Anesthetic Care of the Pregnant Patient With Cardiovascular Disease: A Scientific Statement From the American Heart Association.

The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location, and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.

Overcoming challenges in managing a high-risk pregnancy with placenta previa and newly diagnosed Bombay phenotype.

BACKGROUND: Bombay phenotype is rare and characterized by a lack of H antigen on the surface of red blood cells (RBCs) with naturally occurring anti-H antibodies. The presence of anti-H necessitates the exclusive use of Bombay phenotype RBCs for transfusion. We present a case of a pregnant woman with Bombay phenotype who required urgent cesarean section delivery due to high-risk placenta previa. CASE DESCRIPTION: A 36-year-old G1P0 woman of Indian origin presented at 36 weeks and 4 days gestation for management of a high-risk pregnancy with complete placenta previa. Bombay phenotype was unexpectedly identified on routine testing. Given the rarity of the blood, advanced gestation, and risk of post-partum hemorrhage associated with complete placenta previa and spontaneous labor, prompt strategic planning commenced for a successful delivery. Two frozen allogeneic Bombay phenotype RBCs were available as part of a concise transfusion plan. Intraoperative cell salvage was successfully employed and allogeneic transfusion was not required. CONCLUSION: Management of patients with rare blood types can be extremely challenging and guidance for those presenting later in pregnancy is scarce. Our patient's gestational age precluded the use of well-known effective strategies, including hemoglobin optimization, autologous and directed donation, and procurement of large quantities of rare blood. Rather, our approach utilized multidisciplinary expertise and strategic planning to yield a successful outcome.

Hypertensive Disorders of Pregnancy and the Cardiovascular System: Causes, Consequences, Therapy, and Prevention.

Hypertensive disorders of pregnancy continue to be significant contributors to adverse perinatal outcome and maternal mortality, as well as inducing life-long cardiovascular health impacts that are proportional to the severity and frequency of pregnancy complications. The placenta is the interface between the mother and fetus and its failure to undergo vascular maturation in tandem with maternal cardiovascular adaptation by the end of the first trimester predisposes to hypertensive disorders and fetal growth restriction. While primary failure of trophoblastic invasion with incomplete maternal spiral artery remodeling has been considered central to the pathogenesis of preeclampsia, cardiovascular risk factors associated with abnormal first trimester maternal blood pressure and cardiovascular adaptation produce identical placental pathology leading to hypertensive pregnancy disorders. Outside pregnancy blood pressure treatment thresholds are identified with the goal to prevent immediate risks from severe hypertension >160/100 mm Hg and long-term health impacts that arise from elevated blood pressures as low as 120/80 mm Hg. Until recently, the trend for less aggressive blood pressure management during pregnancy was driven by fear of inducing placental malperfusion without a clear clinical benefit. However, placental perfusion is not dependent on maternal perfusion pressure during the first trimester and risk-appropriate blood pressure normalization may provide the opportunity to protect from the placental maldevelopment that predisposes to hypertensive disorders of pregnancy. Recent randomized trials set the stage for more aggressive risk-appropriate blood pressure management that may offer a greater potential for prevention for hypertensive disorders of pregnancy. KEY POINTS: · Optimal management of maternal blood pressure to prevent preeclampsia and its risks is undefined.. · Early gestational rheological damage to the intervillous space predisposes to preeclampsia and FGR.. · First trimester blood pressure management may need to aim for normotension to prevent preeclampsia..

Pregnancy-Associated Extracorporeal Membrane Oxygenation in the United States.

OBJECTIVE: The use of extracorporeal membrane oxygenation (ECMO) therapy has increased in the adult population. Studies from the H1N1 influenza pandemic suggest that ECMO deployment in pregnancy is associated with favorable outcomes. With increasing numbers of pregnant women affected by COVID-19 (coronavirus disease 2019) and potentially requiring this life-saving therapy, we sought to compare comorbidities, costs, and outcomes between pregnancy- and nonpregnancy-associated ECMO therapy among reproductive-aged female patients. STUDY DESIGN: We used the 2013 to 2019 National Readmissions Database. Diagnosis and procedural coding were used to identify ECMO deployment, potential indications, comorbid conditions, and pregnancy outcomes. The primary outcome was in-hospital mortality during the patient's initial ECMO stay. Secondary outcomes included length of stay and hospital charges/costs, occurrence of thromboembolic or bleeding complications during ECMO hospitalization, and mortality and readmissions up to 330 days following ECMO stay. Univariate and multivariate regression models were used to model the associations between pregnancy status and outcomes. RESULTS: The sample included 324 pregnancy-associated hospitalizations and 3,805 nonpregnancy-associated hospitalizations, corresponding to national estimates of 665 and 7,653 over the study period, respectively. Pregnancy-associated ECMO had lower incidence of in-hospital death (adjusted odds ratio [aOR]: 0.56, 95% confidence interval [CI]: 0.41-0.75) and bleeding complications (aOR: 0.67, 95% CI: 0.49-0.93). Length of stay was significantly shorter (adjusted rate ratio (aRR): 0.86, 95% CI: 0.77-0.96) and total hospital costs were less (aRR: 0.83, 95% CI: 0.75-0.93). Differences in the incidence of thromboembolic events (aOR: 1.04, 95% CI: 0.78-1.38) were not statistically significant. CONCLUSION: Pregnancy-associated ECMO therapy had lower incidence of in-hospital death, bleeding complications, total inpatient cost, and length of stay when compared with nonpregnancy-associated ECMO therapy without increased thromboembolic complications. Pregnancy-associated ECMO therapy should be offered to eligible patients. KEY POINTS: · Pregnancy-related ECMO use was compared with nonpregnant use.. · Outcomes were equal or favored pregnancy-related deployment.. · These data may be useful when considering ECMO use in pregnancy..

Inpatient Management and OBICU Care for Pregnant Patients With Severe COVID-19 Disease.

This manuscript will review intensive care management considerations for pregnant patients with severe COVID-19 disease.

Differences in Surgery Classification and Indications for Peripartum Hysterectomy at a Major Academic Institution.

OBJECTIVE: Peripartum hysterectomy is associated with increased morbidity and mortality relative to elective gynecologic hysterectomy and its incidence has grown with the rising cesarean delivery rate. We sought to understand indications and perioperative outcomes for peripartum hysterectomy at our academic institution and to evaluate differences among racial/ethnic groups. STUDY DESIGN: We performed a retrospective chart review of women at a tertiary care center who underwent delivery of a newborn and had a peripartum hysterectomy during the same admission between 2008 and 2018. Demographic, clinical, and socioeconomic characteristics of patients were compared with respect to patient's race/ethnic group. RESULTS: A total of 112 hysterectomies were included in our study. White women undergoing peripartum hysterectomy were more likely to have had an elective/anticipated peripartum hysterectomy (vs. a nonelective/emergent peripartum hysterectomy) than Black women. There were racial differences detected in the indication for peripartum hysterectomy; White women were more likely to have abnormal placentation (75 vs. 54% in Black women, p = 0.036), whereas Black women were more likely to present with postpartum hemorrhage (27 vs. 2%, p = 0.002). Black women were also more likely to undergo reoperation after peripartum hysterectomy (15 vs. 2% in White women, p = 0.048). There were no differences in any other perioperative outcomes including blood transfusion, accidental laceration, and 30-day readmission. CONCLUSION: Differences exist among elective versus nonelective peripartum hysterectomy by race/ethnicity and in indications for peripartum hysterectomy by race/ethnicity. Further investigation should be performed to determine whether the differences identified are due to disparate management of atony/postpartum hemorrhage or inequitable referral patterns for suspected abnormal placentation by race/ethnicity. KEY POINTS: · White patients were more likely to have an elective hysterectomy when compared with Black women.. · Abnormal placentation was the indication more often for White patients; hemorrhage for Black ones.. · Black patients were likely to be nulliparous or at greater gestational age at the time of hysterectomy..

ACC-AHA Diagnostic Criteria for Hypertension in Pregnancy Identifies Patients at Intermediate Risk of Adverse Outcomes.

OBJECTIVE: The aim of the study is to compare maternal and neonatal outcomes among patients who are normotensive, hypertensive by Stage I American College of Cardiology-American Heart Association (ACC-AHA) criteria, and hypertensive by American College of Obstetricians and Gynecologists (ACOG) criteria. STUDY DESIGN: Secondary analysis of a prospective first trimester cohort study between 2007 and 2010 at three institutions in Baltimore, MD, was conducted. Blood pressure at 11 to 14 weeks' gestation was classified as (1) normotensive (systolic blood pressure [SBP] <130 mm Hg and diastolic blood pressure [DBP] <80 mm Hg); (2) hypertensive by Stage I ACC-AHA criteria (SBP 130-139 mm Hg or DBP 80-89 mm Hg); or (3) hypertensive by ACOG criteria (SBP ≥140 mm Hg or DBP ≥90 mm Hg). Primary outcomes included preeclampsia, small for gestational age (SGA) neonate, and preterm birth. RESULTS: Among 3,422 women enrolled, 2,976 with delivery data from singleton pregnancies of nonanomalous fetuses were included. In total, 20.2% met hypertension criteria (Stage I ACC-AHA n = 254, 8.5%; ACOG n = 347, 11.7%). The Stage I ACC-AHA group's risk for developing preeclampsia was threefold higher than the normotensive group (adjusted relative risk [aRR] 3.70, 95% confidence interval [CI] 2.40-5.70). The Stage I ACC-AHA group had lower preeclampsia risk than the ACOG group but the difference was not significant (aRR 0.87, 95% CI 0.55-1.37). The Stage I ACC-AHA group was more likely than the normotensive group to deliver preterm (aRR 1.44, 95% CI 1.02-2.01) and deliver an SGA neonate (aRR 1.51, 95% CI 1.07-2.12). The Stage I ACC-AHA group was less likely to deliver preterm compared with the ACOG group (aRR 0.65, 95% CI 0.45-0.93), but differences in SGA were not significant (aRR 1.31, 95% CI 0.84-2.03). CONCLUSION: Pregnant patients with Stage I ACC-AHA hypertension in the first trimester had higher rates of preeclampsia, preterm birth, and SGA neonates compared with normotensive women. Adverse maternal and neonatal outcomes were numerically lower in the Stage I ACC-AHA group compared with the ACOG group, but these comparisons only reached statistical significance for preterm birth. Optimal pregnancy management for first trimester Stage I ACC-AHA hypertension requires active study. KEY POINTS: · Women with first trimester American College of Cardiology-American Heart Association (ACC-AHA) Stage I hypertension were more likely to develop preeclampsia, deliver preterm, and deliver a small-for-gestational age neonate than normotensive women.. · Women with first trimester American College of Obstetricians and Gynecologists (ACOG) hypertension (consistent with stage II ACC-AHA hypertension) had the highest numeric rate of adverse outcomes; however, compared with Stage I ACC-AHA hypertension, there was only statistically significant difference for preterm delivery.. · The risk profile for pregnant women with Stage I ACC-AHA hypertension and women with hypertension by conventional ACOG criteria may be more similar than previously understood..

Cardiomyopathies in Pregnancy: Etiologies and Management Strategies.

The cardiomyopathies are a diverse group of disorders characterized by structural abnormalities of heart muscle, many of which have a genetic component. They are associated with substantial morbidity and mortality in pregnancy. We review the distinct forms of cardiomyopathy (dilated, hypertrophic, and functional) which can be seen during pregnancy, discuss complications associated with each distinct group such as heart failure, arrhythmias, and transmission to offspring, and address management strategies for stable and unstable patients.

Maternal super obesity and risk for intensive care unit admission in the MFMU Cesarean Registry.

INTRODUCTION: Obesity is a risk factor for intensive care unit (ICU) admission in nonpregnant populations. Less is known about maternal obesity and ICU admission risk. The objective of this study was to estimate the association between maternal obesity and ICU admission among women who delivered via cesarean section or vaginal birth after cesarean section (VBAC). MATERIAL AND METHODS: This is a retrospective cohort analysis of women who delivered via VBAC or cesarean section in the Maternal-Fetal Medicine Unit (MFMU) Cesarean Registry. We defined exposure as body mass index (BMI) at delivery stratified as non-obese (BMI 18.5-29.9 kg/m2 ), class I or II obese (BMI 30-39.9 kg/m2 ), morbidly obese (BMI 40-49.9 kg/m2 ), and super obese (BMI ≥ 50 kg/m2 ). The primary outcome was ICU admission. Modified Poisson regression models estimated relative risk (RR) of ICU admission by obesity strata, after adjusting for confounders. Mediation analysis was used to estimate the proportion of ICU admission risk attributable specifically to obesity. RESULTS: We included 68 455 women; 40% non-obese, 46% class I or II obese, 12% morbidly obese, and 2% super obese. Super obese women were at higher risk for ICU admission compared with non-obese women (0.7 vs. 1.3%, adjusted RR 1.61; 95% CI 1.01-2.65), after adjusting for confounders. Among super obese women, medical comorbidities mediated 58% of ICU admission risk, suggesting that a significant proportion of ICU admission is driven by maternal obesity. CONCLUSIONS: Super obese women who deliver by cesarean section or VBAC are at increased risk of peripartum ICU admission. Obstetricians and critical care specialists should consider possible ICU admission during delivery planning.

Variation and correlates of psychosocial wellbeing among nulliparous women with preeclampsia.

OBJECTIVES: To identify classes of psychosocial stressors among women who developed preeclampsia and to evaluate the associations between these classes and correlates of psychosocial wellbeing. STUDY DESIGN: We performed a secondary analysis of women who developed preeclampsia (n = 727) from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) cohort (2010-2013). Latent class analysis was used to identify classes of social stressors based on seven psychological and sociocultural indicators. Associations between latent classes and correlates (demographics, health behavior, and health-systems level) were estimated using multinomial logistic regression. MAIN OUTCOME MEASURES: Classes of psychosocial wellbeing. RESULTS: Among women who developed preeclampsia, three classes reflective of psychosocial wellbeing were identified: Class 1: Intermediate Psychosocial Wellbeing (53 %), Class 2: Positive Psychosocial Wellbeing (31 %), Class 3: Negative Psychosocial Wellbeing (16 %). Women in the Negative Psychosocial Wellbeing Class were more likely to have poor sleep and a sedentary lifestyle compared with the Positive and Intermediate Psychosocial Wellbeing Classes. Both the Negative and Intermediate Psychosocial Wellbeing Classes reported concern about their quality of medical care compared with the Positive Psychosocial Wellbeing Class (adjusted odds ratio [aOR]: 6.19, 95 % confidence interval [CI]: 3.37, 11.36 and aOR: 2.19, 95 % CI: 1.31, 3.65, respectively). CONCLUSIONS: Women who develop preeclampsia are heterogenous and experience different intensities of internal and external stressors. Understanding the linkages between psychosocial wellbeing during pregnancy and modifiable behavioral and structural factors may inform future tailored management strategies for preeclampsia and the optimization of maternal postpartum health.

CT angiography for characterization of advanced placenta accreta spectrum: indications, risks, and benefits.

Placenta accreta spectrum disorder (PASD) encompasses various types of abnormal placentation in which chorionic villi directly adhere to or invade the myometrium. The incidence of PASD has dramatically risen in the US over the past 3 decades owing to the increased rates of patients undergoing cesarean sections. While PASD remains a significant cause of maternal morbidity and mortality, accurate prenatal identification and characterization of PASD is associated with improved outcomes. Although ultrasound is the first-line imaging modality in the evaluation of PASD, with MRI serving as an adjunct, computed tomography angiography (CTA) may also offer unique diagnostic advantages in cases of advanced PASD by providing superior visualization of placental and abdominopelvic vasculature and enabling the creation of comprehensive vascular maps to roadmap complex surgical interventions. This paper represents the first evaluation of CTA as a diagnostic tool and operative planning aid in this context. Appropriate indications and diagnostic advantages of CTA in this setting are reviewed, and key multimodal imaging features of normal and abnormal placentation are highlighted.

Preconception Counseling for a Patient With a Mechanical Tricuspid Valve.

A 37-year-old woman with mechanical tricuspid valve thrombosis presented for preconception consultation. Multimodality imaging confirmed a malfunctioning bileaflet mechanical tricuspid valve with both leaflets fixed and open. This case highlights the key discussions held by the multidisciplinary pregnancy heart team.

Regional Differences in the US in Outcomes with Preeclampsia.

This study explores preeclampsia outcomes across US regions and examines regional differences in specific preeclampsia-associated pregnancy complications and disease management. Patient-reported measures were obtained from The Preeclampsia Registry, an open-access database composed of women with at least one pregnancy diagnosed with a hypertensive disorder of pregnancy. Pregnancies and associated outcomes were stratified by US region (Northeast, Midwest, South and West). Among 2,667 pregnancies of which 92% were in White women, maximum systolic blood pressure at any time in pregnancy was highest among women in the South and Midwest (p=0.039). Furthermore, more women in the South received pre-pregnancy antihypertensives (p=0.026) and antenatal steroids (p=0.025) and delivered at an earlier gestational age (p=0.014) compared to women in other regions. Pregnancy complications such as elevated liver enzymes were higher in women in the South (p=0.019), and women in the South and West had additional end-organ damage such as renal complications (p<0.001) and hemolysis (p=0.008) as compared to women in other regions. Further investigation is needed to assess whether healthcare access or policy could be contributing to these regional discrepancies.

Placental bands on MRI in the setting of placenta accreta spectrum: Case report with radiologic-pathologic correlation.

Placental bands on T2-weighted magnetic resonance imaging (MRI) are a known imaging finding in placenta accreta spectrum (PAS). It is believed that these linear T2 hypo-intensities may reflect increased fibrin deposition in the setting of placental hemorrhage or infarct. However, to date there is little published data regarding histopathologic analysis of placental parenchyma at the site of identified bands. We report the case of a 34-year-old female with a single placental band demonstrated on preoperative MRI which was evaluated postoperatively and found to represent a placental infarct.

The association between severe maternal morbidity and mortality and race/ethnicity with community type in Maryland.

BACKGROUND: Severe maternal morbidity and mortality are increasing in the United States with continued healthcare disparities among Non-Hispanic Black women. However, there is sparse data on the disparities of severe maternal morbidity and mortality by race/ethnicity as it relates to community type. OBJECTIVE: To determine whether residing in rural communities increases the racial/ethnic disparities in severe maternal morbidity and mortality. DESIGN: This study is a cross-sectional analysis of women admitted for delivery from 2015 to 2020. A total of 204,140 adults who self-identified as women, were admitted for delivery, who resided in Maryland, and were between the ages 15 and 54 were included in our analysis. Community type was defined as either rural or urban. METHODS: A multivariable logistic regression, which included an interaction term between race/ethnicity and community type, was used to assess the effect of community type on the relationship between race/ethnicity and severe maternal morbidity and mortality. Data were obtained from the Maryland Health Service Cost Review Commission database. The primary outcome was a composite, binary variable of severe maternal morbidity and mortality. Exposures of interest were residence in either rural or urban counties in Maryland and race/ethnicity. RESULTS: Our study found that after adjusting for confounders, odds of severe maternal morbidity and mortality were 65% higher in Non-Hispanic Black women (odds ratio 1.65, 95% confidence interval: 1.46-1.88, p < 0.001) and 54% higher in Non-Hispanic Asian women (odds ratio 1.54, 95% confidence interval: 1.24-1.90, p < 0.001) compared to Non-Hispanic White women. The interaction term used to determine whether community type modified the relationship between race/ethnicity and severe maternal morbidity and mortality was not statistically significant for any race/ethnicity (Non-Hispanic Black women, p = 0.60; Non-Hispanic Asian women, p = 0.91; Hispanic women, p = 0.15; Other/Unknown race/ethnicity, p = 0.54). CONCLUSION: Although our study confirmed the known disparities in maternal outcomes by race/ethnicity, we found that residing in rural communities did not increase racial/ethnic disparities.

Psychosocial Stressors as a Determinant of Maternal Cardiovascular Health During Pregnancy.

Maternal psychosocial stress may be a risk factor for poor cardiovascular health (CVH) during pregnancy. We aimed to identify classes of psychosocial stressors in pregnant women and to evaluate their cross-sectional association with CVH. We performed a secondary analysis of women from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) cohort (2010 to 2013). Latent class analysis was used to identify distinct classes of exposure to psychosocial stressors based on psychological (stress, anxiety, resilience, depression) and sociocultural indicators (social support, economic stress, discrimination). Optimal and suboptimal CVH was defined based on the presence of 0 to 1 and ≥2 risk factors (hypertension, diabetes mellitus, smoking, obesity, inadequate physical activity), respectively based on the American Heart Association Life's Essential 8. We used logistic regression to evaluate the association between psychosocial classes and CVH. We included 8,491 women and identified 5 classes reflective of gradations of psychosocial stress. In unadjusted models, women in the most disadvantaged psychosocial stressor class were approximately 3 times more likely to have suboptimal CVH than those in the most advantaged class (odds ratio 2.98, 95% confidence interval: 2.54 to 3.51). Adjusting for demographics minimally attenuated the risk (adjusted odds ratio 2.09, 95% confidence interval: 1.76 to 2.48). We observed variation across psychosocial stressor landscapes in women in the nuMoM2b cohort. Women in the most disadvantaged psychosocial class had a greater risk of suboptimal CVH which was only partially explained by differences in demographic characteristics. In conclusion, our findings highlight the association of maternal psychosocial stressors with CVH during pregnancy.

Mode of delivery among women with maternal cardiac disease.

OBJECTIVE: To determine if maternal cardiac disease affects delivery mode and to investigate maternal morbidity. STUDY DESIGN: Retrospective cohort study performed using electronic medical record data. Primary outcome was mode of delivery; secondary outcomes included indication for cesarean delivery, and rates of severe maternal morbidity. RESULTS: Among 14,160 deliveries meeting inclusion criteria, 218 (1.5%) had maternal cardiac disease. Cesarean delivery was more common in women with maternal cardiac disease (adjusted odds ratio 1.63 [95% confidence interval 1.18-2.25]). Patients delivered by cesarean delivery in the setting of maternal cardiac disease had significantly higher rates of severe maternal morbidity, with a 24.38-fold higher adjusted odds of severe maternal morbidity (95% confidence interval: 10.56-54.3). CONCLUSION: While maternal cardiac disease was associated with increased risk of cesarean delivery, most were for obstetric indications. Additionally, cesarean delivery in the setting of maternal cardiac disease is associated with high rates of severe maternal morbidity.

Racial disparities in care escalation for postpartum hemorrhage requiring transfusion.

BACKGROUND: Postpartum hemorrhage is a leading cause of maternal morbidity and mortality in the United States and disproportionately affects pregnant persons of color. OBJECTIVE: This study aimed to identify the demographic and obstetrical characteristics of those who received different levels of antihemorrhagic intervention in the setting of severe postpartum hemorrhage requiring blood transfusion. STUDY DESIGN: This was a retrospective cohort study of patients with documented postpartum hemorrhage (estimated blood loss of ≥1000 mL) and blood product transfusion. Moreover, 3 levels of antihemorrhagic intervention were defined as follows: level 1, administration of uterotonics only; level 2, performance of a procedure (ie, B-Lynch suture, O'Leary stitch, Bakri balloon, dilation and curettage, laceration repair, or embolization); and level 3, hysterectomy. Maternal demographics, obstetrical characteristics, and comorbidities were extracted from electronic health records. Ordinal logistic regression was used to estimate the odds of higher intervention levels adjusting for maternal demographic and obstetrical characteristics. RESULTS: Of note, 365 patients were included in this study, with a racial or ethnic composition of 30% White, 42% Black, 18% Hispanic, and 10% other. Moreover, 233 patients (64%) received level 1 intervention, 98 patients (27%) received level 2 intervention, and 34 patients (9%) received level 3 intervention. Patients receiving higher levels of intervention were more likely to have greater estimated blood loss (P<.001), have more transfusions (P<.001), and be of advanced maternal age (P=.004). Black and Hispanic patients were less likely to have received higher levels of intervention than White patients (P=.034). After adjusting for estimated blood loss, advanced maternal age, placenta accreta spectrum, and fibroids, Black patients remained significantly less likely to receive higher levels of intervention (adjusted odds ratio, 0.55; 95% confidence interval, 0.30-0.98). This difference persisted at an estimated blood loss of ≥3000 mL, with Black and Hispanic patients being significantly less likely to receive higher levels of intervention than White patients (odds ratio, 0.31 [95% confidence interval, 0.10-0.92] and 0.10 [95% confidence interval, 0.01-0.53], respectively). CONCLUSION: Among patients experiencing postpartum hemorrhage and receiving transfusion, Black patients are less likely to receive higher levels of antihemorrhagic intervention. This disparity is concerning in this high-risk population and requires further attention and investigation.

Dichorionic diamniotic heterotopic twin gestation with cesarean section scar implantation and placenta increta.

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.

The role of proprotein convertase subtillisin/kexin type 9 in placental salvage and lipid metabolism in women with preeclampsia.

INTRODUCTION: Preeclampsia is associated with decreased maternal low-density lipoprotein cholesterol (LDL-c), which is essential for fetal growth. The underlying mechanisms for decreased LDL-c in preeclampsia remain unknown. Proprotein convertase subtillisin/kexin type 9 (PCSK9) regulates serum LDL-c via LDL receptor (LDL-R) degradation. We describe the possible role of PCSK9 in lipid metabolism in all compartments of the parturient (maternal blood, placental tissue, and fetal blood) in pregnancies with and without preeclampsia. METHODS: This is an observational study examining PCSK9 levels in maternal sera, umbilical cord blood, and PCSK9 protein content in placental tissue in three different locations (maternal placental interface, fetal placental interface, and umbilical cord) in women with and without preeclampsia at >23 weeks gestation. RESULTS: 68 parturients with preeclampsia and 55 without preeclampsia were enrolled. Maternal serum LDL-c (116.6 ± 48.9 mg/dL vs 146.1 ± 47.1 mg/dL, p = 0.0045) and PCSK9 (83 [61.8127.6] ng/mL vs 105.3 [83.5142.9] ng/mL, p = 0.011) were also reduced in the preeclamptics versus controls. There were no differences in PCSK9 protein content between preeclamptics and controls at comparative placental interfaces. However, PCSK9 protein content increased between the preeclampsia maternal placental interface (1.87 ± 0.62) and the preeclampsia umbilical cord (2.67 ± 1.08, p = 0.0243). DISCUSSION: PCSK9 levels are lower in maternal sera in preeclampsia when compared to controls. Placental PCSK9 protein content in preeclampsia increases from the maternal interface to the umbilical cord; however, this is not seen in controls. This suggests a potential compensatory mechanism for PCSK9 which allows for higher circulating fetal LDL-c levels in preeclampsia.