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Background: Placenta accreta spectrum (PAS) disorders are characterized by an abnormal adherence of the placenta to the uterine myometrium. Magnetic resonance imaging (MRI) is an important adjunct in antenatal diagnosis. Objective: We sought to determine if there are patient and MRI characteristics that limit the accuracy of PAS diagnosis and degree of invasion. Study design: We conducted a retrospective cohort analysis of patients who were evaluated for PAS by MRI from 01/2007-12/2020. Patient characteristics evaluated included number of prior cesarean deliveries, history of dilation and curettage (D&C) or dilation and evacuation (D&E), short interval pregnancy

To describe rates of postpartum sterilization and indications for unfulfilled requests when Medicaid policy is not a limiting factor.We conducted a single-institution, retrospective review. Women who requested postpartum tubal ligation after vaginal delivery from August 2015 to March 2019 were studied. Select demographic characteristics were compared between those who did and did not undergo the procedure. Reasons for why the procedure was cancelled, alternate contraceptive plans, and subsequent pregnancies were collected. Statistical analysis included the t test and chi-squared test, with p0.05 considered significant.A total of 4103 patients requested postpartum tubal ligation following vaginal delivery. About 3670 (89.4%) procedures were performed and 433 (10.6%) were canceled. Of the 433, 423 (98%) were not performed at patient request; 10 (2 %) were cancelled based on physician recommendation. Of these, 3 were due to significant maternal anemia in the setting of refusal of blood products, 1 due to anesthesia concerns, 1 for increased body mass index, and 1 due to delivery events. Alternative contraception methods were offered; 72 (28% of patients not receiving a tubal ligation) received Depo Provera prior to discharge. One-fourth (n = 110, 25.4%) did not keep the postpartum follow-up appointment. 83 (19.2%) of the 433 patients had at least one subsequent pregnancy. Although over half expressed interest at the time of discharge in long-acting reversible contraceptives, only 20% obtained this method at the postpartum visit.Postpartum sterilization was predominantly achieved, among women whose requests were unfulfilled, the majority (98%) were at patient request with a minority by physician recommendation.When the availability of postpartum tubal ligation is independent of Medicaid reimbursement and the hospital system and providers are organized to support timely access to permanent postpartum contraception, the majority of tubal ligations requests can be fulfilled following vaginal delivery.

To characterize the data on medications for lactating people in the LactMed database and evaluate the strength of the data for the most commonly administered medications in lactating women.A retrospective analysis of all medications in the LactMed database in 12/2020 was performed. Each medication was classified into one of three categories: absent data, minimal-moderate data, strong data pertaining to safety in lactation. No data was defined as no available research studies associated with the medication. Minimal-moderate data was defined as absent research studies in one or more of the four LactMed categories: maternal drug levels, infant drug levels, effects on infants, effects on lactation, or if data was limited to a case report or observational study. Strong data was classified as availability of research studies in all four LactMed categories with data derived from pharmacokinetic/pharmacodynamic, cohort, case control, or randomized control studies. Additionally, the most commonly used medications in lactating women as defined by prior literature were analyzed for strength of data.1408 medications were evaluated: 714 (51%) had no associated data, 664 (47%) had minimal-moderate data, and 30 (2%) had strong data. Maternal drug level category had the highest proportion of rigorous supportive data while the effect on lactation category had the least supportive data. Of the most common mediations used in lactating women, sex hormones (contraception) and the nervous system medication classes had the most robust supportive data while respiratory, blood forming organs, and galactogogues had the weakest supportive data.There is significant variability and dearth in the quality of data guiding recommendations for use of medications in lactation providing numerous opportunities for research.

OBJECTIVES Our primary objective was to evaluate how prenatal diagnosis of a major fetal structural anomaly and resulting pregnancy outcome affected postpartum depression risk, as assessed by the Edinburgh Postnatal Depression Scale (EPDS). Secondary objectives were to review the rate of mental health follow-up and subsequent diagnosis of postpartum depression in screen-positive women. STUDY DESIGN Singleton pregnancies with prenatal diagnosis of one or more major fetal structural anomalies were ascertained from prospectively maintained databases that included perinatal outcomes and subsequent EPDS responses from January 2010 to May 2018. EPDS scores of 13 or higher were considered positive and prompted referral for mental health follow-up, which was verified by medical record review. Statistical analyses were performed using Student's t-test, χ2, and odds ratios (ORs) with p

ImportanceExisting reports of pregnant patients with COVID-19 disease who require extracorporeal membrane oxygenation (ECMO) are limited, with variable outcomes noted for the maternal-fetal dyad.ObjectiveTo examine maternal and perinatal outcomes associated with ECMO used for COVID-19 with respiratory failure during pregnancy.Design, Setting, and ParticipantsThis retrospective multicenter cohort study examined pregnant and postpartum patients who required ECMO for COVID-19 respiratory failure at 25 hospitals across the US. Eligible patients included individuals who received care at one of the study sites, were diagnosed with SARS-CoV-2 infection during pregnancy or up to 6 weeks post partum by positive nucleic acid or antigen test, and for whom ECMO was initiated for respiratory failure from March 1, 2020, to October 1, 2022.ExposuresECMO in the setting of COVID-19 respiratory failure.Main outcome and measuresThe primary outcome was maternal mortality. Secondary outcomes included serious maternal morbidity, obstetrical outcomes, and neonatal outcomes. Outcomes were compared by timing of infection during pregnancy or post partum, timing of ECMO initiation during pregnancy or post partum, and periods of circulation of SARS-CoV-2 variants.ResultsFrom March 1, 2020, to October 1, 2022, 100 pregnant or postpartum individuals were started on ECMO (29 [29.0%] Hispanic, 25 [25.0%] non-Hispanic Black, 34 [34.0%] non-Hispanic White; mean [SD] age: 31.1 [5.5] years), including 47 (47.0%) during pregnancy, 21 (21.0%) within 24 hours post partum, and 32 (32.0%) between 24 hours and 6 weeks post partum; 79 (79.0%) had obesity, 61 (61.0%) had public or no insurance, and 67 (67.0%) did not have an immunocompromising condition. The median (IQR) ECMO run was 20 (9-49) days. There were 16 maternal deaths (16.0%; 95% CI, 8.2%-23.8%) in the study cohort, and 76 patients (76.0%; 95% CI, 58.9%-93.1%) had 1 or more serious maternal morbidity events. The largest serious maternal morbidity was venous thromboembolism and occurred in 39 patients (39.0%), which was similar across ECMO timing (40.4% pregnant [19 of 47] vs 38.1% [8 of 21] immediately postpartum vs 37.5% postpartum [12 of 32]; P > .99).Conclusions and RelevanceIn this multicenter US cohort study of pregnant and postpartum patients who required ECMO for COVID-19–associated respiratory failure, most survived but experienced a high frequency of serious maternal morbidity.

OBJECTIVES To characterize population-based use of fetal magnetic resonance imaging (MRI) incorporating recent American College of Radiology (ACR)-Society of Perinatal Radiologists (SPR) guidelines about fetal anomalies for which MRI may provide valuable additional information when sonography is limited. METHODS We conducted a retrospective review of nonreferred singleton pregnancies that received prenatal care and had prenatal sonographic diagnosis of 1 or more major structural anomalies at our hospital between January 2010 and May 2018. Detailed sonography was performed in all anomaly cases. Fetal anomaly information was obtained from a prospectively maintained database, and medical records were reviewed to determine the rationale for why MRI was or was not performed, according to the indication. RESULTS A total of 104,597 singleton pregnancies underwent sonographic assessments of anatomy at our institution during the study period. Major structural anomalies were identified in 1650 (1.6%) of these pregnancies. Potential indications for fetal MRI per ACR-SPR guidelines were identified in 339 cases. However, fetal MRI was performed in only 253 cases, 15% of those with major anomalies and 75% with a potential indication. Magnetic resonance imaging was not performed in 41 (20%) of identified pregnancies because of an improved prognosis on serial sonography (36), because of a poor prognosis (3), or because it would not alter management (2). CONCLUSIONS Fetal MRI was used in 15% of those pregnancies with prenatal diagnosis of a major structural anomaly. This amounted to fewer than 0.3% of singleton deliveries. Judicious application of ACR-SPR guidelines in the context of serial sonography results in a relatively small number of fetal MRI examinations in a nonreferred population.

Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome are both associated with significant maternal and perinatal morbidity and mortality. Because of the overlap of several clinical and laboratory findings differentiation can sometimes be difficult. Both disorders have been of interest for more than 100 years, however they were not completely characterized until the early 1980s. It was not until the 1980s that AFLP and HELLP syndrome, and more specifically their clinical, laboratory, and pathologic findings, were further differentiated in the literature. More recently, the pathophysiologic mechanisms have been elucidated. In this review, we outline the similarities and differences in the clinical presentation, laboratory findings, maternal and perinatal outcomes, and clinical recovery for women diagnosed with these two syndromes. From our observations, we suggest that levels of fibrinogen, creatinine, cholesterol, and total bilirubin be used to assist with differentiating AFLP from HELLP syndrome upon admission in women presenting with either suspected disease. The rationale for identifying the specific conditions is that clinical consequences for recovery vary considerably. Specifically, AFLP is associated with significantly more hepatic and renal dysfunction as well as coagulopathy. Fortunately, both conditions can be managed with supportive measures with overall improved perinatal outcomes including morbidity and mortality.

Postpartum anemia is common after delivery, and postpartum blood transfusion is the leading indicator of severe maternal morbidity in the United States. Although hematologic changes during the antepartum period are well understood, little is known about postpartum hematologic changes. Therefore, we investigated the hematologic changes in the postpartum period in a large, contemporary cohort.This study aimed to characterize hematologic recovery in the postpartum period and evaluate the effect of demographics, medical conditions, and pregnancy characteristics on the recovery.In a contemporary cohort of deliveries in 2019 at a single institution, the hematocrit of postpartum women before hospital discharge was compared with the hematocrit of women at the postpartum follow-up. Our population was composed of a predominantly Hispanic population at an urban, safety-net hospital. All women received a complete blood count on postpartum day 1 and a spun hematocrit at their postpartum follow-up visit in our hospital system. All women were scheduled for a routine postpartum visit 2 to 3 weeks after delivery. All deliveries of a live-born infant with available postpartum hematocrit before hospital discharge and at postpartum follow-up were included. Demographics and pregnancy characteristics, along with medical conditions, were evaluated. To evaluate an uncomplicated cohort, those with multiple gestation, preeclampsia with severe features, chronic hypertension, and diabetes mellitus were excluded in the secondary analysis. Statistical analysis included chi-square, paired Student t test, Student t test for independent groups, and analysis of variance.Of 12,456 deliveries, 9003 met the inclusion criteria. The average number of days from discharge to follow-up was 21.73±10.39 days. The average hematocrit levels were 30.77±3.61 before discharge and 38.70±3.61 at postpartum follow-up. From discharge to postpartum follow-up, the hematocrit levels increased by an average of 7.93±3.24. In the cohort without complications, the average increase in hematocrit levels was 8.19±3.09. The rise in hematocrit levels was significantly lower for those with chronic hypertension (6.9±3.6), diabetes mellitus (7.3±3.3), and preeclampsia with severe features (6.9±3.7). The severity of anemia influenced the rise in hematocrit levels in the postpartum period. In women with postpartum anemia (hematocrit30%), the rise in hematocrit levels was 9.49±2.97 in the uncomplicated cohort. Postpartum hemorrhage did not influence the rise in postpartum hematocrit levels; women receiving blood transfusion had a greater rise in hematocrit levels (9.01±3.29).Our study establishes the natural course of hematologic recovery in the postpartum period, and we found that women with asymptomatic postpartum anemia may have a hematocrit level of 37% to 39% at their postpartum follow-up approximately 3 weeks after hospital discharge. Women with preexisting and obstetrical complications experienced less hematologic recovery and adapted more slowly to postpartum physiological changes.

Acute fatty liver of pregnancy is a rare, but potentially fatal obstetric disorder characterized principally by varying degrees of hepatic failure with an onset typically in late pregnancy. This review outlines the etiopathogenesis and describes the multiorgan involvement that often results in a number of clinical and laboratory aberrations. These laboratory derangements provide distinct features to differentiate from other obstetric complications, such as hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Once recognized, central to the management of acute fatty liver of pregnancy is delivery planning and meticulous supportive care. One particularly dangerous complication is profound coagulopathy. After delivery, the coagulation defect resolves over 1-2 days, and hepatic and renal function are restored soon thereafter. This report offers anticipated recovery and management strategies for commonly associated complications. Application of these factors has served to decrease mortality from as high as 80% down to 10%; however, given the seriousness of this condition, severe maternal morbidities are frequently associated with this obstetric emergency.

OBJECTIVE To evaluate the association of increasing body mass index (BMI) on postpartum tubal ligation safety and estimate the rates of procedure complication. METHODS We conducted a single-institution, retrospective review. Women undergoing postpartum permanent contraception after vaginal delivery from August 2015 to March 2019 were studied. Our primary outcome included a composite morbidity of intraoperative complications (bleeding requiring additional surgery, and extension of incision), blood transfusion, aborted procedure, anesthetic complication, readmission, wound infection, venous thromboembolism, ileus or small bowel obstruction, incomplete transection, and subsequent pregnancy. Statistical analysis included t test, χ test, and Wilcoxon rank-sum test, with P

Objectives The objective of this study is to assess Obstetrics and Gynecology (Ob/Gyn) resident experiences with and preferences for ethics education.

Peripartum cardiomyopathy is defined by left ventricular dysfunction and development of cardiac failure without a known cause and occurring in the final month of pregnancy and up to 5 months postpartum. Peripartum cardiomyopathy is an important and steadily increasing cause of pregnancy-associated morbidity and mortality. The incidence of peripartum cardiomyopathy in the United States has been estimated recently as 1 in 2,230 births and approximately 1 in 1,000 births worldwide. The etiopathogenesis of peripartum cardiomyopathy remains elusive; however, it is generally thought to be from a two-hit hypothesis in which an underlying cardiomyocyte protein mutation results in apoptosis mediated by vascular and hormonal actions. Clinical recognition is integral to the management of this disease, because there must be careful exclusion of alternative etiologies. Although there are no disease-specific therapies, management of peripartum cardiomyopathy is based on treatment of heart failure and its symptoms, repressing neurohormonal responses, and preventing long-term sequelae. Ventricular function recovery and rates of recurrence of peripartum cardiomyopathy vary by ethnicity and geography. Mortality rates associated with peripartum cardiomyopathy range from 3% to 40%, depending on geographic location. In this review, normal cardiovascular adaptations in pregnancy are summarized and current evidence-based clinical management of the disease is discussed.

Key Points Question What is the current state of US Food and Drug Administration labeling of medications in relation to pregnancy and lactation? Findings In this cross-sectional study of 290 newly approved medications from January 2010 to December 2019, all products submitted after June 20, 2015, were in compliance with the Pregnancy and Lactation Labeling Rule (PLLR); however, of those submitted between 2010 and 2015, 32.6% were not in PLLR format by the designated date of June 30, 2019. Human data on pregnancy and lactation were available in less than 20% of new product labeling. Meaning This study found that with the implementation of PLLR in the last decade, new therapeutic products are in compliance with the new rule; however, more than one-third of labels remain out of PLLR compliance., This cross-sectional study identifies the drugs that have adhered to the new US Food and Drug Administration Pregnancy and Lactation Labeling Rule, sheds light on the continued need for implementation of pregnancy, lactation, and reproduction into clinical studies, and evaluates how many new therapeutic products have human and animal data specific to pregnancy and lactation., Importance The US Food and Drug Administration (FDA) Pregnancy and Lactation Labeling Rule (PLLR), implemented in 2015, includes information on pregnancy, lactation, and women and men with reproductive potential. Objectives To identify the drugs that have adhered to the new PLLR format; to shed light on the continued need for implementation of pregnancy, lactation, and reproduction into clinical studies; and to evaluate how many new therapeutic products have human and animal data specific to pregnancy and lactation. Design, Setting, and Participants This cross-sectional study of 290 new therapeutic drugs reviewed labeling data for newly FDA-approved therapeutic products from January 2010 to December 2019. Therapeutic products submitted on or after June 30, 2015, were required to be in PLLR format; those approved from June 30, 2007, to June 29, 2015, had until June 30, 2019, to be in PLLR format. Approval data and subsequent labeling revision were evaluated for pregnancy and lactation data (human and animal), pregnancy registry, black-box warnings, and inclusion of PLLR labeling format. Exposures Date of new drug approval by FDA. Main Outcomes and Measures Compliance with PLLR; presence of animal or human data; presence of pregnancy registries; and presence of information regarding female and male reproductive potential. Results A total of 290 new molecular entities or therapeutic products were approved by the FDA between 2010 and 2019 in 19 categories. Black-box warnings occurred in 89 drugs (30.7%; 95% CI, 25.4%-36.3%), with 3 (3.4%; 95% CI, 0.7%-9.5%) involving pregnancy. All products submitted after June 30, 2015, were in PLLR format; however, of the 138 submitted between 2010 and that date, 45 (32.6%; 95% CI, 24.9%-41.1%) were not in PLLR format by June 30, 2019. During the 10 years of data analyzed, significantly more were in PLLR format (P for trend

INTRODUCTION:To evaluate how the diagnosis of major fetal anomalies and resulting pregnancy outcomes affected the risk of postpartum depression, as assessed by the Edinburgh Postnatal Depression Scale (EPDS).METHODS:Singleton pregnancies with prenatal diagnosis of major fetal anomalies were ascertai

The Task Force on Research Specific to Pregnant Women and Lactating Women was established by the 21st Century Cures Act and charged with providing advice and guidance to the Secretary of Health and Human Services on activities related to identifying and addressing gaps in knowledge and research on safe and effective therapies for pregnant women and lactating women, including the development of, collaboration on, and coordination of such activities. The Task Force developed 15 recommendations based on information gleaned during four meetings and a public comment period. These recommendation include concrete actionable items to facilitate information and data for providers and the public.

“Is It Safe?” More than half of new mothers take one or more medications in the months after delivery. But health care providers often lack the evidence they need to counsel breast-feeding women on...

This paper tabulates the results of 175 static load tests carried out in Ireland, and includes bored, continuous flight auger and driven piles in fine- and coarse-grained material, and also piles terminating in rock. These data are used to show that the ultimate pile resistance (defined at 0·1 times the effective pile diameter, D) predicted using Chin's extrapolation method was within the range 85–100% of the measured resistance when the pile head settlement was greater than 0·05D. The coefficient of variation of the compressive resistance of the ground against a pile, Rc, for a varying number of load tests carried out on a site reduced from 40% where a single test was carried out to 20% where eight tests occurred. This is considered to be a reasonable lower bound to the within-site variation in Rc, and it is recommended that this level of variation be considered for pile design.

Financial institutions today have a huge role in fighting money laundering and terrorist financing. How can IT auditing help? © 2011 Wiley Periodicals, Inc.

No one could have predicted the outcry from the industry, the public, Congress and the media on the know your customer (KYC) proposal unveiled on 7th December, 1998. For many years, compliance officers had heard about the possibility of a regulatory proposal to formalise the policy of identifying new account holders, reporting suspicious activity and training all employees. What was finally released went far beyond that.

Cytochrome P450 1B1 (CYP1B1) is involved in the activation of many carcinogens and in the metabolism of steroid hormones. We compared allele, genotype and haplotype frequencies of six single-nucleotide polymorphisms (SNPs) within CYP1B1 among non-Hispanic Caucasians (496 cases and 498 controls) and Hispanic Caucasians (153 cases and 240 controls). In the Hispanic Caucasians, the GG genotype for rs1056836 decreased the risk for prostate cancer (PCa) when compared with the CC genotype [odds ratio (OR) = 0.31, P = 0.04, 95% confidence interval (CI) = 0.10-0.96]. Among non-Hispanic Caucasian men with more aggressive PCa, the prevalence of several SNPs (rs2567206, rs2551188, rs2617266, rs10012 and rs1056836) was significantly associated with the disease status. A common C-G-C-C-G-A haplotype for rs2567206-rs2551188-rs2617266-rs10012-rs1056836-rs1800440 showed an inverse association with PCa risk in Hispanic Caucasians (OR = 0.19, P = 0.04, 95% CI = 0.04-0.95) and with aggressive disease status (i.e. Gleason score >or=7) in non-Hispanic Caucasian cases (OR = 0.64, P = 0.008, 95% CI = 0.47-0.89). In the non-Hispanic Caucasian cases, a second major haplotype T-A-T-G-C-A was positively associated with the high-grade disease status (OR = 1.77, P = 0.002, 95% CI = 1.24-2.53). Our findings suggest that genetic polymorphisms in CYP1B1 may modify the risk for PCa and support the role of CYP1B1 as a candidate gene for PCa.

Clinical findings and radiographic studies are the most valuable tools in differential diagnosis of intestinal obstruction. Treatment depends on the type of obstruction. Functional ileus does not require surgery, but mechanical obstruction usually does. Ischemic obstruction demands urgent surgery to prevent or remove gangrene. Even when intestinal obstruction seems to be nonmechanical and uncomplicated, repeated follow-up observation is necessary. Functional ileus may transform to mechanical obstruction.

Objective The objective of the study was to assess the current status of ethics education in obstetrics-gynecology residency programs. Study Design A cross-sectional, web-based survey was designed in conjunction with a professional survey laboratory at the University of Chicago. The survey was piloted with a convenience sample of clinical medical ethics fellows to assess question content and clarity. The survey was deployed by e-mail to all obstetrics-gynecology residency program directors. Descriptive statistics were used to analyze participant responses. The University of Chicago's Institutional Review Board deemed this study exempt from institutional review board formal review. Results Of 242 eligible obstetrics-gynecology residency program directors, 118 (49%) completed the survey. Most respondents were from university-based programs (n = 78, 66%) that were not religiously affiliated (n = 98, 83%) and trained 4-6 residents per postgraduate year (n = 64, 70%). Although 50% of program directors (n = 60) reported having ethics as part of their core curriculum, most programs teach ethics in an unstructured manner. Fifty-seven percent of respondents (n = 66) stated their program dedicated 5 or fewer hours per year to ethics. The majority of program directors (n = 80, 73%) responded they would like more to a lot more ethics education and believed that ethics education should be required (n = 93, 85%) for residents to complete their training. Respondents identified that crowding in the curriculum was a significant barrier to increased ethics training (n = 50, 45%) and two-thirds (n = 74, 67%) reported a lack of faculty expertise as a moderate barrier to providing ethics education in the residency curriculum. Conclusion This study found that a lack of structured curricula, inadequate faculty expertise, and limited time were important barriers for ethics education in obstetrics-gynecology programs across the nation. Despite these existing challenges, program directors have a strong interest in increasing ethics education in residency training. Therefore, additional resources are needed to assist program directors in enhancing resident ethics education.

(1991). A Modest Proposal for Preventing the Children of America from Being a Burden to Their Parents or Country, and for Making Them Beneficial to the Public. The Clearing House: A Journal of Educational Strategies, Issues and Ideas: Vol. 64, No. 5, pp. 327-329.