Perinatal and cardiac outcomes of women with hypertrophic cardiomyopathy.

RATIONALE: Pregnancy causes important physiologic stress for women with hypertrophic cardiomyopathy. Data regarding the impact of this condition on obstetrical outcomes is missing. OBJECTIVES: Our objective was to report obstetrical and cardiac outcomes in pregnant women with hypertrophic cardiomyopathy and to assess the possible adverse effects of left ventricular outflow tract obstruction in pregnancy. STUDY DESIGN: This was a retrospective cohort study of pregnant women diagnosed with HCM and followed at single tertiary center between 1995 and 2019. Demographic, medical and surgical data, echocardiographic parameters, and pregnancy outcomes were abstracted through extensive chart review. Patients were divided into 2 groups: obstructive (maximal left ventricular outflow tract gradient over 30 mmHg) versus non-obstructive hypertrophic cardiomyopathy. Outcomes between groups were compared with t-test, Mann-Whitney and Fisher's exact tests when appropriate. RESULTS: Eighteen women with 27 pregnancies were included. The study population was formed of 18 women with a total of 27 pregnancies that reached at least 20 weeks of gestation: 12 pregnancies in women with obstructive hypertrophic cardiomyopathy and 15 pregnancies in women with non-obstructive hypertrophic cardiomyopathy. Among the non-obstructive hypertrophic cardiomyopathy, 5 of them had been treated for their obstruction. One patient with obstructive hypertrophic cardiomyopathy had a medical termination of pregnancy for uncontrolled arrhythmia at 21 weeks. There were no maternal deaths. Left ventricular outflow tract obstruction was associated with increased cardiac events including arrhythmias and heart failure (5/12 versus 0/15; p = .006). Preterm birth occurred in more than 50% of cases, resulting from induced delivery for a maternal (40%) or fetal reason (60%). Most deliveries were late preterm between 34 and 36 6/7 weeks. In both groups, birthweight was mainly distributed below the 50th percentile (89%) and 35% of neonates were born small for gestational age defined as a birthweight below the 10th percentile. Most severe cases of small for gestational age (birthweight under the 5th percentile) were found in patients with treated obstructive hypertrophic cardiomyopathy. CONCLUSION: Hypertrophic cardiomyopathy is associated with prematurity and small for gestational age. Left ventricular outflow tract obstruction is associated with adverse cardiac events including arrythmias or heart failure. Treated obstructive cardiomyopathy constitutes a sub-group of patients at high risk of severe small for gestational age and deserves a close surveillance. Therefore, fetal growth surveillance with ultrasound, early in the third trimester and doppler studies to assess the utero-placental perfusion in the second and third trimesters are warranted in all patients with hypertrophic cardiomyopathy regardless of the severity of their condition.

Using simulation team training with human's factors components in obstetrics to improve patient outcome: A review of the literature.

OBJECTIVE: to assess the evidence from multidisciplinary simulation team training in obstetrics that integrates human's factors components on patient outcome. INTRODUCTION: It has been stated that simulation-based education has the potential to improve technical and nontechnical skills. Reports from enquiries into maternal and newborn adverse outcomes, highlight that the majority of incidents are due to a breakdown of communication and a lack of crisis resource management skills (CRM). It is therefore reasonable to think that a better training on teamwork based on simulation will ultimately improve obstetrics care. In order to explore further that idea, we conducted a literature review on patient outcome after a multidisciplinary simulation training in obstetrics. METHOD: Pubmed, Advances in health sciences education, BMC in medical education, BMC in pregnancy and Childbirth, BMJ open, BMJ Simulation and technology enhanced learning were searched from inception to May 2020 for full-text publications in English on interprofessional, multidisciplinary, obstetrics, simulation training, non-technical skills, CRM. Searches were limited to studies with a report on patient outcome after a multidisciplinary simulation program that included elements of CRM. RESULT: Out of the ten studies selected in our review, five were single site before and after prospective studies and five were cluster before and after randomized trials. All the single site studies reported a positive outcome in low and high resource countries. Three single site studies reported a reduction between 41 and 50 % of blood transfusion after simulation team training. Two single studies reported a reduction of maternal mortality by 34 % and a decrease in an adverse obstetrics index outcome from 0.052 to 0.048 with a p-value of 0.05. Cluster studies showed either no change or some improvement in patient outcomes such as a 37 % improvement on weighted obstetrics adverse outcome, a 17 % reduction in the incidence of PPH and a 47 % reduction in the incidence of retained placenta. Stillbirths rate was reduced by 34 % while newborn deaths was down by 62 %. There was also a 15 % reduction of maternal mortality in favor of the trained team after adjustment to the secular mortality trend. Neonatal death from 24 weeks during the first 24 h was also reduced by 83 % in the intervention site compare with an increase by 18 % in the control site. CONCLUSION: There is evidence that simulation team training that includes CRM is associated with better patient outcome. In order to consolidate this finding, appropriate methodology should be used in future studies with the support of health authorities.

Evaluation of Complications in Postpartum Women Receiving Therapeutic Anticoagulation.

OBJECTIVE: To evaluate complications associated with early postpartum therapeutic anticoagulation. METHODS: A multicenter retrospective cohort study was done to evaluate the association between therapeutic anticoagulation postpartum and major complications (hemorrhagic and wound complications). Secondary outcomes included minor complications, risk factors associated with total complications (including the time to therapeutic anticoagulation resumption after delivery) and recurrent thrombotic events within 6 weeks postpartum. RESULTS: From 2003 to 2015, 232 consecutive women were treated with therapeutic anticoagulation within 96 hours postpartum; among those treated, 91 received unfractionated heparin, 138 received low-molecular-weight heparin, and three received other anticoagulants. The primary outcome, a composite of major hemorrhagic complications (requiring transfusion, hospitalization, volume resuscitation, transfer to intensive care unit, or surgery) and major wound complications, occurred in 7 of 83 (8.4%) for cesarean deliveries and 9 of 149 (6.0%) for vaginal deliveries (P=.490). Total complications (including major and minor hemorrhagic and wound complications) occurred in 13 of 83 (15.7%) for cesarean deliveries compared with 9 of 149 (6.0%) for vaginal deliveries (P=.016). When comparing cases associated with and without complications, the median delay before resuming anticoagulation was significantly shorter for both cesarean (12 vs 33 hours, P=.033) and vaginal deliveries (6 vs 19 hours, P=.006). For vaginal deliveries, 8 of 51 (15.7%) women had complications when anticoagulation was started before 9.25 hours postpartum, compared with 1 of 98 (1.0%) when started after 9.25 hours. For cesarean deliveries, 7 of 21 (33.3%) of women experienced complications compared with 6 of 62 (9.7%) if anticoagulation was started before or after 15.1 hours, respectively. Two (0.9%) episodes of venous thromboembolism occurred within 6 weeks postpartum. CONCLUSION: Among postpartum women who received early therapeutic anticoagulation, major complications occurred in 8.4% for cesarean deliveries and 6.0% for vaginal deliveries. Complications were associated with earlier resumption of therapeutic anticoagulation, particularly before 9.25 hours for vaginal deliveries and before 15.1 hours for cesarean deliveries.

Navigating creativity within arts-based pedagogy: Implications of a constructivist grounded theory study.

BACKGROUND: Educators implement arts-based pedagogy with the hope that it will foster meaningful learning for students. However, nursing students have varied reactions to artistic assignments, and there is a need to further understand students' learning processes with this novel approach and the factors influencing their learning. This understanding could promote the more effective implementation of arts-based pedagogy into nursing education. OBJECTIVE: To develop a theoretical understanding of how and when undergraduate nursing students learn through arts-based pedagogy. DESIGN: Constructivist grounded theory. SETTINGS: Canadian baccalaureate nursing program. PARTICIPANTS: Thirty third-year undergraduate nursing students and eight of their nursing instructors. METHODS: Participants who had experienced arts-based assignments were recruited with purposive and then theoretical sampling. We collected four sources of data: a socio-demographic questionnaire, semi-structured interviews, photo/art elicitation, and field notes. The socio-demographic data were analyzed with descriptive statistics and all other data with constructivist grounded theory procedures. RESULTS: Our findings revealed that students had to navigate a creative process with arts-based assignments, which involved several iterative phases. This type of learning was unique within their program and somewhat constrained by the context of nursing education. There was notable variation in the students' experiences. Although many reported meaningful learning, approximately 20% of the students did not value the assignment. Our findings elucidated multi-level enabling and restraining factors that influenced students' engagement with and learning from this creative process. CONCLUSIONS: These findings provide insight into modifiable factors that influenced students' engagement and learning, and have important implications for making ABP accessible and meaningful for more students.

The arts as a catalyst for learning with undergraduate nursing students: findings from a constructivist grounded theory study.

Background: There is a growing interest in arts-based pedagogy (ABP) to promote the wide range of competencies needed for professional nursing. The aim of this study was to develop a theoretical understanding of how students learn through ABP in undergraduate nursing education. Methodology and Methods: We used a constructivist grounded theory methodology which incorporated art-elicitation interviews. Thirty nursing students and eight nurse educators shared about their ABP experiences. Data were analyzed with grounded theory procedures. Results: The arts as a catalyst for learning emerged as the core category and elucidates how the unique quality of the arts created powerful pedagogical processes for many students. When students engaged with these processes, they resulted in surprising and transformative learning outcomes for professional nursing. Conclusions: These findings provide insight into why and how students learned through ABP, and can inform the effective implementation of ABP into healthcare education.

Obstetric and cardiac outcomes in women with Marfan syndrome and an aortic root diameter ≤ 45mm.

OBJECTIVE: To assess obstetric and aortic outcomes in women with Marfan Syndrome according to aortic root diameter, in view of recommendations for caesarean delivery when the aortic root diameter is ≥40 mm in the 2010 American guidelines versus >45 mm in the 2011 European guidelines. STUDY DESIGN: In this retrospective cohort study conducted at Sainte-Justine Mother and Child Tertiary Hospital, 27 pregnancies in 20 women with Marfan Syndrome as defined by the international criteria, were followed prospectively between 1994 and 2017, after excluding women with prior aortic surgery. Obstetric and aortic outcomes were compared in 2 groups according to aortic root diameter: < 40 mm (21 pregnancies) and 40-45 mm (6 pregnancies). RESULTS: 21/27 women had a vaginal delivery. The caesarean section rate was 23.8% and 16.7% in women with diameter <40 mm and 40-45 mm respectively (p-value = 1), and perinatal outcome was similar across groups. Two women with a prepregnancy aortic root diameter <40 mm developed an acute type B dissection during the third trimester. Both had a family history of aortic dissection. CONCLUSIONS: Vaginal delivery with rigorous pain control and avoidance of Valsalva maneuver may be safely considered in women with Marfan Syndrome and an aortic root diameter ≤45 mm. The risk of type B aortic dissection during pregnancy is hard to predict. Other factors such as family history of dissection and descending aorta size may play an important role, and this may modify our counselling.

Effectiveness and experience of arts-based pedagogy among undergraduate nursing students: a mixed methods systematic review.

BACKGROUND: To develop well rounded professional nurses, educators need diverse pedagogical approaches. There is growing interest in arts-based pedagogy (ABP) as the arts can facilitate reflection, create meaning and engage healthcare students. However, the emerging body of research about ABP needs to be systematically examined. OBJECTIVES: To synthesize the best available evidence on the effectiveness of ABP in enhancing competencies and learning behaviors in undergraduate nursing education and to explore nursing students' experiences with art-based pedagogy. INCLUSION CRITERIA TYPES OF PARTICIPANTS: The review considered studies that included participants who are undergraduate nursing students. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST: The qualitative (QL) component considered studies investigating nursing students' experiences of ABP, and the quantitative (QN) component considered studies evaluating the effectiveness of ABP in undergraduate nursing education. TYPES OF STUDIES: The QL component considered QL studies including designs such as phenomenology, grounded theory, ethnography, action research and feminist research. The QN component considered studies that examined the effectiveness of ABP including designs such as randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies, analytical cross-sectional studies, case series, individual case reports and descriptive cross-sectional studies. OUTCOMES: The following QN outcomes of ABP were assessed: knowledge acquisition, level of empathy, attitudes toward others, emotional states, reflective practice, self-transcendence, cognitive/ethical maturity, learning behaviors and students' perspectives of ABP. SEARCH STRATEGY: An extensive three-step search strategy was conducted for primary research studies published between January 1, 1994 and April 7, 2015. The strategy included searching CINAHL, MEDLINE, ERIC, PsycINFO, Academic Search Complete, Arts and Humanities Citation Index, Art Full Text, Scopus, ProQuest Dissertations and Theses, A&I, and gray literature. Only studies published in English were included. METHODOLOGICAL QUALITY: Two reviewers assessed all studies for methodological quality using appropriate critical appraisal checklists from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) or the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). DATA EXTRACTION: Data were extracted from included articles using the standardized data extraction tool from JBI-QARI or JBI-MAStARI. DATA SYNTHESIS: Qualitative studies were pooled through a meta-synthesis. Data from the QN studies were combined using a narrative synthesis as a meta-analysis was not possible. The researchers used a segregated mixed methods approach to integrate the QL and QN components. RESULTS: Twenty-one QL studies of high methodological quality were included. The two synthesized findings revealed that art forms could create meaning and inspire learning in undergraduate nursing education and that ABP can develop important learner outcomes/competencies for professional nursing. These synthesized findings received a moderate ConQual rating. Fifteen experimental/quasi-experimental studies of moderate methodological quality were included. The narrative synthesis suggested that ABP improved nursing students' knowledge acquisition, level of empathy, attitude toward others, emotional states, level of reflective practice, learning behaviors and aspects of cognitive/ethical maturity. In five cross-sectional studies, the majority of students had a positive perspective of ABP. When the QL and QN findings were interpreted as a whole, ABP appeared to facilitate learning in the cognitive and affective domains and may be especially useful in addressing the affective domain. CONCLUSION: Nurse educators should consider using ABP as students found that this approach offered a meaningful way of learning and resulted in the development of important competencies for professional nursing. The QN studies provide a very low level of evidence that ABP improved students' knowledge acquisition, level of empathy, attitude toward others, emotional states, level of reflective practice, learning behaviors and aspects of cognitive/ethical maturity. Although the QN findings can inform future research, the evidence is not robust enough to demonstrate improved outcomes.

Hypercalcemia in pregnancy - a multifaceted challenge: case reports and literature review.

Hypercalcemia in pregnancy is an uncommon event that can cause major maternal morbidity and/or fetal or neonatal morbidity and mortality. Management is a challenge for the clinicians, especially as regards to investigations in pregnancy, surgery, and the use of cinacalcet and bisphosphonates. We present three case reports and discuss management.

Massive hemorrhage following thrombolysis for postpartum pulmonary embolism with cardiac arrest.

BACKGROUND: Cardiac arrest following a massive pulmonary embolism in pregnancy or the puerperium is a rare and catastrophic event. CASE: We describe a case of massive pulmonary embolism with cardiac arrest in a 36-year-old patient, presenting 48 hours postpartum. She was treated with thrombolytic therapy and suffered a massive hemorrhage thereafter, which was compounded by disseminated intravascular coagulation. Following an emergency hysterectomy and massive blood-product transfusion, she survived with no neurological sequelae. The medical team present had participated in two simulation sessions with similar scenarios in the weeks before the event. CONCLUSION: To our knowledge, this is only the fifth case reported in the literature on thrombolytic therapy in the postpartum period, and of these has the most severe hemorrhagic complication. An effective multidisciplinary approach to such a complex situation can be acquired through simulation-based training.

Contexte : L'arrêt cardiaque qui suit une embolie pulmonaire massive pendant la grossesse ou la puerpéralité constitue un événement rare et catastrophique. Cas : Nous décrivons un cas d'embolie pulmonaire massive donnant lieu à un arrêt cardiaque qui s'est manifesté 48 heures à la suite de l'accouchement chez une patiente de 36 ans. Un traitement thrombolytique a été administré à la patiente et celle-ci a par la suite connu une hémorragie massive, laquelle a été aggravée par une coagulation intravasculaire disséminée. À la suite d'une hystérectomie d'urgence et d'une transfusion massive de produits sanguins, la patiente a survécu sans séquelles neurologiques. L'équipe médicale présente avait participé à deux sessions de simulation ayant fait appel à des scénarios similaires au cours des semaines précédant l'événement. Conclusion : À notre connaissance, il s'agit seulement du cinquième cas à être signalé dans la littérature en ce qui concerne la mise en œuvre d'un traitement thrombolytique pendant la période postpartum, en plus d'être celui qui a connu la complication hémorragique la plus grave. Une approche multidisciplinaire efficace permettant de faire face à une situation d'une telle complexité peut être acquise par l'intermédiaire d'une formation fondée sur la simulation.

Blood pressure assessments in different subtypes of hypertensive pregnant women: office versus home patient- or nurse-measured blood pressure.

OBJECTIVE: To explore the difference between distinct methods of assessing blood pressure (BP) in pregnant women with different hypertensive disorders. METHODS: We compared office BP to home patient- and nurse-measured diastolic BP in pregnant women with essential chronic hypertension (CH), preeclampsia (PE) and isolated hypertension (IOH). RESULTS: Office BP was lower or similar to home patient- and nurse-measured BP in women with CH. Office BP was higher than home patient-measured BP in women with PE and in women with IOH (p < 0.0001). Nurse-measured BP was higher than patient-measured BP in women with PE (p < 0.01). CONCLUSIONS: BP assessments in women with PE are significantly influenced by the environment, which should be considered in managing these women.

Low-dose ASA response using the PFA-100 in women with high-risk pregnancy.

OBJECTIVES: To study the platelet function response to low-dose ASA with the Platelet Function Analyzer (PFA-100) in pregnant women and to identify maternal characteristics associated with non-responsiveness. METHODS: We conducted a prospective cohort study involving 87 pregnant women on ASA. The platelet function response to ASA was measured as the closure time obtained with epinephrine cartridges (CT-EPI) by the PFA-100. Non-response to ASA was defined as a CT-EPI < or =150 seconds after four weeks of therapy. Non-responders were given an escalating dose of ASA and their CT-EPI was tested again. RESULTS: After four weeks of enteric-coated ASA 81 mg daily, 25/87 women (28.7%) were non-responders (95% CI 16.1 to 41.4). Among these women, a CT-EPI < or =150 seconds was found in 8/24 women (33.3%) after another four weeks of alternating ASA 81 mg and 162 mg daily. After a further four-week course of ASA 162 mg daily, a CT-EPI < or =150 seconds was found in 3/6 women (50.0%). Among the women who initially responded and who were reassessed at 24-32 weeks of pregnancy, the CT-EPI was < or =150 seconds in 9/36 (25.0%). There was no statistical difference in maternal characteristics between ASA responders and non-responders. CONCLUSION: A significant number of pregnant women showed a lack of platelet function response to ASA 81 mg that was in most cases overcome with higher dosing. Furthermore, the prevalence of non-responsiveness increased with advancing pregnancy.