors that may decrease her chance of successful vaginal birth after cesarean delivery or increase her risks with TOLAC. Once all things are considered, the risk:benefit of TOLAC should be weighed up before a decision is reached. Each of these factors is discussed in respect to maternal risk:benefit, with the focus on evidence presented in the current literature.