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Background: Thromboelastography (TEG) is utilized as a point-of-care test of coagulation function to improve evidence-based blood product replacement in adults. In contrast to standard indices of coagulation, TEG reflects the dynamic interactions among the elements involved in hemostasis, including fibrinolysis. Although normal adult values and various abnormalities have been characterized, normative values for term neonates have not been described. Studies of neonatal TEG remain limited and have small sample sizes with inconsistent methodology. The aim of this study is to provide normative data on healthy term neonates, and to assess the impact of mode of delivery on TEG parameters at term.Methods: Venous umbilical blood was obtained from the placenta within 10 min of delivery. TEG analysis of citrated kaolin-activated samples was performed for 50 healthy term vaginal and 50 cesarean deliveries. Samples collected for cesarean sections were from scheduled cases or unscheduled ones due to failure of progression of labor.Results: Healthy neonates with uncomplicated vaginal term deliveries resulted in the following TEG parameters: R: 5.41 ± 1.34 (mean ± SD) min; K: 1.62 ± 0.75 min; α-angle: 65.39 ± 8.77°; MA: 65.86 ± 5.81 mm; and LY30: 1.40 ± 1.18%. Results for the cesarean delivery neonatal TEG assays showed: R: 5.51 ± 1.74 (mean ± SD) min; K: 1.52 ± 0.47 min; α-angle: 64.15 ± 4.61°; MA: 64.15 ± 4.61 mm; and LY30: 2.44 ± 3.51%. Of note, no statistical differences were observed (p < .01) between the groups.Conclusion: TEG measurements from term neonates were no different when the neonates were delivered vaginally or by cesarean section. Labor had no effect on neonatal TEG levels. Neonatal TEG values may therefore serve as insight for fetal values at the appropriate postconceptional age. [ABSTRACT FROM AUTHOR]

Because they share a common placenta, monochorionic gestations are subject to unique pregnancy complications that can threaten the life and health of both fetuses and therefore impose a disproportionate disease burden on overall perinatal morbidity and mortality. Early detection of these unique disease processes may allow for prompt referral to a regional treatment center, comprehensive counseling, and better patient outcomes. The North American Fetal Therapy Network is a consortium of 30 medical institutions in the United States and Canada with established expertise in fetal surgery and other forms of multidisciplinary care for complex fetal disorders. The goal of this publication is to briefly describe complications of monochorionic gestations and to provide multidisciplinary, evidence-based, and consensus-driven recommendations for surveillance of uncomplicated monochorionic gestations. [ABSTRACT FROM AUTHOR]

Study Objective: Privileging and credentialing requirements are determined by medical staff leadership at the hospital level to ensure clinicians provide safe healthcare services. No standardized guidelines exist for gynecologic surgery. The objective of this study is to examine the variability of the criteria used to grant surgical privileges and credentials for gynecologic procedures at 5 high-volume academic and community-based US hospitals.Design: We conducted a cross-sectional study (Canadian Task Force classification III).Setting: Data was obtained from obtained from 5 geographically diverse hospital systems.Intervention: We examined criteria for designating core gynecologic privileges, credentialing, and other training requirements as well as minimum and annual case numbers for initial granting and maintenance of surgical privileges.Measurements and Main Results: Major inconsistencies in privileging were found across the 5 institutions. Hospitals varied widely in procedures designated as core versus those requiring advanced training. Institutions greatly contrasted in the case numbers and temporal factors used to define experience. Of particular concern was absent privileging criteria for 38.4% to 76.9% of minor procedures, 26.7% to 46.7% of endoscopic procedures, and 6.67% to 56.7% of major procedures. Initial and maintenance privileging requirements for special procedures (i.e., robotic-assisted surgery) were likewise discrepant, with minimum annual case numbers ranging from 3 to 48 across hospitals.Conclusion: Considerable variability exists in the criteria used by hospitals for granting and maintaining surgical privileges for gynecologic procedures. Standardization will likely require efforts at a national leadership level. [ABSTRACT FROM AUTHOR]

Background: In early-onset severe hemolytic disease of the fetus and newborn (HDFN), transplacental transfer of maternal antierythrocyte IgG alloantibodies causes fetal anemia that leads to the use of high-risk intrauterine transfusions in order to avoid fetal hydrops and fetal death. Nipocalimab, an anti-neonatal Fc receptor blocker, inhibits transplacental IgG transfer and lowers maternal IgG levels., Methods: In an international, open-label, single-group, phase 2 study, we assessed treatment with intravenous nipocalimab (30 or 45 mg per kilogram of body weight per week) administered from 14 to 35 weeks' gestation in participants with pregnancies at high risk for recurrent early-onset severe HDFN. The primary end point was live birth at 32 weeks' gestation or later without intrauterine transfusions as assessed against a historical benchmark (0%; clinically meaningful difference, 10%)., Results: Live birth at 32 weeks' gestation or later without intrauterine transfusions occurred in 7 of 13 pregnancies (54%; 95% confidence interval, 25 to 81) in the study. No cases of fetal hydrops occurred, and 6 participants (46%) did not receive any antenatal or neonatal transfusions. Six fetuses received an intrauterine transfusion: five fetuses at 24 weeks' gestation or later and one fetus before fetal loss at 22 weeks and 5 days' gestation. Live birth occurred in 12 pregnancies. The median gestational age at delivery was 36 weeks and 4 days. Of the 12 live-born infants, 1 received one exchange transfusion and one simple transfusion and 5 received only simple transfusions. Treatment-related decreases in the alloantibody titer and IgG level were observed in maternal samples and cord blood. No unusual maternal or pediatric infections were observed. Serious adverse events were consistent with HDFN, pregnancy, or prematurity., Conclusions: Nipocalimab treatment delayed or prevented fetal anemia or intrauterine transfusions, as compared with the historical benchmark, in pregnancies at high risk for early-onset severe HDFN. (Funded by Janssen Research and Development; UNITY ClinicalTrials.gov number, NCT03842189.)., (Copyright © 2024 Massachusetts Medical Society.)

Introduction: Fetal aqueductal stenosis (AS) affects approximately 1:1,000 pregnancies. Obstruction of cerebral spinal fluid circulation occurs at the aqueduct of Sylvius, leading to progressive hydrocephalus and macrocephaly, which often necessitates cesarean section (CS). The purpose of this study was to describe maternal outcomes associated with fetal AS., Methods: This study is conducted through the North American Fetal Therapy Network (NAFTNet). Subjects with a prenatal diagnosis of severe fetal central nervous system ventriculomegaly were recruited and followed longitudinally. Maternal events around the delivery of fetuses with AS were recorded and analyzed., Results: Thirty-seven subjects with fetal AS confirmed by neonatal neuroimaging were analyzed. The average gestational age at delivery was 36.7 weeks. Overall, 86% were delivered by CS, and 62% of these were elective. Ninety-one percent of CSs were performed through a Pfannenstiel abdominal incision. A classical uterine incision was required in 13% of cesarean deliveries. The peripartum complication rate was 27%., Conclusion: Women carrying a fetus with AS were at risk for preterm birth, cesarean delivery, a classical uterine incision, and peripartum complications. These data highlight the maternal morbidity associated with fetal AS and the potential benefit of in utero therapy not only for neonatal outcomes but also for maternal outcomes., (© 2024 S. Karger AG, Basel.)

After prenatal diagnosis of bilateral fetal hydrothorax, ascites, and polyhydramnios, bilateral thoracoamniotic shunts were placed at 29 weeks gestation using an ultrasound-guided, minimally invasive technique. Anesthetic care was managed using intravenous sedation and local anesthesia infiltration. The anesthetic considerations for such procedures are discussed.

Background: Heterotopic pregnancy is a rare event that usually presents in the first 6-8 weeks of pregnancy., Case: A 35-year-old primigravida was referred to the hospital at 18+ weeks' gestational age for evaluation of chronic abdominal pain. Ultrasound revealed a heterotopic pregnancy. The patient underwent surgery for removal of the ectopic pregnancy., Conclusion: Heterotopic pregnancy can present at any time during pregnancy and should be considered in any pregnant woman with abdominal pain.

Objective: To determine whether group B Streptococcus (GBS)-colonized pregnant women who report a history of penicillin allergy can safely undergo diagnostic evaluation to rule out or confirm the potential for an IgE-mediated (allergic) reaction to penicillin., Study Design: Over 18 months, all pregnant women with GBS-positive vaginal/rectal cultures and a history of penicillin allergy were referred to the Department of Allergy and Immunology for a history and possible skin testing. Patients who had experienced anaphylaxis were advised to continue avoiding penicillin and were not skin tested. Women without such a history underwent immediate hypersensitivity (percutaneous and intradermal) testing using 2 penicillin reagents with controls. If skin testing was negative, intrapartum antimicrobial prophylaxis with intravenous penicillin was administered., Results: Of 28 patients with both GBS colonization and "penicillin allergy," 25 (89%) had negative skin testing to penicillin and received intrapartum penicillin for GBS prophylaxis without adverse reactions. Skin testing was positive in 2 patients, and intrapartum penicillin was not administered. Penicillin skin testing was not performed on 1 patient due to a history of anaphylaxis from penicillin., Conclusion: These results indicate that most pregnant women reporting penicillin allergy undergo negative skin tests and are able to safely receive intrapartum penicillin GBS prophylaxis.

Objective: To evaluate levels of 24-hour urine insulin excretion before the onset of pre-eclampsia and gestational hypertension., Design: Nested case-control study within the Calcium for Preeclampsia Prevention (CPEP) study cohort., Setting: Five university medical centres in the United States., Sample: Cases had developed pre-eclampsia (n= 70) or gestational hypertension (n= 142) in the absence of gestational diabetes. Controls (n= 429) had remained normotensive without gestational diabetes., Methods: Subjects were required to have had an adequate baseline 24-hour urine collection prior to CPEP enrolment at 13-21 weeks. Controls were matched to cases by enrolment site and specimen storage time, without regard to gestational age or CPEP treatment. Adjusted mean 24-hour urine insulin excretion was, however, calculated using analysis of covariance, with adjustment models for pre-eclampsia considering body mass index, race and smoking status; and for gestational hypertension, gestational age at specimen collection, height, body mass index and smoking. Urine insulin was measured by radio-immunoassay., Main Outcome Measures: Twenty-four-hour urine insulin excretion., Results: Adjusted 24-hour urine insulin excretion at baseline (mean 17 weeks of gestation) was greater in women who developed pre-eclampsia than in normotensive controls (mean [SE]: 15.6 [1.5] vs 13.1 [1.2] x 10(3)microIU/24 hour, P= 0.06), but not in women who developed gestational hypertension (14.7 [0.9] vs 15.0 [0.6] x 10(3)microIU/24 hour, P= 0.79, in cases vs controls). Among women who developed pre-eclampsia, adjusted urine insulin excretion was greater than controls only in women with mild pre-eclampsia and not in severe pre-eclampsia (mild pre-eclampsia vs controls: 17.3 [2.0] vs 13.7 [1.6] x 10(3)microIU/24 hour, P= 0.04; severe pre-eclampsia vs controls: 12.3 [2.2] vs 11.5 [1.2], P= 0.69)., Conclusion: The data suggest that early hyperinsulinaemia, a marker of insulin resistance, may predispose to mild pre-eclampsia.

Hypertensive disorders of pregnancy are common and require special care to prevent maternal and fetal morbidity and mortality. Since the symptoms of preeclampsia, the most dangerous disorder, are variable, overdiagnosis is appropriate. Chronic hypertension complicates 5% of all pregnancies and is becoming more common due to delayed childbearing.