Multidisciplinary care of the pregnant patient with or at risk for venous thromboembolism: a recommended toolkit from the Foundation for Women and Girls with Blood Disorders Thrombosis Subcommittee.

The care of pregnant persons with/at risk of venous thromboembolism is complex and often challenging. Although guidelines have been published regarding the use of specific therapies, such as anticoagulants; in this population, none have provided guidance on how to coordinate multidisciplinary care of these patients. Here we provide an expert consensus on the role of various providers in the care of this patient population, as well as necessary resources and suggestions for best practices.

Anticipated impacts of climate change on women's health: A background primer.

Due to human activities, atmospheric greenhouse gas levels have increased dramatically, leading to an increase in the global mean surface temperature by 1.1° Celsius. Unless we can achieve a significant reduction in emissions, the global mean surface temperature will continue to rise to a dangerous level. Adverse outcomes of this warming will include extreme weather events, a deterioration of food, water and air quality, decreased food security, and an increase in vector-borne infectious disease. Political and economic instability as well as mass population migration will result in reduced access to healthcare resources. Mitigation of and adaptation to climate change will be key determinants of humanity's survival in the face of this existential crisis. Women will be more adversely affected by climate change than men, and pregnant persons will be particularly vulnerable. Particular differential impacts on women include higher heat and particulate-related morbidity and mortality; pregnancy risks including preterm birth, fetal growth lag, hypertensive disorders; and mental health impacts. To prepare for the climate crisis, it  is imperative for women's healthcare providers to assist their patients through political advocacy, provide family planning services, and focus on nutrition and lifestyle counseling.

Craniosynostosis: Clinical Presentation, Genetics, and Prenatal Diagnosis.

IMPORTANCE: Craniosynostosis is a fetal condition caused by premature closure of the cranial sutures. Through provider awareness, we can raise suspicion in high-risk individuals, increase prenatal detection, optimize genetic testing, perform appropriate antenatal surveillance and delivery planning, and allow for a comprehensive, multidisciplinary approach to treatment. OBJECTIVE: The aim of this study was to review what is currently known regarding the genetics, pathophysiology, diagnosis, and treatment of craniosynostosis for the obstetric care provider. EVIDENCE ACQUISITION: A comprehensive literature review was performed using the PubMed database with the search term "craniosynostosis." The search was limited to the English language. RESULTS: A total of 220 articles were identified, and a total of 53 were used in completion of this article. The results highlight the multiple factors involved with abnormal suture formation, including various genetic factors. Although rare at this time, prenatal detection can allow families to prepare and practitioners to provide appropriate clinical treatment. Both 3-dimensional sonography and magnetic resonance imaging have been identified as modalities to aid in detection for high-risk individuals. Early referral allows for less-invasive surgical outcomes with lower complication rates. RESULTS: Familiarity with craniosynostosis among obstetric providers can improve patient counseling, prenatal detection rates, and appropriate antepartum, intrapartum, and postpartum counseling.

Fetal dysrhythmias: a primer for the obstetrician/gynecologist.

During routine fetal auscultation, it is not uncommon to encounter an abnormal fetal heart rate. The rate may be abnormally slow or fast, or irregular. This article focuses on fetal dysrhythmias, defined as any irregular fetal cardiac rhythm or a regular rhythm with an abnormal rate outside the range of 120 to 160 beats per minute (Am J Obstet Gynecol. 2000;182:813-819). This article also helps the reader to recognize the most common types of fetal arrhythmias, understand the fetal risks associated with many fetal arrhythmias, and identify some of the pharmacological options used to treat fetal arrhythmias.

Early goal directed therapy for sepsis during pregnancy.

Sepsis is a leading cause of death in pregnancy and results in significant perinatal mortality. These deaths occur despite the younger age of pregnant patients, the low rate of comorbid conditions and the potential for effective interventions that should result in rapid resolution of illness. To date, no "evidence-based" recommendations are specific to the pregnant patient who is critically ill or septic. Optimal care for the septic patient requires a multidisciplinary team with expertise in obstetrics, maternal-fetal medicine, critical care, infectious disease, anesthesia, and pharmacy. Coordination of care and good communication amongst team members is essential. Incorporation of early goal directed therapy for suspected sepsis into obstetric practice is needed to optimize maternal and neonatal outcomes.

Anticoagulants in pregnancy.

UNLABELLED: Pregnancy is a hypercoagulable state that increases the risk of thromboembolic events. These risks may be further increased in the presence of an acquired or inherited thrombophilia. Thrombophilias have been associated with both maternal and fetal complications. The use of anticoagulants during pregnancy may reduce the risk of maternal thromboses as well as the risk of adverse pregnancy outcomes. The choice of an anticoagulant requires consideration of maternal risks, potential for teratogenicity, the underlying condition necessitating the treatment, and cost. This review examines the options for anticoagulation, the clinical situations that may warrant such treatment, and factors to be considered at delivery and during the postpartum period. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the roles of acquired and inherited thrombophilia in furthering the hypercoagulable state of pregnancy, identify the potential consequences of using anticoagulants during pregnancy, and summarize the treatment options when anticoagulation is required during pregnancy.

Ultrasound assessment of the fetal middle cerebral artery peak systolic velocity: A comparison of the near-field versus far-field vessel.

OBJECTIVE: Doppler assessment of the fetal middle cerebral artery peak systolic velocity may obviate the need for more invasive procedures in the alloimmunized patient. The purpose of this study was to compare middle cerebral artery peak systolic velocity measurements in the near field and far field. STUDY DESIGN: Patients between 16 and 42 weeks of gestation with normal fetuses were eligible (n=151). Peak systolic velocity measurements were obtained at the proximal portion of each middle cerebral artery at its origin in the internal carotid artery, as well as the most distal portion before its division, for a total of 4 measurements per fetus. Comparisons were made among the 4 locations and the data were analyzed using a mixed-model analysis of variance adjusted for gestational age. Results were presented using both P values and 95% CIs. P values <.05 were considered statistically significant. Where appropriate, P values and 95% CIs were adjusted using the Tukey multiple comparison procedure. A subanalysis was performed using 11 patients to assess interobserver reliability, which was calculated using the intraclass correlation coefficient (ICC). RESULTS: All four measurements were obtained for 120 fetuses (79%). The mean gestational age was 27.0 weeks. Statistically significant differences were noted between distal sites (95% CI, -0.05 to 0.01; P<.01) as well as the two sites on each vessel (95% CI, 0.03-0.07 and 0.07-0.12; P<.001 for both vessels). There was no significant difference between the two proximal locations (95% CI, -0.01 to 0.03; P=0.77). CONCLUSION: By which of the 2 vessels the fetal middle cerebral artery peak systolic velocity is affected is selected, as well as the location on the vessel. If the near-field proximal site cannot be interrogated, the far-field proximal site may be the best alternative.

King syndrome in pregnancy.

BACKGROUND: King syndrome is characterized by the presence of a nonspecific myopathy, a susceptibility to malignant hyperthermia, and dysmorphic features similar to the phenotype seen in Noonan syndrome. CASE: A young primigravida with King syndrome presented at 19 weeks' gestation. The patient required nocturnal mechanical ventilation via tracheostomy, and there was concern that the patient would become increasingly dependent on mechanical ventilation during pregnancy. The patient underwent a forceps-assisted delivery at 35 weeks' gestation, and both the patient and her infant did well and were discharged on postpartum day 3. CONCLUSION: In the gravida with King syndrome, agents that may trigger malignant hyperthermia should be avoided. Significant myopathy may result in respiratory compromise, and a multidisciplinary approach is necessary to optimize maternal and fetal outcome.