Placenta accreta spectrum in the second trimester: a clinical conundrum in procedural abortion care.

Given the limitations in perioperative management strategies available at freestanding abortion clinics, abortion providers must commonly discern which patients are too complicated for procedural abortions at their center and must be referred for a hospital-based abortion. The need to transition from freestanding clinics to hospital-based abortion care can lead to delays in completing an abortion and significant social, economic, and psychological repercussions for the pregnant individual. One significant clinical problem that exemplifies the issue of who can be safely taken care of at a freestanding abortion clinic is when placenta accreta spectrum is suspected. Placenta accreta spectrum is one of the major contributors to maternal morbidity and mortality in the United States, requiring coordinated multidisciplinary management to ensure the safest outcome for the pregnant individual. In this Clinical Opinion, we review the literature focused on identifying individuals at risk for placenta accreta spectrum above 14 0/7 weeks gestation, delineate an algorithm to improve the frequency of timely referrals to hospital-based abortion providers, and propose next steps for future training goals and research on placenta accreta spectrum in the second trimester between complex family planning and maternal-fetal medicine subspecialists.

Prematurity and congenital malformations differ according to the type of pregestational diabetes.

BACKGROUND: Diabetes mellitus (DM) is the most common metabolic disorder in pregnancy. Women with Type 2 DM seems to have no better perinatal outcomes than those with Type 1 DM. METHODS: Single-center prospective cohort observational study. Pregnant women with diabetes (141 with Type 1 DM and 124 with Type 2 DM) that were followed in the university hospital between 2009 and 2021 were included in this study. Clinical data and obstetric and perinatal outcomes were collected. RESULTS: As expected, women with Type 1 DM were younger and had a longer duration of diabetes than women with Type 2 DM. Obesity and chronic hypertension were higher in the group of women with Type 2 DM and their value of HbA1c in the second and third trimesters were lower than in Type 1 DM. No differences in prematurity were found, but more extreme prematurity was observed in Type 2 DM, as well as a higher rate of congenital malformations. The frequency of hypoglycemia and the weight of the newborn was higher in Type 1 DM. The maternal independent factors related to the weight of the newborn were: the glycemic control at the third trimester, the weight gain during pregnancy, and pregestational BMI. CONCLUSIONS: Newborns born to mothers with Type 1 DM were larger and had a higher frequency of hypoglycemia, while congenital malformations and precocious preterm was more associated to Type 2 DM. Metabolic control, weight gain and pregestational weight were important determinants of both obstetric and neonatal complications.

Screening of substance use in pregnancy: A Danish cross-sectional study.

INTRODUCTION: There is a paucity of objectively verified data on substance use among Danish pregnant women. We estimated the prevalence of substance use including alcohol and nicotine among the general population of Danish pregnant women. MATERIAL AND METHODS: In this anonymous, national, cross-sectional, descriptive study, pregnant women were invited when attending an ultrasound scan between November 2019 and December 2020 at nine Danish hospitals. Women submitted a urine sample and filled out a questionnaire. Urine samples were screened on-site with a qualitative urine dipstick for 15 substances including alcohol, nicotine, opioids, amphetamines, cannabis, and benzodiazepines. All screen-positive urine samples underwent secondary quantitative analyses with gold standard, liquid chromatography-tandem mass spectrometry (LC-MS/MS) analysis. Results were compared to questionnaire information to analyze the validity of self-reporting and to examine possible cross-reactions. RESULTS: A total of 1903 of 2154 invited pregnant women participated (88.3%). The prevalence of dipstick-positive urine samples was 25.0%. 44.0% of these were confirmed positive, resulting in a total confirmed prevalence of 10.8%. The prevalence of nicotine use was 10.1%-and for all other substances, <0.5%. Nicotine use was more prevalent among younger pregnant women, while other substance use appeared evenly distributed over age groups. Self-reporting of use of nicotine products was high (71.1%), but low for cannabis and alcohol intake (0% and 33.3%, respectively). Prescription medication explained almost all cases of oxycodone, methylphenidate, and benzodiazepine use. CONCLUSIONS: Substance use among pregnant women consisted mainly of nicotine. Dipstick screening involved risks of false negatives and false positives. Except for alcohol intake and cannabis use, dipstick analyses did not seem to provide further information than self-reporting. LC-MS/MS analyses remain gold standard, and future role of dipstick screenings should be discussed.

Collaboration between maternal-fetal medicine and family planning: a survey of Northeast US academic medical centers.

OBJECTIVES: To explore how complex family planning (CFP) and maternal-fetal medicine (MFM) in Northeast academic medical centers work together to provide abortion care. METHODS: We distributed an exploratory cross-sectional online survey to CFP and MFM faculty and fellows at academic medical centers in the Northeast between July and September of 2020. The survey included demographic information, assessment of practice patterns, hospital/administration support and assessment of collaboration. Likert scale questions examined opinions about collaboration and an open-ended question solicited ideas for improvement. We performed bivariate analysis to examine the association between subspecialty and practice location regarding provision of abortion care and perceived barriers to care. RESULTS: The response rate was 31 % and was similar by specialty. Of the 69 respondents, 83 % were MFMs, 75 % were faculty, and 54 % practiced in New York. More than 85 % reported personal participation in some portion of abortion care. The two most common perceived barriers to care were "lack or reluctance of physicians/staff" and state laws prohibiting termination. Nearly all (95 %) stated there was a good working relationship between CFP and MFM divisions; however, almost one-third agreed with or were neutral to the statements "MFM and CFP are siloed in terms of work/patient care." CONCLUSIONS: Academic MFM and CFP providers in the Northeast collaborate well in providing abortion care, though our findings highlight areas that would benefit from improvement. Optimizing collaboration in the Northeast is important given its regional role for ensuring abortion access in the current national landscape. Improved education of all members of the patient care team on the importance of abortion access may also help provide optimal patient care where abortion services still legally exist.

Patient Perception of Telemedicine in Maternal-Fetal Medicine.

Background: Maternal-fetal medicine (MFM) is a medical subspecialty that cares for patients with high-risk pregnancies. Methods: An IRB-approved survey was offered to patients in MFM offices of a tertiary health care system from March 2022 to May 2022. Demographics and responses to 15 statements about telemedicine were collected via a 5-point Likert scale. Exploratory factor analysis was performed to identify factors affecting patient perception of the telemedicine experience. We sought to examine perception of telemedicine in MFM, identify factors affecting perception, and identify whether specific demographics were associated with patients who view telemedicine appointments favorably. Results: Surveys were completed by 327 of 347 (94%) patients. A total of 233 (71%) patients felt that the telemedicine experience was equal in quality to in-person appointments, and 257 (79%) were open to telemedicine appointments in the future. Exploratory factor analysis yielded two factors: "physician attentiveness" and "technology comfort." Telemedicine was viewed favorably or neutrally for both factors. Education (lower) and marital status (single) were associated with a favorable perception of physician attentiveness. Ethnicity (Hispanic), employment status (employed), and prior telemedicine experience were associated with a favorable perception of technology comfort. Conclusion: Most patients felt the quality of telemedicine appointments was equal to those completed in person. Physician attentiveness and technology comfort affect telemedicine perception. Specific patient demographic characteristics were associated with differing perceptions of telemedicine in MFM. Our findings suggest that telemedicine is positively viewed for MFM and can be used for improving health care delivery efficiency in MFM.

Intrahepatic Cholestasis of Pregnancy during COVID-19 Pandemic.

Background and Objectives: Intrahepatic cholestasis of pregnancy (ICP) stands as one of the most prevalent concerns in maternal-fetal medicine, presenting a significant risk to fetal health and often associated with liver dysfunction. Concurrently, the coronavirus-19 (COVID-19) infection can lead to hepatic cell injury through both direct and indirect pathways. Hypothetically, these two conditions may coincide, influencing each other. This study aimed to comparatively assess the incidence and severity of ICP before and during the COVID-19 pandemic. Methods: A retrospective cohort study was conducted, comparing the incidence and severity of ICP between January 2018 and February 2020 (pre-COVID-19 period) and March 2020 to March 2022 (COVID-19 period) across two hospitals, encompassing 7799 deliveries. The diagnosis of ICP was established using the ICD-10 code and defined as total bile acids (BA) levels ≥ 10 µmol/L. Statistical analysis included descriptive statistics, Chi-square and Mann-Whitney U tests, as well as multiple or logistic regression analysis. Results: A total of 226 cases of ICP were identified. The incidence of mild cholestasis (BA < 40 µmol/L) was lower during the pandemic compared to before (3% before versus 2%, p < 0.05), while the incidence of moderate and severe ICP remained unchanged (0.6% before vs. 0.4%, p = 0.2). Overall, the total incidence of ICP was lower during the pandemic (3.6% before versus 2.4%, p = 0.01). No significant differences were observed in severity (as defined by BA and liver function test levels), rates of caesarean section, or neonatal birth weights. Conclusions: During the COVID-19 pandemic, the total incidence of ICP appeared to be lower. However, this reduction was primarily observed in cases of mild ICP, potentially indicating challenges in detection or reduced access to medical services during this period. The incidence of moderate and severe ICP remained unchanged, suggesting that these forms of the condition were unaffected by the pandemic's circumstances.

How do we perform intrauterine transfusions?

BACKGROUND: Intrauterine transfusion (IUT) is an invasive but critical and potentially life-saving intervention for severe fetal anemia with demonstrated improvement in outcomes. The fetus is vulnerable to hemodynamic alterations and transfusion-related adverse events; therefore, special consideration must be given to blood component selection and modification. There is widespread IUT practice variability, and existing guidance primarily relies on expert opinion and single center experiences. STUDY DESIGN AND METHODS: Experts in Maternal Fetal Medicine, Pediatric Hematology, and Transfusion Medicine from centers across the United States, collectively performing about 120 IUT annually, offer a multidisciplinary perspective on the performance of IUT and preparation of blood components. This perspective includes strategies for identifying an at-risk fetus, communicating between disciplines, determining the necessary blood volume, selecting and processing blood components, documenting the procedure in medical record, and managing the neonate. RESULTS: Identifying an at-risk fetus relies on review of the clinical history, non-invasive monitoring, and laboratory evaluation. We recommend the use of relatively fresh, group O, cytomegalovirus-safe, freshly irradiated, red blood cells (RBC) that are Hemoglobin S negative and antigen-negative for any maternal antibody, if indicated. These RBC units should be concentrated to remove additives and increase the hematocrit thus minimizing fluctuations in fetal volume status. The units intended for IUT should be labeled clearly and the documentation of transfusion differentiated in the maternal medical record. DISCUSSION: An awareness of the technical, logistical, and regulatory considerations for IUT performance will facilitate improved communication and patient care, especially when rare units of RBC are required.

Society for Maternal-Fetal Medicine Special Statement: A critical examination of abortion terminology as it relates to access and quality of care.

Legal, institutional, and payer policies regulating reproductive health care lack a shared language with medicine, resulting in great confusion and consternation. This paper critically examines the implications and ramifications of unclear language related to abortion care. Using a case-based approach, we highlight the ways in which language and terminology may affect the quality and accessibility of care. We also address repercussions for providers and patients within their team, institutional, state, and payer landscapes. In particular, we explore the stigmatization of abortion as both a word and a process, the role of caregivers as gatekeepers, the implications of viability as a limit for access, and the hierarchy of deservedness and value. Recognizing the role of language in these discussions is critical to building systems that honor the complexities of patient-centered reproductive decision-making, ensure access to comprehensive reproductive health care including abortion, and center patient autonomy. Healthcare providers are uniquely positioned to facilitate institutional, state, and national landscapes in which pregnant patients are supported in their autonomy and provided with just and equitable reproductive health care.

Society for Maternal-Fetal Medicine Special Statement: Utilizing telemedicine to address disparities in maternal-fetal medicine: a call to policy action.

The combination of deserts in maternal-fetal medicine coverage across the United States and the COVID-19 pandemic accelerated the implementation of telemedicine programs for maternal-fetal medicine care delivery. Although telemedicine-based care has the potential to facilitate timely access to maternal-fetal medicine services, which can improve maternal and neonatal outcomes, telemedicine is a relatively novel healthcare modality that needs to be implemented strategically. As with any medical service, telemedicine care requires rigorous evaluation to assess outcomes and ensure quality. Important health policy considerations, including access to services and insurance coverage, have substantial implications for equity in the implementation of telemedicine, particularly for reproductive healthcare following the 2022 United States Supreme Court decision in Dobbs v Jackson Women's Health Organization that overturned the constitutional right to an abortion. Investing resources and advocating for a rigorous, widely accessible telemedicine infrastructure at this crucial moment will establish an important foundation for more equitable pregnancy care. Key advocacy priorities for maternal-fetal medicine telemedicine include (1) expanding insurance coverage of telemedicine across payers, regardless of geographic location; (2) advocating for interstate licensure parity; (3) increasing access to affordable Internet and digital literacy training; and (4) ensuring access to reproductive healthcare, including abortion care, delivered via telemedicine.

Assessing hospital differences in low-risk cesarean delivery metrics in Florida.

BACKGROUND: Unnecessary cesarean deliveries lead to increased maternal and neonatal morbidities and mortalities. In 2020, Florida had a cesarean delivery rate of 35.9%, the third highest in the nation. An effective quality improvement strategy to reduce overall cesarean delivery rates is to decrease primary cesarean deliveries in low-risk births (nulliparous, term, singleton, vertex). Of note, 3 nationally accepted hospital measures of low-risk cesarean delivery rates include the nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics. Comparing metrics is necessary because accurate and timely measurement is essential to support multihospital quality improvement efforts to reduce low-risk cesarean delivery rates and improve the quality of maternal care. OBJECTIVE: This study aimed to assess differences in hospital low-risk cesarean delivery rates in Florida using 5 different metrics of low-risk cesarean delivery rate based on (1) risk methodology, nulliparous, term, singleton, vertex; Joint Commission; and Society for Maternal-Fetal Medicine metrics, and (2) data source, linked birth certificate and hospital discharge records and hospital discharge records only. STUDY DESIGN: This was a population-based study of live Florida births from 2016 to 2019 to compare 5 approaches to calculating low-risk cesarean delivery rates. Analyses were performed using linked birth certificate data and inpatient hospital discharge data. The 5 low-risk cesarean delivery measures were defined as follows: nulliparous, term, singleton, vertex birth certificate; Joint Commission-linked used Joint Commission exclusions; Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions; Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions. Nulliparous, term, singleton, vertex birth certificate was based on data from birth certificates and not using linked hospital discharge data. Designated as nulliparous, term, singleton, vertex, it does not exclude other high-risk conditions. The second and third measures (Joint Commission-linked used Joint Commission exclusions and Society for Maternal-Fetal Medicine-linked used Society for Maternal-Fetal Medicine exclusions) use data elements from the full-linked dataset to designate nulliparous, term, singleton, vertex and excluded several high-risk conditions. The last 2 measures (Joint Commission hospital discharge with Joint Commission exclusions; and Society for Maternal-Fetal Medicine hospital discharge with Society for Maternal-Fetal Medicine exclusions) were based on data from hospital discharge data only and not using linked birth certificate data. These measures generally reflect term, singleton, and vertex because parity could not be assessed adequately on hospital discharge data. Hospital differences between these 5 measures were calculated overall and by neonatal intensive care unit level. RESULTS: Overall, the median of hospital low-risk cesarean rates decreased across the measures, from NTSV-BC 30.7%, to Joint Commission linked 29.1%, and Society for Maternal Fetal Medicine hospital discharge 29.2% with a large decrease to Joint Commission hospital discharge 19.4% and Society for Maternal Fetal Medicine hospital discharge 18.1%. A similar trend was seen by neonatal intensive care unit level. For each of the measures, level II had the highest median low-risk cesarean rates (nulliparous. term, singleton, vertex birth certificate) 32.7%, Joint Commission linked (31.4%), Society for Maternal Fetal Medicine linked: 31.1%, Society for Maternal Fetal Medicine hospital discharge 19.3%), except for level III Joint Commission hospital discharge (20.0%). A comparison of the median number of low-risk births overall and by neonatal intensive care unit level showed a decreasing number across the linked and hospital discharge measures. Again, a wide gap in low-risk cesarean delivery rates was identified between linked measures and hospital discharge measures. However, this gap narrowed as hospital rates increased. CONCLUSION: Quality monitoring of low-risk cesarean delivery rates measured by the nulliparous, term, singleton, vertex metric using the birth certificate was fairly accurate and provided timely assessment for use by Florida hospitals. The nulliparous, term, singleton, vertex birth certificate rates were comparable with low-risk metrics using the linked data source. Overall, metrics used within the same data source had similar rates, with the Society for Maternal-Fetal Medicine metric having the lowest rates. Across data sources, metrics using hospital discharge data only resulted in substantially underestimated rates because of the inclusion of multiparous women and should be interpreted with caution.

The exciting potential for ChatGPT in obstetrics and gynecology.

Natural language processing-the branch of artificial intelligence concerned with the interaction between computers and human language-has advanced markedly in recent years with the introduction of sophisticated deep-learning models. Improved performance in natural language processing tasks, such as text and speech processing, have fueled impressive demonstrations of these models' capabilities. Perhaps no demonstration has been more impactful to date than the introduction of the publicly available online chatbot ChatGPT in November 2022 by OpenAI, which is based on a natural language processing model known as a Generative Pretrained Transformer. Through a series of questions posed by the authors about obstetrics and gynecology to ChatGPT as prompts, we evaluated the model's ability to handle clinical-related queries. Its answers demonstrated that in its current form, ChatGPT can be valuable for users who want preliminary information about virtually any topic in the field. Because its educational role is still being defined, we must recognize its limitations. Although answers were generally eloquent, informed, and lacked a significant degree of mistakes or misinformation, we also observed evidence of its weaknesses. A significant drawback is that the data on which the model has been trained are apparently not readily updated. The specific model that was assessed here, seems to not reliably (if at all) source data from after 2021. Users of ChatGPT who expect data to be more up to date need to be aware of this drawback. An inability to cite sources or to truly understand what the user is asking suggests that it has the capability to mislead. Responsible use of models like ChatGPT will be important for ensuring that they work to help but not harm users seeking information on obstetrics and gynecology.

Fetal sex and the development of gestational diabetes mellitus in gravidae with multiple gestation pregnancies.

INTRODUCTION: There is an increasing incidence of pregnancies with twin gestations. One outcome more likely to occur with multiple gestations is gestational diabetes mellitus. Studies have suggested that in singleton pregnancies, fetal sex may affect insulin resistance. However, the effects of fetal sex in twins and the development of gestational diabetes mellitus are unknown. We hypothesized that rates of gestational diabetes mellitus and degree of insulin resistance might vary in twin gestations based on the fetal sex pairing: male-male, male-female or female-female. We aimed to employ a large population-based database to ascertain any correlations between fetal sex and gestational diabetes mellitus in multifetal gestations. MATERIAL AND METHODS: A two-hospital, single academic institution database comprised of over 39 000 participants with pregnancy data from August 2011 to January 2022 was employed. All twin deliveries of live-born neonates >24 weeks' gestational age from gravidae without preexisting diabetes or twin-twin transfusion syndrome were included. Entries were then grouped based on the fetal sex of the pairing. The presence or absence of gestational diabetes and type of gestational diabetes - diet-controlled (gestational diabetes mellitus classification A1) vs medication-controlled (gestational diabetes mellitus classification A2) - were identified. Statistical analysis was performed using a generalized linear mixed method, and a P-value ≤0.05 was considered statistically significant. RESULTS: We identified 1924 twin deliveries that met the inclusion criteria in our database (male-male =652; male-female = 638; female-female = 634). We found no association between fetal sex pairing and the development of gestational diabetes mellitus. There was a significant association between the fetal sex pairing and the type of gestational diabetes mellitus developed, with 32.0% of male-male twins, 33.3% of male-female twins and 58.3% of the female-female twin deliveries associated with medication-controlled gestational diabetes classification A2: male-female vs female-female (P = 0.05) and male-male vs female-female (P = 0.046). CONCLUSIONS: While gestational diabetes mellitus is of multifactorial origin, we found a significant association between the fetal sex pairing and the treatment needed for gravidae with twins who develop gestational diabetes mellitus. A higher proportion of female-female twins was associated with gestational diabetes classification A2 compared with male-female or male-male deliveries. Further research on the physiology driving this association is warranted.

Does fetal size affect maternal perception of fetal movements? Evidence from an individual participant data meta-analysis.

INTRODUCTION: Maternal perception of fetal movements during pregnancy are reassuring; however, the perception of a reduction in movements are concerning to women and known to be associated with increased odds of late stillbirth. Prior to full term, little evidence exists to provide guidelines on how to proceed unless there is an immediate risk to the fetus. Increased strength of movement is the most commonly reported perception of women through to full term, but perception of movement is also hypothesized to be influenced by fetal size. The study aimed to assess the pattern of maternal perception of strength and frequency of fetal movement by gestation and customized birthweight quartile in ongoing pregnancies. A further aim was to assess the association of stillbirth to perception of fetal movements stratified by customized birthweight quartile. MATERIAL AND METHODS: This analysis was an individual participant data meta-analyses of five case-control studies investigating factors associated with stillbirth. The dataset included 851 cases of women with late stillbirth (>28 weeks' gestation) and 2257 women with ongoing pregnancies who then had a liveborn infant. RESULTS: The frequency of prioritized fetal movement from 28 weeks' gestation showed a similar pattern for each quartile of birthweight with increased strength being the predominant perception of fetal movement through to full term. The odds of stillbirth associated with reduced fetal movements was increased in all quartiles of customized birthweight centiles but was notably greater in babies in the lowest two quartiles (Q1: adjusted OR: 9.34, 95% CI: 5.43, 16.06 and Q2: adjusted OR: 6.11, 95% CI: 3.11, 11.99). The decreased odds associated with increased strength of movement was present for all customized birthweight quartiles (adjusted OR range: 0.25-0.56). CONCLUSIONS: Increased strength of fetal movements in late pregnancy is a positive finding irrespective of fetal size. However, reduced fetal movements are associated with stillbirth, and more so when the fetus is small.

Introduction of a Maternal-Fetal Medicine Tele-Ultrasound Program in Rural Alberta.

OBJECTIVES: We established a program of Maternal-Fetal Medicine (MFM) telemedicine that is safe and acceptable. Since December 2019, a multi-disciplinary team has been planning this quality improvement project. METHODS: We performed a pilot study to investigate the feasibility of using telemedicine and tele-ultrasound to enable prompt MFM consultations for patients in remote locations. We began with the training of sonographers followed by implementation in a small pilot. Interim analysis of the acceptability and feasibility of the program was done through patient surveys, images audit, and review of neonatal outcomes. RESULTS: Our background epidemiologic data showed that in Alberta, between 2017 and 2022, 460 patients travelled >6 hours, and 5038 travelled >2 hours from home to reach their site of birth. Patients were appropriately triaged to delivery/consultation at the tertiary level center based on diagnosis/suspicion of anomalies, such as abnormally invasive placenta, intrauterine growth restriction, hydrops, and partial agenesis of the corpus callosum, all of which were confirmed postdelivery. There was no neonatal mortality, and the single stillbirth was related to an unpreventable peri-viable co-twin demise. The patient survey demonstrated that for >85% of respondents the program reduced costs and stress. Ultrasound image audit found improvement and consistency in image quality after 3 months of training combined with supervision. CONCLUSION: MFM telemedicine is feasible and can be safe with adequate supervision. Additional support and resources are needed to scale and spread this quality improvement initiative.

Maternal and perinatal outcomes in mixed antenatal care modality implementing telemedicine in the southwestern region of Colombia during the COVID-19 pandemic.

INTRODUCTION: Contingency measures due to the COVID-19 pandemic limited access to routine prenatal care for pregnant women, increasing the risk of pregnancy complications due to poor prenatal follow-up, especially in those patients at high obstetric risk. This prompted the implementation and adaptation of telemedicine. OBJECTIVE: We aim to evaluate the maternal and perinatal outcomes of patients who received prenatal care in-person and by telemedicine. METHODS: We conducted a retrospective observational cohort study of pregnant women who received exclusive in-person and alternate (telemedicine and in-person) care from March to December 20,202, determining each group's maternal and neonatal outcomes. RESULTS: A total of 1078 patients were included, 156 in the mixed group and 922 in the in-person group. The patients in the mixed group had a higher number of prenatal controls (8 (6-9) vs 6 (4-8) p < 0.001), with an earlier gestational age at onset (7.1 (6-8.5) vs 9.3 (6.6-20.3), p < 0.001), however, they required a longer hospital stay (26 (16,67%) vs 86 (9,33%), p = 0.002) compared to those attended in-person; there were no significant differences in the development of obstetric emergencies, maternal death or neonatal complications. DISCUSSION: Incorporating telemedicine mixed with in-person care could be considered as an alternative for antenatal follow-up of pregnant women in low- and middle-income countries with barriers to timely and quality health care access.

Chorioangioma: a single tertiary care center retrospective study.

OBJECTIVES: Chorioangioma represents a challenge due to the rarity of the condition, paucity of sufficient management guidelines, and controversies regarding the best invasive fetal therapy option; most of the scientific evidence for clinical treatment has been limited to case reports. The aim of this retrospective study was to review the natural antenatal history, maternal and fetal complications, and therapeutic modalities used in pregnancies complicated with placental chorioangioma at a single Center. METHODS: This retrospective study was conducted at King Faisal Specialist Hospital and Research Center (KFSH&RC) in Riyadh, Saudi Arabia. Our study population included all pregnancies with ultrasound features of chorioangioma, or histologically confirmed chorioangiomas, between January 2010 and December 2019. Data were collected from the patients' medical records, including the ultrasound reports and histopathology results. All subjects were kept anonymous; case numbers were used as identifiers. Data collected by the investigators were entered into Excel worksheets in an encrypted format. A MEDLINE database was used to retrieve 32 articles for literature review. RESULTS: Over a 10-year period between January 2010 and December 2019, 11 cases of chorioangioma were identified. Ultrasound remains the gold standard for diagnosis and follow-up of the pregnancy. Seven of the 11 cases were detected by ultrasound, allowing proper fetal surveillance and antenatal follow-up. Of the remaining six patients, one underwent radiofrequency ablation, two underwent intrauterine transfusion for fetal anemia due to placenta chorioangioma, one had vascular embolization with an adhesive material, and two were managed conservatively until term with ultrasound surveillance. CONCLUSIONS: Ultrasound remains the gold standard modality for prenatal diagnosis and follow-up of pregnancies with suspected chorioangiomas. Tumor size and vascularity play a significant role in the development of maternal-fetal complications and the success of fetal interventions. To determine the superior modality of fetal intervention mandates more data and research; nevertheless, Fetoscopic Laser Photocoagulation and embolization with adhesive material seem to be a lead choice, with reasonable fetal survival.

"We All Want to Be Able to Tell You Something Hopeful": Clinicians' Experiences Providing Maternal-Fetal Surgery Counseling.

INTRODUCTION: Prenatal counseling about maternal-fetal surgery can be traumatic and confusing for pregnant people. It can also be technically and emotionally complex for clinicians. As maternal-fetal surgery rapidly advances and becomes more common, more evidence is needed to inform counseling practices. The objective of this study was to develop a deeper understanding of the methods clinicians currently use to train for and provide counseling, as well as their needs and recommendations for future education and training. METHODS: We used interpretive description methods and interviewed interprofessional clinicians who regularly counsel pregnant people about maternal-fetal surgery. RESULTS: We conducted 20 interviews with participants from 17 different sites who were maternal-fetal medicine specialists (30%), pediatric surgeons (30%), nurses (15%), social workers (10%), a genetic counselor (5%), a neonatologist (5%), and a pediatric subspecialist (5%). Most were female (70%), non-Hispanic white (90%), and practiced in the Midwest (50%). We identified four overarching themes: (1) contextualizing maternal-fetal surgery counseling; (2) establishing shared understanding; (3) supporting decision-making; and (4) training for maternal-fetal surgery counseling. Within these themes, we identified key practice differences among professions, specialties, institutions, and regions. CONCLUSION: Participants are committed to practicing informative and supportive counseling to empower pregnant people to make autonomous decisions about maternal-fetal surgery. Nevertheless, our findings indicate a dearth of evidence-based communication practices and guidance. Participants identified significant systemic limitations affecting pregnant people's decision-making options related to maternal-fetal surgery.

Creating a Telemedicine Network of Specialists in Maternal-Fetal Medicine: A Prospective Cohort Study.

Background: Even before coronavirus disease 2019, integrating telemedicine into routine health care has become increasingly attractive. Evidence regarding the benefits of telemedicine in prenatal care is still inconclusive. As one of the largest sectors of preventive medicine with a relative paucity of specialists in maternal-fetal medicine (MFM), the implementation of telemedicine solutions into prenatal care is promising. Our objective aimed at establishing a telemedicine network of specialists in MFM for interprofessional exchange regarding high-risk pregnancies. Furthermore, the aims were to evaluate the providers' attitude toward the telemedicine solutions and to quantify the number of inpatient appointments that were avoided through interprofessional video consultations. Methods: This prospective trial was part of a larger telemedicine project funded by the European Regional Development Fund. MFM experts were brought together using the ELVI software. A questionnaire was designed for the evaluation of video consultations. The responses were analyzed by the exact McNemar-Bowker test to compare planned procedures before and after video consultation. Results: An interprofessional network of specialists in prenatal ultrasound was established with a total of 140 evaluations for statistical analysis. Interprofessional video communication was viewed favorably by providers. Overall, 47% (33/70) of the scheduled visits were avoided after video consultation. The providers' tendency to refrain from sending their patients to the University Hospital Münster was statistically noticeable (p = 0.048). Conclusions: Interprofessional exchange through video consultation holds great potential in the context of prenatal care. More prospective research is needed to clearly establish the most beneficial standard of care for both patients and providers. Clinical trial registration number: 2019-683-f-S.

Management of a multiple endocrine neoplasia type 1 during pregnancy: a case with primary hypertension.

Multiple endocrine neoplasia type 1 (MEN 1) is a rare hereditary disease which transmitted as autosomal dominant disorder with high penetrance. MEN1 includes vary combinations of more than 20 endocrine and non-endocrine tumors. Clinically, MEN1 is characterized by tumor or hyperplasia in two or more endocrine tissues (parathyroid, pituitary, pancreas, adrenal glands). Since it is a rare condition, there are no guidelines with respect to the follow-up of pregnant women with MEN 1, here we the first Asian case of a 32-year-old primigravida with a confirmed diagnosis of MEN1 and primary hypertension prior to conception, cesarean section was performed at 34+2 weeks for severe preeclampsia and potential risks, both the patient and fetus recovered well.

Assessment of evidence underlying guidelines by the Society for Maternal-Fetal Medicine.

BACKGROUND: The Society for Maternal-Fetal Medicine, sometimes together with the American College of Obstetricians and Gynecologists, publishes guidelines utilizing the Grading of Recommendations, Assessment, Development, and Evaluation system to rate the quality of evidence and assign the strength of its recommendations. The strength of recommendations is determined by the quality of evidence and 3 other strength determinants that are defined in this system. OBJECTIVE: This study aimed to assess all recommendations by the Society for Maternal-Fetal Medicine assessed by the Grading of Recommendations, Assessment, Development, and Evaluation system, determine the quality of evidence supporting them, evaluate the relationship between quality of evidence and strength of recommendations, and determine the extent to which the other 3 strength determinants were employed to assign recommendation strength. STUDY DESIGN: All publications from the Society for Maternal-Fetal Medicine Publications and Guidelines website were reviewed, but only the ones with Grading of Recommendations, Assessment, Development, and Evaluation recommendations were analyzed. These were aggregated by their rating for quality of evidence and strength. Quality and strength were first compared across all recommendations. Subsequently, they were compared with stratification by recommendation topic and type (eg, interventions, counseling, screening, and diagnosis). References supporting each recommendation were also summarized by type (eg, randomized trial, retrospective study). The quality of evidence for each recommendation was then compared with the supporting reference types. Other characteristics that may contribute to strength were also evaluated. Finally, we compared recommendations authored jointly by the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists with those by the Society for Maternal-Fetal Medicine alone. RESULTS: The Society for Maternal-Fetal Medicine published 24 documents containing 235 recommendations assessed by the Grading of Recommendations, Assessment, Development, and Evaluation system. There were 35 (15%) recommendations supported by high-quality evidence; 34 (97%) were determined to be strong. Recommendations supported by moderate-quality (n=102) and low-quality (n=75) evidence were also rated as strong in 78% and 68% of cases, respectively. Recommendations were supported by randomized trials 8% of the time and references that summarize primary data (eg, meta-analyses, reviews, previous guidelines) 64% of the time. Recommendations with higher quality evidence ratings were more likely to be supported by references that summarize primary data (69% high-quality, 74% moderate-quality, 49% low-quality). Topics with recommendations authored jointly by the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists were supported by higher quality evidence than those by the Society for Maternal-Fetal Medicine alone (high quality, 26% vs 9%, respectively). CONCLUSION: Recommendations by the Society for Maternal-Fetal Medicine assessed by the Grading of Recommendations, Assessment, Development, and Evaluation system were supported by high-quality evidence in 15% of cases. This suggests that well-designed, high-quality clinical trials remain a priority in obstetrics. Strong recommendations were often made on the basis of Grading of Recommendations, Assessment, Development, and Evaluation strength determinants other than quality of evidence. Increased transparency of the Society for Maternal-Fetal Medicine's determination of strong recommendations based on strength determinants other than quality of the evidence may be useful to practicing clinicians.