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2.
Prenat Diagn ; 34(7): 668-76, 2014 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-24855016

RESUMEN

The use of first trimester screening to detect aneuploidy has become an integral part of prenatal care. The application of similar screening algorithms to identify women at the highest risk for other adverse pregnancy outcomes in the first trimester could potentially have a major clinical impact. There has been much investigation into the ability to identify patients early in pregnancy at high risk for adverse pregnancy outcomes who may benefit from further surveillance and/or intervention. For this to be the case, however, as is true of any useful screening test, effective interventions need to be available. Unfortunately, for fetal growth restriction and stillbirth, no such interventions exist short of delivery. For preeclampsia, low dose aspirin has been demonstrated to be of benefit in specific subgroups. For preterm birth, although there are efficacious treatments, first trimester serum markers or cervical length measurements do not add significantly beyond historical or demographic factors, in prediction of preterm birth. Given the current evidence, first trimester screening, via serum or ultrasound markers, does not have sufficiently high enough positive predictive values for the development of preeclampsia, fetal growth restriction, preterm birth or stillbirth. In order to develop effective screening algorithms for adverse pregnancy outcomes in the first trimester, understanding the heterogeneous phenotype of these complications and the underlying pathophysiology is needed.


Asunto(s)
Complicaciones del Embarazo/diagnóstico , Primer Trimestre del Embarazo , Diagnóstico Prenatal , Biomarcadores/sangre , Femenino , Humanos , Valor Predictivo de las Pruebas , Embarazo , Complicaciones del Embarazo/sangre , Resultado del Embarazo , Primer Trimestre del Embarazo/sangre , Diagnóstico Prenatal/métodos , Diagnóstico Prenatal/normas , Pronóstico , Factores de Tiempo
3.
Curr Probl Diagn Radiol ; 53(6): 700-708, 2024.
Artículo en Inglés | MEDLINE | ID: mdl-39004581

RESUMEN

OBJECTIVE: To examine the concordance rate of MRI findings with intraoperative and pathologic findings in patients with Placenta Accreta Spectrum (PAS), as well as the use of structured reporting, and their relationship to clinical outcomes. METHODS: An IRB approved retrospective chart review was performed for patients with a history of cesarean delivery, a diagnosis of PAS on post-operative pathology report, and a placental MRI prior to delivery between 2008-2022. Concordance rates were calculated between final MRI, ultrasound, operative, and pathologic diagnoses, as well as impact on clinical outcomes. Quantitative variables were analyzed using a t-test. Categorical variables were analyzed using chi-squared and Fischer's exact tests. RESULTS: A total of 59 patients met initial inclusion criteria. Of these 59 patients, 8 (13.6%) were interpreted using structured reporting. Discordance between preoperative imaging, operative findings and final pathology diagnoses were associated with increased blood loss, blood transfusion, ICU admission, and postpartum length of stay. Structured reporting was found to significantly reduce the amount of diagnostic discordance (p=.017) and was associated with decreased ICU admissions when utilized (p=.045). CONCLUSIONS: Use of structured reporting in the interpretation of placental MRI may decrease the amount of discordance between imaging and intraoperative or pathologic diagnoses, which in our study is associated with improved patient outcomes including decreased blood loss and amount of blood transfused. Radiologists must be cognizant of key imaging features of PAS on MRI, as interpretation provides an opportunity to positively impact the quality and safety of patient care.


Asunto(s)
Imagen por Resonancia Magnética , Placenta Accreta , Humanos , Placenta Accreta/diagnóstico por imagen , Femenino , Embarazo , Estudios Retrospectivos , Imagen por Resonancia Magnética/métodos , Adulto , Cesárea , Placenta/diagnóstico por imagen , Placenta/patología
4.
Radiol Case Rep ; 18(11): 4006-4011, 2023 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-37691758

RESUMEN

Heterotopic cesarean scar pregnancy is an extremely rare form of pregnancy and is defined as an intrauterine pregnancy coexisting with an ectopic pregnancy implanted in the cesarean scar. Cesarean scar ectopic pregnancy can also be a precursor for placenta accreta spectrum, a potentially life-threatening condition in which the placenta is abnormally adherent to the uterine myometrium and possibly adjacent organs. Although cesarean scar ectopic pregnancies are rare, there has been an increase in their incidence due to the rise in cesarean deliveries. We present the case of a 35-year-old patient with a heterotopic pregnancy with ectopic implantation in a cesarean scar and associated placenta increta, as well as the radiologic evaluation of placenta accreta spectrum and subsequent management.

5.
Obstet Gynecol ; 138(2): 289-304, 2021 08 01.
Artículo en Inglés | MEDLINE | ID: mdl-34237760

RESUMEN

Maternal sepsis is an obstetric emergency and a leading cause of maternal morbidity and mortality. Early recognition in a pregnant or postpartum patient can be a challenge as the normal physiologic changes of pregnancy may mask the signs and symptoms of sepsis. Bedside assessment tools may aid in the detection of maternal sepsis. Timely and targeted antibiotic therapy and fluid resuscitation are critical for survival in patients with suspected sepsis. Once diagnosed, a search for etiologies and early application of source control measures will further reduce harms. If the patient is in septic shock or not responding to initial treatment, multidisciplinary consultation and escalation of care is necessary. Health care professionals should be aware of the unique complications of sepsis in critically ill pregnant and postpartum patients, and measures to prevent poor outcomes in this population. Adverse pregnancy outcomes may occur in association with sepsis, and should be anticipated and prevented when possible, or managed appropriately when they occur. Using a standardized approach to the patient with suspected sepsis may reduce maternal morbidity and mortality.


Asunto(s)
Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/terapia , Antibacterianos/uso terapéutico , Enfermedad Crítica , Femenino , Humanos , Mortalidad Materna , Periodo Posparto , Embarazo , Complicaciones Infecciosas del Embarazo/microbiología , Resultado del Embarazo , Choque Séptico/diagnóstico , Choque Séptico/terapia , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/tratamiento farmacológico , Infecciones Estreptocócicas/mortalidad , Streptococcus pyogenes , Factores de Tiempo
6.
Obstet Gynecol ; 137(5): 855-863, 2021 05 01.
Artículo en Inglés | MEDLINE | ID: mdl-33831915

RESUMEN

OBJECTIVE: To evaluate the association of sex and pregnancy status with rates of naloxone administration during opioid overdose-related emergency department (ED) visits by using the Nationwide Emergency Department Sample. METHODS: A retrospective cohort study was conducted using the Nationwide Emergency Department Sample 2016 and 2017 data sets. Eligible records included men and women, 15-49 years of age, with an opioid overdose-related ED visit; records for women were stratified by pregnancy status (International Classification of Diseases, Tenth Revision O codes). A multivariable logistic regression model was used to assess the primary outcome of naloxone administration (Current Procedural Terminology code: J2310). Secondary outcomes included subsequent admission and mortality. A subgroup analysis compared pregnant women who did receive naloxone compared with those who did not receive naloxone. RESULTS: Records from 443,714 men, 304,364 nonpregnant women, and 25,056 pregnant women were included. Nonpregnant women had lower odds for naloxone administration (1.70% vs 2.10%; adjusted odds ratio [aOR] 0.86 [95% CI 0.83-0.89]) and mortality (2.21% vs 2.99%; aOR 0.71 [95% CI 0.69-0.73]) but higher odds of subsequent admission (30.22% vs 27.18%; aOR 1.04 [95% CI 1.03-1.06]) compared with men. Pregnant women had lower odds for naloxone administration (0.27% vs 1.70%; aOR 0.16 [95% CI 0.13-0.21]) and mortality (0.41% vs 2.21%; aOR 0.28 [95% CI 0.23-0.35]) but higher odds of subsequent admission (40.50% vs 30.22%; aOR 2.04 [95% CI 2.00-2.10]) compared with nonpregnant women. Pregnant women who received naloxone had higher odds of mortality (14% vs 0.39%; aOR 6.30 [95% CI 2.11-18.78]) compared with pregnant women who did not receive naloxone. Pregnant women who did not receive naloxone were more likely to have Medicaid as their expected insurance payer, be in the lowest quartile of median household income for residence ZIP codes, and have a concurrent mental health diagnosis compared with pregnant women who did receive naloxone. CONCLUSION: Reproductive-aged women who are nonpregnant and pregnant were less likely to receive naloxone during opioid overdose-related ED visits compared with reproductive-aged men. Naloxone administration for reproductive-aged women should be prioritized in the efforts to reduce opioid- and pregnancy-related morbidity and mortality in the United States.


Asunto(s)
Naloxona/administración & dosificación , Trastornos Relacionados con Opioides/tratamiento farmacológico , Mujeres Embarazadas , Adolescente , Adulto , Estudios de Cohortes , Servicio de Urgencia en Hospital , Femenino , Disparidades en Atención de Salud , Humanos , Masculino , Persona de Mediana Edad , Antagonistas de Narcóticos/administración & dosificación , Trastornos Relacionados con Opioides/epidemiología , Embarazo , Estudios Retrospectivos , Factores Sexuales , Estados Unidos/epidemiología , Adulto Joven
7.
Prehosp Disaster Med ; 36(5): 570-575, 2021 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-34256885

RESUMEN

INTRODUCTION: In the early phase of the coronavirus disease 2019 (COVID-19) pandemic, United States Emergency Medical Services (EMS) experienced a decrease in calls, and at the same time, an increase in out-of-hospital deaths. This finding led to a concern for the implications of potential delays in care for the obstetric population. HYPOTHESIS/PROBLEM: This study examines the impact of the pandemic on prehospital care amongst pregnant women. METHODS: A retrospective observational study was conducted comparing obstetric-related EMS activations in Maryland (USA) during the pandemic (March 10-July 20, 2020) to a pre-pandemic period (March 10-July 20, 2019). Comparative analysis was used to analyze the difference in frequency and acuity of calls between the two periods. RESULTS: There were fewer obstetric-related EMS encounters during the pandemic compared to the year prior (daily average during the pandemic 12.5 [SD = 3.8] versus 14.6 [SD = 4.1] pre-pandemic; P <.001), although the percent of total female encounters remained unchanged (1.6% in 2020 versus 1.5% in 2019; P = .091). Key indicators of maternal status were not significantly different between the two periods. African-American women represented a disproportionately high percentage of obstetric-related activations (36.2% in 2019 and 34.8% in 2020). CONCLUSIONS: In this state-wide analysis of EMS calls in Maryland early in the pandemic, no significant differences existed in the utilization of EMS by pregnant women. Prehospital EMS activations amongst pregnant women in Maryland only decreased slightly without an increase in acuity. Of note, over-representation by African-American women compared to population statistics raises concern for broader systemic differences in access to obstetric care.


Asunto(s)
COVID-19 , Servicios Médicos de Urgencia , Femenino , Humanos , Maryland/epidemiología , Pandemias , Embarazo , Estudios Retrospectivos , SARS-CoV-2 , Estados Unidos
8.
Obstet Gynecol ; 126(6): 1265-1272, 2015 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-26551186

RESUMEN

OBJECTIVE: To evaluate maternal and neonatal outcomes by attempted mode of operative delivery from a low station in the second stage of labor. METHODS: Retrospective study of 2,518 women carrying singleton fetuses at 37 weeks of gestation or greater who underwent attempted forceps-assisted delivery, attempted vacuum-assisted vaginal delivery, or cesarean delivery from a low station in the second stage of labor. Primary outcomes were stratified by parity and included a maternal adverse outcome composite (postpartum hemorrhage, transfusion, endometritis, peripartum hysterectomy, or intensive care unit admission) and a neonatal adverse outcome composite (5-minute Apgar score less than 4, respiratory morbidity, neonatal intensive care unit admission, shoulder dystocia, birth trauma, or sepsis). RESULTS: In nulliparous patients, the maternal adverse composite was not significantly different between women who underwent attempted forceps (12.1% compared with 10.8%, adjusted odds ratio [OR] 0.77, 95% confidence interval [CI] 0.40-1.34) or vacuum (8.3% compared with 10.8%, adjusted OR 0.68, 95% CI 0.40-1.16) delivery compared with cesarean delivery. Among parous women, the maternal adverse composite was not significantly different with attempted forceps (10.7% compared with 12.5%, adjusted OR 0.40, 95% CI 0.09-1.71) or vacuum (11.3% compared with 12.5%, adjusted OR 0.44, 95% CI 0.11-1.72) compared with cesarean delivery. Compared with neonates delivered by cesarean, the neonatal adverse composite was significantly lower among neonates born to nulliparous women who underwent attempted forceps (9.4% compared with 16.7%, adjusted OR 0.44, 95% CI 0.27-0.72) but not among those who underwent vacuum delivery (11.9% compared with 16.7%, adjusted OR 0.68, 95% CI 0.44-1.04). Among parous women, the neonatal adverse composite was not significantly different after attempted forceps (4.1% compared with 12.5%, adjusted OR 0.28, 95% CI 0.06-1.35) or vacuum (12.5% compared with 12.5%, adjusted OR 1.03, 95% CI 0.28-3.87) compared with cesarean delivery. CONCLUSION: A trial of forceps delivery from a low station compared with cesarean delivery was associated with decreased neonatal morbidity among neonates born to nulliparous women. LEVEL OF EVIDENCE: II.


Asunto(s)
Cesárea/efectos adversos , Extracción Obstétrica/efectos adversos , Enfermedades del Recién Nacido/etiología , Segundo Periodo del Trabajo de Parto , Complicaciones del Trabajo de Parto/etiología , Adulto , Extracción Obstétrica/métodos , Femenino , Humanos , Recién Nacido , Enfermedades del Recién Nacido/epidemiología , Modelos Logísticos , Complicaciones del Trabajo de Parto/epidemiología , Oportunidad Relativa , Embarazo , Estudios Retrospectivos
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