Accuracy and Completion Rate of the Fetal Anatomic Survey in the Super Obese Parturient.

OBJECTIVE: To determine the completion rate of ultrasound in with a body mass index (BMI) ≥ 50 to women with BMI 18.5 to 29.9. STUDY DESIGN: This study was a retrospective cohort study. Women with a singleton pregnancy, age 18 to 45 with a BMI ≥50 that delivered between 2013-2016 were compared to women with a BMI 18.5 to 29.9 during that same time period to assess the accuracy and, as a second aim, the completion rate of the fetal anatomic survey. Data were analyzed using two-sample t test, chi-square test, or logistic regression as appropriate. RESULTS: Eighty-one cases with a BMI ≥50 were compared with 81 patients with a BMI 18.5 to 29.9. Maternal demographics and timing (gestational age) at the time of the ultrasound were similar between groups. In women with a BMI 18.5 to 29.9, completion of anatomy was 58% of the time with the first ultrasound, 81% with second ultrasound, and 84% with the third ultrasound. In women with BMI ≥50, completion of anatomy was 10% of the time with the first ultrasound, 33% with the second ultrasound, and 42% with the third ultrasound. Each time frame was statistically significant. Agreement level on the accuracy to detect fetal anomalies between groups were not statistically significant between the groups. CONCLUSION: In women with a BMI ≥50 compared to women with BMI of 18.8 to 29.9, more ultrasounds are needed to complete the anatomic survey although overall accuracy in fetal anomaly detection is similar.

Accuracy of the Ultrasound Estimate of the Amniotic Fluid Volume (Amniotic Fluid Index and Single Deepest Pocket) to Identify Actual Low, Normal, and High Amniotic Fluid Volumes as Determined by Quantile Regression.

OBJECTIVES: To identify abnormal amniotic fluid volumes (AFVs), normal volumes must be determined. Multiple statistical methods are used to define normal amniotic fluid curves; however, quantile regression (QR) is gaining favor. We reanalyzed ultrasound estimates in identifying oligohydramnios, normal fluid, and polyhydramnios using normal volumes calculated by QR. METHODS: Data from 506 dye-determined or directly measured AFVs along with ultrasound estimates were analyzed. Each was classified as low, normal, or high for both the single deepest pocket (SDP) and amniotic fluid index (AFI). A weighted κ statistic was used to assess the level of agreement between the AFI and SDP compared to actual AFVs by QR. RESULTS: The overall level of agreement for the AFI was fair (κ = 0.26), and that for the SDP was slight (κ = 0.19). Although not statistically significant (P = .792), the positive predictive value to classify a low volume using the AFI was lower compared to the SDP (35% vs 43%). The positive predictive value for a high volume was higher using the AFI compared to the SDP (55% versus 31%) but not statistically significant. The missed-call rate for high-volume identification by the SDP versus AFI was statistically significant (odds ratio, 5.5; 95% confidence interval, 2.04-14.97). The missed-call rate for low-volume identification by the AFI versus SDP was not statistically significant (odds ratio, 3.3; 95% confidence interval, 0.96-11.53). CONCLUSIONS: Both the AFI and SDP identify actual normal AFVs by QR, with sensitivity higher than 90%. The SDP is superior for identification of oligohydramnios, and the AFI superior for identification of polyhydramnios.

Maternal Transport, What Do We Know: A Narrative Review.

Objective: This review examines the initial development of a transport system for neonates, followed by a subsequent evolution of a transportation system for the maternal/fetal unit, and then a maternal transport system (antepartum, intrapartum, and postpartum) to specifically address maternal morbidity/mortality. Methods: A literature search was undertaken using the electronic databases PubMed, Embase, and CINAHL. The search terms used were "maternal transport" AND "perinatal care" OR "labor" "obstetrics" OR "delivery". The years searched were 1960-2023. Results: There were 260 abstracts identified and 52 of those are the basis of this review. The utilization of a transportation system with the regionalization of levels of care has resulted in a significant reduction in neonatal, perinatal, and maternal morbidity and mortality. Although preterm delivery remains a concern in women transported, the number of deliveries that have occurred during transport is relatively small. Reimbursement for transportation continues to be a problem in several states. Conclusion: A state-of-the-art transportation system has evolved that transfers neonates, maternal/fetal dyad, and pregnant women (antepartum, intrapartum, postpartum) to the appropriate level of care facility to ensure the best maternal/fetal/neonatal outcomes.

The Impact of Adenomyosis on Pregnancy and Pregnancy Outcomes: A Review.

Objective: The aim of this review was to describe the risk factors, diagnosis, and effects on pregnancy of the gynecologic condition adenomyosis. Methods: A PubMed, Web of Science, and CINAHL search was undertaken. Citations were limited to the past 30 years. Results: There were 223 articles identified, with 31 articles being the basis of this review. Adenomyosis is a relatively common gynecologic condition that was previously thought to predominantly occur in older women, as it was diagnosed most commonly after a hysterectomy. As imaging techniques have advanced, this condition is now able to be diagnosed much earlier in life and is estimated to affect up to 20% of reproductive aged women. As studies have followed these women through subsequent pregnancies, an increased risk of adverse pregnancy outcomes has been observed. These include miscarriage, preterm birth, preterm prelabor rupture of membranes, small for gestational age, low birthweight, and preeclampsia, among others. This review is to examine the incidence, risk factors, and diagnostic criteria of adenomyosis and to then discuss its role in adverse pregnancy outcomes. Conclusions: Adenomyosis has been predominately a gynecologic condition, but now has been shown to adversely affect pregnancy outcomes. Diagnosis is made with histology, but may be suspected based on magnetic resonance imaging and ultrasound findings. Despite evidence of adverse pregnancy outcomes, there are no established strategies to risk, stratify, or prevent any of these outcomes.

Elevated Blood Pressure and Stage 1 Hypertension in Pregnancy: A Review of the Literature.

Importance: Maternal and perinatal morbidity/mortality is significantly increased in pregnancies complicated by hypertension. The definition of hypertension has recently changed with the addition of 2 categories: elevated blood pressure (BP) and stage 1 hypertension. Should these categories be considered during pregnancy? Objective: The aim of this study was to analyze the impact of the new hypertensive categories of elevated BP and stage 1 hypertension on maternal/perinatal outcomes. Methods: Literature search of PubMed, Web of Science, and CINAHL search was undertaken. Citations were limited to the past 20 years. Results: Of the 333 articles identified, 26 articles were the basis of this review. In 2017, new guidelines on the diagnosis and management of hypertension were published. Prepregnancy hypertension was replaced by elevated BP (systolic BP 120-129 mm Hg and diastolic BP <80 mm Hg) and stage 1 hypertension (systolic BP 130-139 mm Hg and diastolic BP 80-89 mm Hg). The risk factors for elevated BP and stage 1 hypertension are similar to chronic hypertension (CHTN) risk factors, diagnosed by BP readings before pregnancy or before 20 weeks' gestation. Patients with elevated BP and stage 1 hypertension are at increased risk for hypertensive disorders of pregnancies compared with normal patients. Treatment strategies for elevated BP and stage 1 hypertension are uncertain. Before 2017, these patients would not have been considered hypertensive and no guidelines existed. Conclusions: Elevated BP and stage 1 hypertension increase the number of women labeled with hypertension in pregnancy. These women are at increased risk for adverse perinatal and maternal outcomes. There are currently no firm guidelines on management during pregnancy.

Preconception, Antepartum, and Peripartum Care for the Woman With a Spinal Cord Injury: A Review of the Literature.

IMPORTANCE: Spinal cord injury (SCI) may result in temporary or permanent loss of sensory, motor, and autonomic function, presenting unique medical and psychosocial challenges in women during their childbearing years. OBJECTIVE: The aim of this study was to review the literature and describe the spectrum of pregnancy considerations, complications, and evidence-based obstetric practices in women with SCI. EVIDENCE ACQUISITION: A literature search was undertaken using the search engines of PubMed and Web of Science using the terms "spinal cord injury" or "spinal cord complications" and "pregnancy outcomes" or "pregnancy complications." The search was limited to the English language, and there was no restriction on the years searched. RESULTS: The search identified 174 abstracts, 50 of which are the basis for this review. Pregnancy in women who have experienced an SCI requires a multidisciplinary approach. Common complications during pregnancy include recurrent urinary tract infection, upper respiratory tract infection, hypertension, venous thromboembolism, and autonomic dysreflexia (AD), which is a potentially life-threatening complication. Obstetricians should avoid potential triggers and be familiar with acute management of AD. Postpartum complications include difficulty initiating and maintaining breastfeeding and increased risk of postpartum depression and other mental health issues. CONCLUSIONS AND RELEVANCE: Obstetricians caring for women with an SCI must be familiar with the unique challenges and complications that may occur during pregnancy and puerperium. RELEVANCE STATEMENT: An evidence-based literature review of the care of pregnant women with spinal cord injury.

Uterine Inversion: A Review of a Life-Threatening Obstetrical Emergency.

IMPORTANCE: Uterine inversion is frequently accompanied by postpartum hemorrhage and hypovolemic shock. Morbidity and mortality occur in as many as 41% of cases. Prompt recognition and management are of utmost importance. OBJECTIVE: The aim of this review is to describe risk factors, clinical and radiographic diagnostic criteria, and management of this rare but potentially life-threatening complication of pregnancy. EVIDENCE ACQUISITION: A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched. RESULTS: There were 86 articles identified, with 25 being the basis of review. Multiple risk factors for a uterine inversion have been suggested including a morbidly adherent placenta, short umbilical cord, congenital weakness of the uterine wall or cervix, weakening of the uterine wall at the placental implantation site, fundal implantation of the placenta, uterine tumors, uterine atony, sudden uterine emptying, fetal macrosomia, manual removal of the placenta, inappropriate fundal pressure, excessive cord traction, and the use of uterotonic agents prior to placental removal. The diagnosis is almost exclusively clinical, and successful treatment depends on prompt recognition of the uterine inversion. Treatment options include manual and surgical replacement of the inverted uterus. There is no consensus regarding mode of delivery in subsequent pregnancies as reinversion in a subsequent pregnancy is unpredictable. However, if surgical replacement was required in the index pregnancy and involved an incision into the contractile portion of the uterus, cesarean delivery is a reasonable management option similar to that offered for a prior classic cesarean section. CONCLUSIONS: Successful treatment is dependent on prompt recognition. Management should include resuscitation of maternal hypovolemic shock, as well as repositioning of the inverted uterine fundus. RELEVANCE: Uterine inversion is a rare but potentially life-threatening obstetrical emergency.

Chronic pain during pregnancy: a review of the literature.

BACKGROUND AND PURPOSE: The majority of the reviews and studies on chronic pain in pregnancy have primarily focused on the pharmacological and non-pharmacological treatment options. The purpose of our review was to identify evidence-based clinical research for the evaluation and management of preexisting chronic pain in pregnancy, chronic pain associated with pregnancy, and chronic pain in relation to mode of delivery. METHODS: A literature search was undertaken using the search engines PubMed, CINAHL, EBSCOhost, and Web of Science. Search terms used included "chronic pain" AND "pregnant OR pregnancy" OR "pregnancy complications" from inception through August 2016. RESULTS: The basis of this review was the 144 articles that met inclusion criteria for this review. Based on our review of the current literature, we recommend 7 guidelines for chronic pain management during and after pregnancy: 1) complete history and physical examination; 2) monitor patients for alcohol, nicotine, and substance use; 3) collaborate with patient to set treatment goals; 4) develop a management plan; 5) for opioids, use lowest effective dose; 6) formulate a pain management plan for labor and delivery; and 7) discuss reproductive health with women with chronic pain. CONCLUSION: The management of chronic pain associated with pregnancy is understudied. Obstetrical providers primarily manage chronic pain during pregnancy. Some general guidelines are provided for those health care providers until more information is available.

Incarceration of the Gravid Uterus.

OBJECTIVE: The aim of this review was to describe the risk factors, clinical and radiographic criteria, and management of this rare complication of pregnancy. METHODS: A PubMed, Web of Science, and CINAHL search was undertaken with no limitations on the number of years searched. RESULTS: There were 60 articles identified, with 53 articles being the basis of this review. Multiple risk factors have been suggested in the literature including retroverted uterus in the first trimester, deep sacral concavity with an overlying sacral promontory, endometriosis, previous abdominal or pelvic surgery, pelvic or uterine adhesions, ovarian cysts, leiomyomas, multifetal gestation, uterine anomalies, uterine prolapse, and uterine incarceration in a prior pregnancy. The diagnosis is difficult to make owing to the nonspecific presenting symptoms. The diagnosis is clinical and confirmed by imaging. Magnetic resonance imaging is superior to ultrasound to accurately diagnose and elucidate the distorted maternal anatomy. Treatment is dictated by gestational age at diagnosis based on risks and benefits. The recommended route of delivery is cesarean delivery when uterine polarity cannot be corrected. CONCLUSIONS: Incarceration of the gravid uterus is a rare but serious complication of pregnancy. The diagnosis is clinical and confirmed with imaging, with magnetic resonance imaging being superior to delineate the distorted maternal anatomy. Reduction of the incarcerated uterus should be attempted to restore polarity and avoid unnecessary cesarean delivery.