Trends in Reporting of Nuchal Translucency Measurements After the Clinical Introduction of Cell-Free DNA Screening.

Nuchal translucency (NT) measurement in conjunction with serum analytes has been used for first-trimester aneuploidy screening in the United States since 2005. We sought to analyze the trends in reporting of NT measurements to the Nuchal Translucency Quality Review program in all pregnancies beginning after the clinical introduction of cell-free DNA (cfDNA) screening for fetal aneuploidy in 2011. Overall, reported NT measurements decreased 74.3% from 2012 to 2022. A similar decline was noted among individuals with pregnancies at increased risk for aneuploidy based on patient age and twin gestations. The decrease in reporting aligns temporally with the availability of cfDNA screening and the coronavirus disease 2019 (COVID-19) pandemic.

Neurologic Emergencies in Pregnancy.

Neurologic emergencies in pregnancy require prompt evaluation and early, focused intervention to improve neurologic outcomes for the affected person and to avoid further injury. Neurologic events in pregnancy, although rare, present a time of extreme risk of permanent injury for the person who is pregnant. Therefore, obstetric clinicians should be well versed in the risk factors for potential neurologic events and understand the symptoms and events that should prompt evaluation for a neurologic event. In addition, they should support other specialties in aggressive and early neurologic care for the patient to improve outcomes while assessing fetal well-being and care optimization for the dyad. Obstetric clinicians can uniquely provide knowledge of changes in pregnancy physiology that can increase the risk of neurologic events, as well as change the treatment of these events. For all patients with neurologic events, "time is brain." Therefore, it is important to be aware of changes in common presenting pregnancy concerns that should prompt evaluation for other pathogeneses. Finally, pregnancy care teams should be prepared to begin the initial stabilization and management of acute neurologic emergencies, including seizure, stroke, and meningitis, while seeking aid from other medical and neurologic specialists who can support their care and interventions. Early and aggressive interventions for individuals with neurologic events during pregnancy and postpartum are critical to the overall well-being of the dyad.

Association between sex steroid hormones and subsequent hyperglycemia during pregnancy.

Objective: Sex steroid hormones may play a role in insulin resistance and glucose dysregulation. However, evidence regarding associations between early-pregnancy sex steroid hormones and hyperglycemia during pregnancy is limited. The primary objective of this study was to assess the relationships between first trimester sex steroid hormones and the subsequent development of hyperglycemia during pregnancy; with secondary evaluation of sex steroid hormones levels in mid-late pregnancy, concurrent with and subsequent to diagnosis of gestational diabetes. Methods: Retrospective analysis of a prospective pregnancy cohort study was conducted. Medically low-risk participants with no known major endocrine disorders were recruited in the first trimester of pregnancy (n=319). Sex steroid hormones in each trimester, including total testosterone, free testosterone, estrone, estradiol, and estriol, were assessed using high-performance liquid chromatography and tandem mass spectrometry. Glucose levels of the 1-hour oral glucose tolerance test and gestational diabetes diagnosis were abstracted from medical records. Multivariable linear regression models were fitted to assess the associations of individual first trimester sex steroids and glucose levels. Results: In adjusted models, first trimester total testosterone (ß=5.24, 95% CI: 0.01, 10.46, p=0.05) and free testosterone (ß=5.98, 95% CI: 0.97, 10.98, p=0.02) were positively associated with subsequent glucose concentrations and gestational diabetes diagnosis (total testosterone: OR=3.63, 95% CI: 1.50, 8.78; free testosterone: OR=3.69; 95% CI: 1.56, 8.73). First trimester estrone was also positively associated with gestational diabetes (OR=3.66, 95% CI: 1.56, 8.55). In mid-late pregnancy, pregnant people with gestational diabetes had lower total testosterone levels (ß=-0.19, 95% CI: -0.36, -0.02) after adjustment for first trimester total testosterone. Conclusion: Early-pregnancy sex steroid hormones, including total testosterone, free testosterone, and estrone, were positively associated with glucose levels and gestational diabetes in mid-late pregnancy. These hormones may serve as early predictors of gestational diabetes in combination with other risk factors.

Management of hepatic haemangioma in pregnancy.

Hepatic cavernous haemangioma is a benign tumour of vascular origin found within the liver. Often incidentally diagnosed, the management of these vascular masses is frequently determined by the size of the mass and symptoms associated with its compression of adjacent structures. Tumours >10 cm are known as giant haemangiomas and are associated with increased risks of compression symptoms, coagulopathies and haemorrhage. Known to express hormone receptors for oestrogen, intervention for these masses remains controversial in the setting of pregnancy where concerns for tumour growth and life-threatening complications are increased. Here we present the case of a woman in her 30s recently diagnosed with a giant haemangioma who is found to be pregnant, their management and a review of the literature.

Correlation between medical management and teamwork in multidisciplinary high-fidelity obstetrics simulations.

BACKGROUND: Teamwork and communication gaps are consistently cited as contributors to adverse outcomes in obstetrics. The Critical Care in Obstetrics Course provides an innovative experience by combining brief interactive didactics with the opportunity to practice and implement the knowledge gained with hands-on simulation. Most participants have never worked together, which creates a unique environment to evaluate the importance of teamwork and communication. OBJECTIVE: This study aimed to evaluate the association between teamwork and medical management in high-fidelity critical care simulations. STUDY DESIGN: The participants were separated into multidisciplinary teams and taken through simulations, including placental abruption, hypertensive emergency, eclampsia, sepsis, cardiac arrest, venous thromboembolism, diabetic ketoacidosis, and thyroid storm. Facilitators completed a validated checklist assessment for each group's performance in medical care and teamwork. Each element was rated on a scale from 1 to 5, with 1 being unacceptable and 5 being perfect. We evaluated 5 communication measures, including the use of closed-loop communication and orientation of new team members. A Spearman correlation was used to evaluate the relationship between total medical management and total teamwork scores and specific measures of team communication. Receiver operating characteristic curves were created for total teamwork score as a predictor of good or perfect medical management. RESULTS: A total of 354 multidisciplinary teams participated in 1564 high-fidelity simulations. There was a significant correlation between medical management and teamwork and communication scores for all scenarios. The strongest correlation was for the total teamwork score for all simulations (ρ=0.84). Teamwork scores were highly predictive of medical management scores with an area under the curve of at least 0.88 for all simulations, although this was not significant for diabetic ketoacidosis. CONCLUSION: The quality of teamwork and communication correlated with the quality of clinical performance in newly formed multidisciplinary teams. This demonstrates the importance of teamwork training, with a focus on key communication tools and strategies, among medical providers to optimize the management of complex and emergent obstetrical conditions.

Maternal prenatal infection and anxiety predict neurodevelopmental outcomes in middle childhood.

Prenatal maternal infection and anxiety have been linked, in separate lines of study, with child neurodevelopment. We extend and integrate these lines of study in a large prospective longitudinal cohort study of child neurodevelopment. Data are based on the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort; prenatal maternal anxiety was assessed from self-report questionnaire; prenatal infection was derived from reports of several conditions in pregnancy (n = 7,042). Child neurodevelopment at approximately 8 years of age was assessed by in-person testing, reports of social and communication problems associated with autism, and psychiatric evaluation. Covariates included psychosocial, demographic, and perinatal/obstetric risks. Prenatal infection was associated with increased likelihood of co-occurring prenatal risk, including anxiety. Regression analyses indicated that both prenatal infection and prenatal anxiety predicted child social and communication problems; the predictions were largely independent of each other. Comparable effects were also found for the prediction of symptoms of attention problems and anxiety symptoms. These results provide the first evidence for the independent effects of prenatal infection and anxiety on a broad set of neurodevelopmental and behavioral and emotional symptoms in children, suggesting the involvement of multiple mechanisms in the prenatal programming of child neurodevelopment. The results further underscore the importance of promoting prenatal physical and mental health for child health outcomes. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The association of skin incision placement during cesarean delivery with wound complications in obese women: a systematic review and meta-analysis.

OBJECTIVE: To determine the risk of wound complications by skin incision type in obese women undergoing cesarean delivery.Data sources: Electronic databases (MEDLINE, Scopus, and Ovid) were searched from their inception through August 2018.Methods of study selection: We included all randomized controlled trials and cohort studies reporting the placement of skin incision during cesarean section in obese women, defined as those with BMI ≥30 kg/m2. Studies were included if they compared one placement of skin incision with a different one as comparison group. The primary outcome was incidence of wound complications, while secondary outcomes included wound infection, hematoma, seroma, postpartum hemorrhage, and endometritis. Demographics and outcomes for each individual study identified were reported as part of the review. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) or relative risk (RR) with 95% confidence interval (CI). Sub-group analyses (vertical versus Pfannenstiel) were also reported.Tabulation, integration and results: Seventeen studies (including 3 RCTs; 8960 participants among the 15 non-overlapping studies) were included in the systematic review. Vertical incisions were associated with a relative risk of 2.07 (95% CI1.61-2.67) for wound complications compared to transverse incisions, however significant possible confounders were present. Studies were mildly-moderately heterogeneous (I2 44.81%, 95% CI 0.00-71.85%) with varying definitions of obesity and wound complications. High transverse incisions (3 studies, 218 participants) trend toward a lower risk of wound complications compared to low transverse incisions (RR 0.338, 95% CI 0.114-1.004). CONCLUSIONS: Vertical incisions may be associated with an increased risk for wound complications compared to transverse incisions for cesarean delivery in obese women. Randomized controlled trials are needed to evaluate optimal cesarean skin incisions for these women.

The Biopsychosocial Model and Perinatal Health Care: Determinants of Perinatal Care in a Community Sample.

Insufficient care in the perinatal period is associated with poorer maternal health, poorer perinatal outcomes, infant mortality, and health inequalities. Identifying the sources of and reducing the rates of insufficient care is therefore a major clinical and public health objective. We propose a specific application of the biopsychosocial model that conceptualizes prenatal and postpartum care quality as health markers that are influenced by psychological factors and family and social context. Clinic attendance data were abstracted from the electronic medical records of N = 291 participants enrolled in a longitudinal pregnancy cohort study of healthy women who have been followed since the first trimester; the Kotelchuck Index (KI) was calculated as an index of perinatal care utilization. Detailed prenatal psychological, social, and sociodemographic data were collected from self-report questionnaire and interview. Bivariate analyses indicated socio-demographic (e.g., race), psychological (e.g., response to perceived racism, affective symptoms, trauma experience), and social and family context (e.g., social support, family size) significantly influenced pre- and post-natal care utilization. Multivariate logistic regression analyses, adjusting for medical complications, identified social and family context as robust predictors of perinatal care utilization. The findings underscore the need for biopsychosocial models of health care and highlight several potential strategies for improving health care utilization.

Associations Between Historically Redlined Districts and Racial Disparities in Current Obstetric Outcomes.

Importance: Despite much higher health care expenditure than comparable countries, striking racial and ethnic disparities exist in obstetric outcomes in the United States. A multifaceted exploration of the factors influencing these disparities, including the legacy of structural racism, is important to improve health outcomes for all. Objective: To characterize the association of the historic racially discriminatory home loan practice of redlining with disparities in modern obstetric outcomes. Design, Setting, and Participants: In this retrospective cohort study of a 9-county birth certificate database in the Finger Lakes region of New York state from 2005 to 2018, modern obstetric outcomes were matched with regions classified by the federal government for mortgage loan servicing based on racially discriminatory criteria from the 1940 Home Owners' Loan Corporation map (HOLC; also known as the redline map). Patients with a live birth recorded in the data system with a recorded home zip code within the historic HOLC categories were included. Data were analyzed from July to December 2019. Exposure: Regions previously categorized by historic, racially discriminatory criteria. Main Outcomes and Measures: Each HOLC area was analyzed for the primary outcome of preterm birth and secondary outcomes of obstetric and medical complications, with logistic regression to address regional and patient-level covariates. Results: From 2005 until 2018, there were 64 804 live births within the 15 zip codes overlaying historic HOLC regions. Prevalence of preterm birth increased with decreasing HOLC categories, from the lowest overall preterm birth rate of 217 of 2873 births (7.55%) in the zip code historically defined as "Best" or "Still Desirable" and the highest overall preterm birth rate of 427 of 3449 births (12.38%) in the zip code historically defined as "Hazardous." These associations with preterm birth remained significant in logistic regression controlling for poverty levels and educational attainment (adjusted odds ratio, 1.46; 95% CI, 1.08-1.97) and parental race (adjusted odds ratio, 1.38; 95% CI, 1.25-1.53). Conclusions and Relevance: In this cohort study, the linkage of historic and modern community data sets with an obstetric data set offered the opportunity to characterize modern obstetric disparities associated with a system of historic inequity. The persistence of these findings after correcting for contemporary community socioeconomic characteristics suggest potential influences of a system of profound structural inequity that ripple forward in time, with impacts that extend beyond measurable socioeconomic inequity.

Biological changes in the pregnancy-postpartum period and subsequent cardiometabolic risk-UPSIDE MOMS: A research protocol.

Multiple physiological changes occur in pregnancy as a woman's body adapts to support the growing fetus. These pregnancy-induced changes are essential for fetal growth, but the extent to which they reverse after pregnancy remains in question. For some women, physiological changes persist after pregnancy and may increase long-term cardiometabolic disease risk. The National Institutes of Health-funded study described in this protocol addresses a scientific gap by characterizing weight and biological changes during pregnancy and an extended postpartum period in relation to cardiometabolic risk. We use a longitudinal repeated measures design to prospectively examine maternal health from early pregnancy until 3 years postpartum. The aims are: (1) identify maternal weight profiles in the pregnancy-postpartum period that predict adverse cardiometabolic risk profiles three years postpartum; (2) describe immune, endocrine, and metabolic biomarker profiles in the pregnancy-postpartum period, and determine their associations with cardiometabolic risk; and (3) determine how modifiable postpartum health behaviors (diet, physical activity, breastfeeding, sleep, stress) (a) predict weight and cardiometabolic risk in the postpartum period; and (b) moderate associations between postpartum weight retention and downstream cardiometabolic risk. The proposed sample is 250 women. This study of mothers is conducted in conjunction with the Understanding Pregnancy Signals and Infant Development study, which examines child health outcomes. Biological and behavioral data are collected in each trimester and at 6, 12, 24, and 36 months postpartum. Findings will inform targeted health strategies that promote health and reduce cardiometabolic risk in childbearing women.

Effect of gabapentin on hyperemesis gravidarum: a double-blind, randomized controlled trial.

BACKGROUND: Hyperemesis gravidarum is a disabling disease of nausea, vomiting, and undernutrition in early pregnancy for which there are no effective outpatient therapies. Poor weight gain in hyperemesis gravidarum is associated with several adverse fetal outcomes including preterm delivery, low birthweight, small for gestational age, low 5-minute Apgar scores, and neurodevelopmental delay. Gabapentin is most commonly used clinically for treating neuropathic pain but also substantially reduces chemotherapy-induced and postoperative nausea and vomiting. Pregnancy registry data have shown maternal first-trimester gabapentin monotherapy to be associated with a 1.2% rate of major congenital malformations among 659 infants, which compares favorably with the 1.6% to 2.2% major congenital malformation rate in the general population. Open-label gabapentin treatment in hyperemesis gravidarum was associated with reduced nausea and vomiting and improved oral nutrition. OBJECTIVE: This study aimed to determine whether gabapentin is more effective than standard-of-care therapy for treating hyperemesis gravidarum. STUDY DESIGN: A double-blind, randomized, multicenter trial was conducted among patients with medically refractory hyperemesis gravidarum requiring intravenous hydration. Patients were randomized (1:1) to either oral gabapentin (1800-2400 mg/d) or an active comparator of either oral ondansetron (24-32 mg/d) or oral metoclopramide (45-60 mg/d) for 7 days. Differences in Motherisk-pregnancy-unique quantification of nausea and emesis total scores between treatment groups averaged over days 5 to 7, using intention-to-treat principle employing a linear mixed-effects model adjusted for baseline Motherisk-pregnancy-unique quantification of nausea and emesis scores, which served as the primary endpoint. Secondary outcomes included Motherisk-pregnancy-unique quantification of nausea and emesis nausea and vomit and retch subscores, oral nutrition, global satisfaction of treatment, relief, desire to continue therapy, Nausea and Vomiting of Pregnancy Quality of Life, and Hyperemesis Gravidarum Pregnancy Termination Consideration. Adjustments for multiple comparisons were made employing the false discovery rate. RESULTS: A total of 31 patients with hyperemesis gravidarum were enrolled from October 2014 to May 2019. Among the 21 patients providing primary outcome data (12 assigned to gabapentin and 9 to the active comparator arm), 18 were enrolled as outpatients and all 21 were outpatients from days 5 to 7. The study groups' baseline characteristics were well matched. Gabapentin treatment provided a 52% greater reduction in days 5 to 7 baseline adjusted Motherisk-pregnancy-unique quantification of nausea and emesis total scores than treatment with active comparator (95% confidence interval, 16-88; P=.01). Most secondary outcomes also favored gabapentin over active comparator treatment including 46% and 49% decreases in baseline adjusted Motherisk-pregnancy-unique quantification of nausea and emesis nausea (95% confidence interval, 19-72; P=.005) and vomit and retch subscores (95% confidence interval, 21-77; P=.005), respectively; a 96% increase in baseline adjusted oral nutrition scores (95% confidence interval, 27-165; P=.01); and a 254% difference in global satisfaction of treatment (95% confidence interval, 48-459; P=.03). Relief (P=.06) and desire to continue therapy (P=.06) both showed trends favoring gabapentin treatment but Nausea and Vomiting of Pregnancy Quality of Life (P=.68) and Hyperemesis Gravidarum Pregnancy Termination Consideration (P=.58) did not. Adverse events were roughly equivalent between the groups. There were no serious adverse events. CONCLUSION: In this small trial, gabapentin was more effective than standard-of-care therapy for reducing nausea and vomiting and increasing oral nutrition and global satisfaction in outpatients with hyperemesis gravidarum. These data build on previous findings in other patient populations supporting gabapentin as a novel antinausea and antiemetic therapy and support further research on gabapentin for this challenging complication of pregnancy.

Does transvaginal ultrasound at 13-15 weeks improve anatomic survey completion rates in obese gravidas?

Objective: Obesity increases the difficulty of completing the fetal anatomic survey. This is of added concern in obese gravidas who are at higher risk of congenital fetal anomalies. We hypothesized that incorporation of an early transvaginal assessment could improve the completion rate of the fetal anatomic survey in obese women.Methods: We performed a prospective, longitudinal, blinded study of obese gravidas (BMI ≥ 35 kg/m2) comparing the use of a single early second trimester transvaginal ultrasound in addition to midtrimester transabdominal ultrasound versus traditional serial midtrimester ultrasound alone for completion of the anatomic survey. Transvaginal ultrasound for anatomy was performed between 13 0/7 and 15 6/7 week followed by midtrimester anatomic ultrasound, with each patient serving as her own control. Structures were marked as optimally or suboptimally viewed after each ultrasound. Sonographers and reviewers were blinded to images from the transvaginal ultrasound. Completion rates and gestational age at completion were compared between groups.Results: Fifty subjects were included. Fetal anatomic survey was completed in 62% using standard midtrimester assessment versus 78% with the addition of early transvaginal assessment (p = .04). The survey was completed at an earlier gestational age utilizing the transvaginal approach (22 0/7 ± 6 3/7) compared to traditional midtrimester transabdominal ultrasound approach (25 2/7 ± 5 3/7) p < .0005.Conclusions: Incorporation of an early transvaginal assessment of anatomy in obese women improved the rate of completion and led to earlier gestational age at completion of the fetal anatomic survey. Consideration should be given to including an early transvaginal sonogram as part of routine assessment of women with a BMI ≥ 35.

Prenatal Ultrasound Measurement of Fetal Stomach Size Is Predictive of Postnatal Development of GERD in Isolated Cleft Lip and/or Palate.

OBJECTIVE: To determine whether prenatal ultrasound measurement of fetal stomach size, as a surrogate marker of fetal swallowing, is predictive of postnatal development of gastroesophageal reflux disease (GERD) in cases of isolated cleft lip and/or palate (CL/P). DESIGN: This is a retrospective case-control study. The outcome of interest is postnatal diagnosis of GERD in isolated CL/P. The exposure of interest is prenatal stomach size measurement by ultrasound. SETTING: The study population was selected from an academic, tertiary care center between 2003 and 2011. PATIENTS/PARTICIPANTS: Cases were neonates undergoing CL/P repair during the study period. Cases with other known structural or chromosomal abnormalities were excluded. Controls were contemporary, nondiabetic neonates that matched gestational age (within one week) to cases. Each case measurement was matched ∼1:2 with control measurement. INTERVENTIONS: None. MAIN OUTCOME MEASURE: The primary outcome was difference in mean prenatal ultrasound measurement of fetal stomach size between cases and controls. We hypothesized that patients with postnatal development of GERD would have smaller mean fetal stomach size. RESULTS: There were 32 cases including 19 patients with unilateral cleft lip and palate, 8 with unilateral cleft lip, and 4 with bilateral cleft lip and palate. Cases were noted to have smaller mean anterior-posterior and transverse fetal stomach measurements as compared to controls. This was statistically significant from 16 to 21 weeks, 25 to 27 weeks, and 28 to 36 weeks (P < .01 for all). CONCLUSIONS: Prenatal ultrasound measurement of fetal stomach size as a surrogate marker of fetal swallowing is predictive of postnatal development of GERD in isolated CL/P.

Evaluating sensitivity and specificity of handheld point-of-care ultrasound testing for gynecologic pathology: a pilot study for use in low resource settings.

BACKGROUND: Point-of-care ultrasound (POC-US) is a diagnostic test conducted at the site of patient care with direct interpretation by the clinician, providing immediate results. POC-US for gynecologic application is not well characterized by current literature yet has the potential to increase access in limited resource settings. We compared the diagnostics of three POC-US devices for gynecologic (GYN) pathology and then performed evaluation of sensitivity and specificity of a single best POC-US device for intended use in a low resource setting. METHODS: This is prospective, pilot descriptive study of 60 subjects. In part 1, comparison of three POC-US devices was performed. Twenty subjects underwent POC-US with three test units [GE Vscan (Vscan), Sonosite Iviz (Iviz), Philips Lumify (Lumify)] followed by diagnostic ultrasound (Dx-US) for reference imaging. Image quality and correlation for devices was scored by blinded reviewers and quantitative measurements of GYN pathology were compared. In part 2, forty subjects underwent POC-US validation with the highest scoring device (Lumify) and Dx-US for reference imaging. Concordance of POC-US operator-interpreted diagnosis with reference imaging interpretation were assessed by Cohen's unweighted kappa coefficient. Accuracy and agreement of POC-US were assessed by linear regression and Bland-Altman plot analysis. Sensitivity and specificity of POC-US for gynecologic pathologies were calculated. RESULTS: In aggregate qualitative measurements, Lumify and Iviz units performed superiorly to Vscan. There was no statistically significant difference in quantitative measurements between devices, but a trend towards lower mean error was seen for Lumify and Iviz as compared to Vscan. Lumify device had highest overall scoring and was selected for further testing. In validation comparison of Lumify to Dx-US, no statistically significant differences were found for measurements of endometrium, uterus, ovaries, adnexal pathology, or leiomyomata, (P < 0.02) with excellent agreement in operator-interpreted diagnosis (Kappa > 0.7). Sensitivity and specificity of detecting pathology was 80-100% with PPV and NPV 76-100%. CONCLUSION: Among three POC-US devices, Lumify and Iviz devices show highest potential for successful application to clinical gynecologic ultrasound. Clinician-performed POC-US has high diagnostic accuracy, sensitivity, and specificity for basic GYN anatomy and pathology. POC-US is an acceptable and feasible diagnostic tool with potential for future application in a low resource setting to increase access to ultrasound.

Practice Modification for Pandemics: A Model for Surge Planning in Obstetrics.

This review highlights proposed pandemic-adjusted modifications in obstetric care, with discussion of risks and benefits based on available evidence. We suggest best practices for balancing community-mitigation efforts with appropriate care of obstetric patients.

Ultrasound Assessment of the Intrauterine Device.

As the use of intrauterine devices (IUDs) has expanded in the United States, both as a highly effective form of long-acting reversible contraception (LARC) and as a tool for effective management of other gynecologic conditions, effective imaging of IUDs has become increasingly important. Ultrasound is a cost-effective, accurate, safe, and accessible imaging solution for the assessment of IUDs. This article explores the role of ultrasound in evaluation of IUDs as well as the literature regarding ultrasound guidance for device placement. It also examines the evaluation and management of IUDs with a concurrent intrauterine pregnancy.

Neurological diseases in pregnancy.

PURPOSE OF REVIEW: To summarize recent research findings and current concepts related to care of neurologic diseases in pregnancy and the risks of pregnancy to the mother-infant dyad. Recent publications related to best practices for neurologic care, risks of pregnancy, rate of relapse during and after pregnancy, as well as medication safety in pregnancy and lactation for more commonly used neurologic medications are reviewed. RECENT FINDINGS: Data continues to grow that women with neurologic conditions can experience pregnancy with minimal risks. Additionally, as more data is being published on medication safety in pregnancy and lactation, most medical therapy is now thought to be compatible, improving symptoms and care for women with neurologic conditions who require pharmacologic treatment. However, data remains limited from clinical trials and from more objective studies. Researchers continue to clarify the impact of pregnancy on the course of chronic neurologic diseases such as multiple sclerosis, myasthenia gravis, epilepsy, migraine, and cerebral aneurysms as well as the impact of these diseases on antepartum, labor and delivery, and postpartum management and neonatal course. Acute neurological conditions with pregnancy-associated risk such as stroke, posterior reversible encephalopathy syndrome, and cerebral venous sinus thrombosis are increasingly studied to determine individuals who are most vulnerable to these serious complications. SUMMARY: Many neurological diseases coexist with pregnancy. Recent research indicates a good prognosis for both mother and neonate. Although research related to neurologic disease in pregnancy is growing, it remains an area that deserves further focus to guide evidence-based care. With advances in research on therapeutic options, some women can achieve a safe pregnancy in the setting of chronic neurological disease. VIDEO ABSTRACT: http://links.lww.com/COOG/A45.

Surgical management of postpartum hemorrhage.

When medical management of PPH is unsuccessful, surgical options should be utilized in a timely fashion in order to reduce maternal morbidity and mortality. This chapter describes ways of effective preparation, mobilization of resources and an organized approach to evaluation and surgical amelioration of PPH. Multiple fertility preserving surgical techniques to control PPH are described. Although a variety of conservative surgical approaches can be used in the setting of PPH, in a hemodynamically unstable patient, readiness for definitive management with a hysterectomy is necessary in order to reduce the risk of maternal mortality.