102 results on '"Pacheco LD"'
Search Results
2. Management of uterine hyperstimulation with concomitant use of oxytocin and terbutaline.
- Author
-
Pacheco LD, Rosen MP, Gei AF, Saade GR, and Hankins GD
- Published
- 2006
- Full Text
- View/download PDF
3. Burns in pregnancy.
- Author
-
Pacheco LD, Gei AF, VanHook JW, Saade GR, and Hankins GDV
- Published
- 2005
- Full Text
- View/download PDF
4. Fetal/neonatal alloimmune thrombocytopenia: more data favouring less invasive treatment.
- Author
-
Pacheco, LD and Pacheco, L D
- Subjects
- *
PREGNANCY , *BLOOD platelets , *ANTIGENS , *HEMORRHAGE , *PREGNANT women , *LONGITUDINAL method , *PRENATAL care , *THROMBOCYTOPENIA - Abstract
The article discusses a 2015 study by Tiller et al that focused on the outcomes in subsequent pregnancies in women with previous history of fetal/neonatal alloimmune thrombocytophenia. Topics include neonatal platelet counts, human platelet antigen-la incompatibility, and intrauterine platelet transfusion.
- Published
- 2016
- Full Text
- View/download PDF
5. Obstetric sepsis: Clinical pearls for diagnosis and management.
- Author
-
Behnia F, Omere CI, Clifford CC, and Pacheco LD
- Subjects
- Humans, Pregnancy, Female, Vasoconstrictor Agents therapeutic use, Sepsis diagnosis, Sepsis therapy, Anti-Bacterial Agents therapeutic use, Fluid Therapy methods, Pregnancy Complications, Infectious diagnosis, Pregnancy Complications, Infectious therapy, Pregnancy Complications, Infectious drug therapy
- Abstract
Sepsis is a leading cause of maternal morbidity and mortality worldwide. Early recognition and treatment improve outcomes. Multiple sepsis diagnostic screening tools are available and may be used in clinical practice; however, early thorough bedside evaluation of the patient is fundamental. Obstetricians should be able to recognize sepsis and promptly initiate potentially life-saving treatments, such as fluid resuscitation, vasopressors, broad-spectrum antibiotics, and early source control. It is recommended that obstetrical care, including delivery timing, not be altered solely due to the diagnosis of sepsis., Competing Interests: Declaration of competing interest The authors report no potential conflicts of interest. (Authors please confirm, complete and correct)., (Copyright © 2024 Elsevier Inc. All rights reserved.)
- Published
- 2024
- Full Text
- View/download PDF
6. Peripheral Use of Vasopressors in Shock: Clinical Considerations and Recommendations for Use in Obstetrics.
- Author
-
Pacheco LD, Fox KA, Clifford CC, Behnia F, Bauer ME, Saad AF, and Saade GR
- Abstract
Objective: This study aimed to evaluate the safety of peripheral administration of vasopressor agents among patients with circulatory shock., Study Design: We reviewed the published literature evaluating the use of peripheral norepinephrine in patients with shock and proposed a protocol for use in labor and delivery units., Results: Peripheral administration of norepinephrine is a safe and potentially lifesaving intervention for patients in labor and delivery with extremely low complication rates., Conclusion: Adoption of a protocol for peripheral administration of vasopressors in labor and delivery is safe and may prevent life threatening delays in hemodynamic resuscitation., Key Points: · Administering vasopressors through a peripheral line is safe and helps avoid delays in care.. · An established protocol is essential for the safe peripheral administration of vasopressors.. · Understanding continuous blood pressure monitoring is crucial for managing critically ill patients.., Competing Interests: None declared., (Thieme. All rights reserved.)
- Published
- 2024
- Full Text
- View/download PDF
7. Tranexamic acid for postpartum bleeding: a systematic review and individual patient data meta-analysis of randomised controlled trials.
- Author
-
Ker K, Sentilhes L, Shakur-Still H, Madar H, Deneux-Tharaux C, Saade G, Pacheco LD, Ageron FX, Mansukhani R, Balogun E, Brenner A, Prowse D, Arribas M, Ahmadzia H, Chaudhri R, Olayemi O, and Roberts I
- Subjects
- Female, Humans, Pregnancy, Randomized Controlled Trials as Topic, Thromboembolism prevention & control, Thromboembolism drug therapy, Antifibrinolytic Agents therapeutic use, Postpartum Hemorrhage drug therapy, Postpartum Hemorrhage prevention & control, Tranexamic Acid therapeutic use, Tranexamic Acid adverse effects
- Abstract
Background: Tranexamic acid is a recommended treatment for women with a clinical diagnosis of postpartum haemorrhage, but whether it can prevent bleeding is unclear. We conducted a systematic review and individual patient data (IPD) meta-analysis of randomised controlled trials to assess the effects of tranexamic acid in women giving birth., Methods: In this systematic review and IPD meta-analysis, we searched the WHO International Clinical Trials Registry Platform from database inception to Aug 4, 2024 for randomised trials that assessed the effects of tranexamic acid in women giving birth. Trials were eligible if they were prospectively registered, placebo-controlled, included more than 500 women, and had a low risk of bias for random sequence generation and allocation concealment. IPD were requested from the trial investigators. The primary outcomes were the numbers of women with life-threatening bleeding and thromboembolic events. We used a one-stage model to analyse the data and explored whether the effect of tranexamic acid varied by the underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anaemia, or timing of administration (before or after a diagnosis of postpartum haemorrhage). This study is registered with PROSPERO, CRD42022345775., Findings: We analysed data on 54 404 women from five trials. We obtained IPD for 43 409 women from four trials and aggregate data on 10 995 women from one trial. All trials had a low risk of bias. Life-threatening bleeding occurred in 178 (0·65%) of 27 300 women in the tranexamic acid group versus 230 (0·85%) of 27 093 women in the placebo group (pooled odds ratio [OR] 0·77 [95% CI 0·63-0·93]; p=0·008). There was no evidence that the effect of tranexamic acid varied by the underlying risk of life-threatening bleeding, type of birth, presence of moderate or severe anaemia or timing of administration. No significant difference was identified between tranexamic acid and placebo groups with regard to thromboembolic events: 50 (0·2%) of 26 571 women in the tranexamic acid group had fatal or non-fatal thromboembolic events versus 52 (0·2%) of 26 373 women in the placebo group (pooled OR 0·96 [0·65-1·41]; p=0·82) with no significant heterogeneity identified in the subgroup analyses., Interpretation: Tranexamic acid reduces the risk of life-threatening postpartum bleeding. We found no evidence that tranexamic acid increases the risk of thrombosis. Although we do not recommend the use of tranexamic acid in all women giving birth, consideration should be given to its use before a diagnosis of postpartum haemorrhage in women at high risk of death., Funding: The Bill & Melinda Gates Foundation., Competing Interests: Declaration of interests IR and HS-S declare receipt of support from the National Institute for Health and Care Research, Wellcome, and the John Moulton Foundation for support of their other research activities into the effects of tranexamic acid. All payments were made to their employing institution (London School of Hygiene & Tropical Medicine). IR also declares an unpaid role as convenor of an ad-hoc group (The Joint Royal Colleges tranexamic acid in surgery implementation group) to increase the use of tranexamic acid in surgical patients as per National Institute for Health and Care Excellence guidance. LS reports receipt of payment or honoraria from Ferring Pharmaceuticals, Norgine, Bayer, Pfizer, GlaxoSmithKline, and Organon for lectures, presentations, speakers bureaus, manuscript writing, or educational events. HA declares receipt of support from the National Institute of Child Health and Human Development/National Institutes of Health for grant OPTIMUM OB-TXA: Optimal TIMing, route and dose of tranexamic acid prior to UMbilical cord clamp for postpartum haemorrhage prevention; consulting fees from Hemosonics, Coagulant Therapeutics, Hemosquid; and payment or honoraria from COR2ED for lectures, presentations, speakers bureaus, manuscript writing, or educational events. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)
- Published
- 2024
- Full Text
- View/download PDF
8. A practical approach to the diagnosis and initial management of acute right ventricular failure during pregnancy using point-of-care ultrasound.
- Author
-
Martins JG, Saad A, Saade G, and Pacheco LD
- Abstract
Acute right ventricular failure is a critical condition in pregnancy that can lead to severe maternal and fetal complications. This expert review discusses the instrumental role of point-of-care ultrasound in diagnosing and managing ARVF in pregnant patients, highlighting its benefits for immediate clinical decision-making in obstetric emergencies. The unique physiological changes during pregnancy, such as increased blood volume and cardiac output, can exacerbate underlying or latent cardiac issues, making pregnant patients particularly susceptible to acute right ventricular failure. Common causes during pregnancy include pulmonary embolism, peripartum cardiomyopathy, and congenital heart diseases, each presenting distinct challenges in diagnosis and management. The real-time capability of point-of-care ultrasound allows for the immediate assessment of right ventricular size and function, evaluation of fluid status via the inferior vena cava, and identification of potential pulmonary embolism, offering a non-invasive, rapid, and dynamic diagnostic tool right at the bedside. The expert review details specific point-of-care ultrasound techniques adapted for pregnant patients, including the parasternal long and short axis and apical 4-chamber view, essential for evaluating right heart function and guiding acute management strategies. These include fluid management, adjustment of pharmacological treatment, and immediate interventions to support cardiac function and reduce ventricular overload. Point-of-care ultrasound enhances clinical outcomes by allowing clinicians to make informed decisions quickly, reducing the time to intervention, and tailoring management strategies to individual patient needs. However, despite its apparent advantages, the adoption of point-of-care ultrasound requires specialized training and familiarity with obstetric-specific protocols. This review advocates for the integration of point-of-care ultrasound into standard obstetric care protocols, emphasizing the need for clear guidelines and structured protocols that equip healthcare providers with the skills necessary to utilize this technology effectively. Future research should aim to refine these protocols and expand the evidence base to solidify the role of point-of-care ultrasound in improving maternal and fetal outcomes in acute right ventricular failure., (Copyright © 2024 Elsevier Inc. All rights reserved.)
- Published
- 2024
- Full Text
- View/download PDF
9. Post-Acute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) After Infection During Pregnancy.
- Author
-
Metz TD, Reeder HT, Clifton RG, Flaherman V, Aragon LV, Baucom LC, Beamon CJ, Braverman A, Brown J, Cao T, Chang A, Costantine MM, Dionne JA, Gibson KS, Gross RS, Guerreros E, Habli M, Hadlock J, Han J, Hess R, Hillier L, Hoffman MC, Hoffman MK, Hughes BL, Jia X, Kale M, Katz SD, Laleau V, Mallett G, Mehari A, Mendez-Figueroa H, McComsey GA, Monteiro J, Monzon V, Okumura MJ, Pant D, Pacheco LD, Palatnik A, Palomares KTS, Parry S, Pettker CM, Plunkett BA, Poppas A, Ramsey P, Reddy UM, Rouse DJ, Saade GR, Sandoval GJ, Sciurba F, Simhan HN, Skupski DW, Sowles A, Thorp JM Jr, Tita ATN, Wiegand S, Weiner SJ, Yee LM, Horwitz LI, Foulkes AS, and Jacoby V
- Subjects
- Humans, Female, Pregnancy, Adult, Risk Factors, United States epidemiology, Prevalence, Cohort Studies, Severity of Illness Index, COVID-19 epidemiology, COVID-19 complications, Pregnancy Complications, Infectious epidemiology, Pregnancy Complications, Infectious virology, SARS-CoV-2, Post-Acute COVID-19 Syndrome
- Abstract
Objective: To estimate the prevalence of post-acute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC) after infection with SARS-CoV-2 during pregnancy and to characterize associated risk factors., Methods: In a multicenter cohort study (NIH RECOVER [Researching COVID to Enhance Recovery]-Pregnancy Cohort), individuals who were pregnant during their first SARS-CoV-2 infection were enrolled across the United States from December 2021 to September 2023, either within 30 days of their infection or at differential time points thereafter. The primary outcome was PASC , defined as score of 12 or higher based on symptoms and severity as previously published by the NIH RECOVER-Adult Cohort, at the first study visit at least 6 months after the participant's first SARS-CoV-2 infection. Risk factors for PASC were evaluated, including sociodemographic characteristics, clinical characteristics before SARS-CoV-2 infection (baseline comorbidities, trimester of infection, vaccination status), and acute infection severity (classified by need for oxygen therapy). Multivariable logistic regression models were fitted to estimate associations between these characteristics and presence of PASC., Results: Of the 1,502 participants, 61.1% had their first SARS-CoV-2 infection on or after December 1, 2021 (ie, during Omicron variant dominance); 51.4% were fully vaccinated before infection; and 182 (12.1%) were enrolled within 30 days of their acute infection. The prevalence of PASC was 9.3% (95% CI, 7.9-10.9%) measured at a median of 10.3 months (interquartile range 6.1-21.5) after first infection. The most common symptoms among individuals with PASC were postexertional malaise (77.7%), fatigue (76.3%), and gastrointestinal symptoms (61.2%). In a multivariable model, the proportion PASC positive with vs without history of obesity (14.9% vs 7.5%, adjusted odds ratio [aOR] 1.65, 95% CI, 1.12-2.43), depression or anxiety disorder (14.4% vs 6.1%, aOR 2.64, 95% CI, 1.79-3.88) before first infection, economic hardship (self-reported difficulty covering expenses) (12.5% vs 6.9%, aOR 1.57, 95% CI, 1.05-2.34), and treatment with oxygen during acute SARS-CoV-2 infection (18.1% vs 8.7%, aOR 1.86, 95% CI, 1.00-3.44) were associated with increased prevalence of PASC., Conclusion: The prevalence of PASC at a median time of 10.3 months after SARS-CoV-2 infection during pregnancy was 9.3% in the NIH RECOVER-Pregnancy Cohort. The predominant symptoms were postexertional malaise, fatigue, and gastrointestinal symptoms. Several socioeconomic and clinical characteristics were associated with PASC after infection during pregnancy., Clinical Trial Registration: ClinicalTrials.gov , NCT05172024., Competing Interests: Financial Disclosure Torri D. Metz is the site PI for a Pfizer study of Paxlovid in pregnancy and was the site PI for a Pfizer study of COVID-19 vaccination in pregnancy. She has received UpToDate royalties for two topics on trial of labor after cesarean. Carmen J. Beamon disclosed receiving payments from Wellcare of North Carolina. Ann Chang's institution received payment from New York University for her efforts on this study. Kelly S. Gibson disclosed that her institution received funding from the NICHD, NHLBI, and Materna. Rachel Hess received payment from Astellas Pharmaceuticals. M. Camile Hoffman disclosed her institution received payment for her expert testimony for one medicolegal trial from Wheeler, Trigg, and Associates (a defense attorneys firm). Her institution also received payment for a disease state presentation on postpartum depression and zuranolone from SAGE/Biogen. Brenna L. Hughes disclosed receiving payments from UpToDate and Moderna. Stuart Katz disclosed payments for providing expert testimony for Venable LLP. Jennifer Hadlock has received funding (paid to institution) for retrospective studies of COVID-19 from Pfizer, Novartis, Janssen, and Gilead. Grace A. McComsey served as an advisor for Gilead and ViiVGlaxoSmithKline. Patrick Ramsey disclosed receiving royalties from UpToDate. His institution was paid by the Texas Collaborative for Healthy Mothers and Babies (TCHMB)—Texas PQC for part of his efforts. Daniel W. Skupski reports receiving payments from Organon, Inc and Cooper Surgical. Alan T.N. Tita disclosed money paid to his institution from Pfizer for his efforts in this study. Andrea Foulkes disclosed receiving past payments from Round Table, Inc. The other authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)
- Published
- 2024
- Full Text
- View/download PDF
10. The role of point-of-care ultrasound to monitor response of fluid replacement therapy in pregnancy.
- Author
-
Gevaerd Martins J, Saad A, Saade G, and Pacheco LD
- Abstract
Fluid management in obstetrical care is crucial because of the complex physiological conditions of pregnancy, which complicate clinical manifestations and fluid balance management. This expert review examined the use of point-of-care ultrasound to evaluate and monitor the response to fluid therapy in pregnant patients. Pregnancy induces substantial physiological changes, including increased cardiac output and glomerular filtration rate, decreased systemic vascular resistance, and decreased plasma oncotic pressure. Conditions, such as preeclampsia, further complicate fluid management because of decreased intravascular volume and increased capillary permeability. Traditional methods for assessing fluid volume status, such as physical examination and invasive monitoring, are often unreliable or inappropriate. Point-of-care ultrasound provides a noninvasive, rapid, and reliable means to assess fluid responsiveness, which is essential for managing fluid therapy in pregnant patients. This review details the various point-of-care ultrasound modalities used to measure dynamic changes in fluid status, focusing on the evaluation of the inferior vena cava, lung ultrasound, and left ventricular outflow tract. Inferior vena cava ultrasound in spontaneously breathing patients determines diameter variability, predicts fluid responsiveness, and is feasible even late in pregnancy. Lung ultrasound is crucial for detecting early signs of pulmonary edema before clinical symptoms arise and is more accurate than traditional radiography. The left ventricular outflow tract velocity time integral assesses stroke volume response to fluid challenges, providing a quantifiable measure of cardiac function, which is particularly beneficial in critical care settings where rapid and accurate fluid management is essential. This expert review synthesizes current evidence and practice guidelines, suggesting the integration of point-of-care ultrasound as a fundamental aspect of fluid management in obstetrics. It calls for ongoing research to enhance techniques and validate their use in broader clinical settings, aiming to improve outcomes for pregnant patients and their babies by preventing complications associated with both under- and overresuscitation., (Copyright © 2024 Elsevier Inc. All rights reserved.)
- Published
- 2024
- Full Text
- View/download PDF
11. Ischemic Hepatitis and Septic Shock Secondary to Murine Typhus Infection in Pregnancy.
- Author
-
Berry M, Wang AM, Lahham RF, Zhang X, and Pacheco LD
- Abstract
Infection with murine typhus may be associated with significant morbidity. With nonspecific symptoms and laboratory abnormalities, diagnosis may be challenging. In this case, a pregnant patient presented with complaints of fevers and myalgias. Her laboratory results included severe transaminitis as well as thrombocytopenia and hyponatremia. She ultimately required vasopressor support and intensive care unit admission despite fluid resuscitation and broad-spectrum antibiotics. Empiric doxycycline was initiated due to suspicion for murine typhus, which laboratory testing later confirmed. Her clinical status improved with these interventions. This was a severe case of murine typhus resulting in septic shock and ischemic hepatitis. It is important to know the typical findings of murine typhus and consider it in a differential diagnosis, especially when practicing in endemic areas., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)
- Published
- 2024
- Full Text
- View/download PDF
12. Early vs delayed amniotomy following transcervical Foley balloon in the induction of labor: a randomized clinical trial.
- Author
-
Berry M, Lamiman K, Slan MN, Zhang X, Arena Goncharov DD, Hwang YP, Rogers JA, Pacheco LD, Saade GR, and Saad AF
- Subjects
- Humans, Female, Pregnancy, Adult, Time Factors, Catheterization methods, Delivery, Obstetric methods, Labor, Induced methods, Amniotomy methods, Cervical Ripening
- Abstract
Background: The optimal timing of amniotomy during labor induction is a topic of ongoing debate due to the potential risks associated with both amniotomy and prolonged labor. As such, individuals in the field of obstetrics and gynecology must carefully evaluate the associated benefits and drawbacks of this procedure. While amniotomy can expedite the labor process, it may also lead to complications such as umbilical cord prolapse, fetal distress, and infection. Therefore, a careful and thorough examination of the risks and benefits of amniotomy during labor induction is essential in making an informed decision regarding the optimal timing of this procedure., Objective: This study aimed to determine if an amniotomy within 2 hours after Foley balloon removal reduced the duration of active labor and time taken to achieve vaginal delivery when compared with an amniotomy ≥4 hours after balloon removal among term pregnant women who underwent labor induction., Study Design: This was an open-label, randomized controlled trial that was conducted at a single academic center from October 2020 to March 2023. Term participants who were eligible for preinduction cervical ripening with a Foley balloon were randomized into 2 groups, namely the early amniotomy (rupture of membranes within 2 hours after Foley balloon removal) and delayed amniotomy (rupture of membranes performed more than 4 hours after Foley balloon removal) groups. Randomization was stratified by parity. The primary outcome was time from Foley balloon insertion to active phase of labor. Secondary outcomes, including time to delivery, cesarean delivery rates, and maternal and neonatal complications, were analyzed using intention-to-treat and per-protocol analyses., Results: Of the 150 participants who consented and were enrolled, 149 were included in the analysis. In the intention-to-treat population, an early amniotomy did not significantly shorten the time between Foley balloon insertion and active labor when compared with a delayed amniotomy (885 vs 975 minutes; P=.08). An early amniotomy was associated with a significantly shorter time from Foley balloon placement to active labor in nulliparous individuals (1211; 584-2340 vs 1585; 683-2760; P=.02). When evaluating the secondary outcomes, an early amniotomy was associated with a significantly shorter time to active labor onset (312.5 vs 442.5 minutes; P=.02) and delivery (484 vs 587 minutes; P=.03) from Foley balloon removal with a higher rate of delivery within 36 hours (96% vs 85%; P=.03). Individuals in the early amniotomy group reached active labor 1.5 times faster after Foley balloon insertion than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1.1-2.2; P=.02). Those with an early amniotomy also reached vaginal delivery 1.5 times faster after Foley balloon removal than those in the delayed group (hazard ratio, 1.5; 95% confidence interval, 1-2.2; P=.03). A delayed amniotomy was associated with a higher rate of postpartum hemorrhage (0% vs 9.5%; P=.01). No significant differences were observed in the cesarean delivery rates, length of hospital stay, maternal infection, or neonatal outcomes., Conclusion: Although an early amniotomy does not shorten the time from Foley balloon insertion to active labor, it shortens time from Foley balloon removal to active labor and delivery without increasing complications. The increased postpartum hemorrhage rate in the delayed amniotomy group suggests increased risks with delayed amniotomy., (Copyright © 2024 Elsevier Inc. All rights reserved.)
- Published
- 2024
- Full Text
- View/download PDF
13. Validation of Three Models for Prediction of Blood Transfusion during Cesarean Delivery Admission.
- Author
-
Bruno AM, Federspiel JJ, McGee P, Pacheco LD, Saade GR, Parry S, Longo M, Tita ATN, Gyamfi-Bannerman C, Chauhan SP, Einerson BD, Rood K, Rouse DJ, Bailit J, Grobman WA, and Simhan HN
- Subjects
- Adult, Female, Humans, Pregnancy, Algorithms, Antifibrinolytic Agents therapeutic use, Area Under Curve, Erythrocyte Transfusion, Postpartum Hemorrhage therapy, Risk Assessment methods, ROC Curve, Tranexamic Acid therapeutic use, United States, Blood Transfusion statistics & numerical data, Cesarean Section
- Abstract
Objective: Prediction of blood transfusion during delivery admission allows for clinical preparedness and risk mitigation. Although prediction models have been developed and adopted into practice, their external validation is limited. We aimed to evaluate the performance of three blood transfusion prediction models in a U.S. cohort of individuals undergoing cesarean delivery., Study Design: This was a secondary analysis of a multicenter randomized trial of tranexamic acid for prevention of hemorrhage at time of cesarean delivery. Three models were considered: a categorical risk tool (California Maternal Quality Care Collaborative [CMQCC]) and two regression models (Ahmadzia et al and Albright et al). The primary outcome was intrapartum or postpartum red blood cell transfusion. The CMQCC algorithm was applied to the cohort with frequency of risk category (low, medium, high) and associated transfusion rates reported. For the regression models, the area under the receiver-operating curve (AUC) was calculated and a calibration curve plotted to evaluate each model's capacity to predict receipt of transfusion. The regression model outputs were statistically compared., Results: Of 10,785 analyzed individuals, 3.9% received a red blood cell transfusion during delivery admission. The CMQCC risk tool categorized 1,970 (18.3%) individuals as low risk, 5,259 (48.8%) as medium risk, and 3,556 (33.0%) as high risk with corresponding transfusion rates of 2.1% (95% confidence interval [CI]: 1.5-2.9%), 2.2% (95% CI: 1.8-2.6%), and 7.5% (95% CI: 6.6-8.4%), respectively. The AUC for prediction of blood transfusion using the Ahmadzia and Albright models was 0.78 (95% CI: 0.76-0.81) and 0.79 (95% CI: 0.77-0.82), respectively ( p = 0.38 for difference). Calibration curves demonstrated overall agreement between the predicted probability and observed likelihood of blood transfusion., Conclusion: Three models were externally validated for prediction of blood transfusion during cesarean delivery admission in this U.S., Cohort: Overall, performance was moderate; model selection should be based on ease of application until a specific model with superior predictive ability is developed., Key Points: · A total of 3.9% of individuals received a blood transfusion during cesarean delivery admission.. · Three models used in clinical practice are externally valid for blood transfusion prediction.. · Institutional model selection should be based on ease of application until further research identifies the optimal approach.., Competing Interests: None declared., (Thieme. All rights reserved.)
- Published
- 2024
- Full Text
- View/download PDF
14. Immunosuppressant Medications in Pregnancy.
- Author
-
Saad AF, Pacheco LD, and Saade GR
- Subjects
- Pregnancy, Female, Humans, Tacrolimus adverse effects, Immunosuppressive Agents adverse effects, Azathioprine adverse effects, Organ Transplantation, Autoimmune Diseases drug therapy
- Abstract
Pregnant patients are often on immunosuppressant medications, most commonly to manage transplantation or autoimmune disorders. Most immunosuppressant agents, including tacrolimus, corticosteroids, azathioprine, and calcineurin inhibitors, are safe during pregnancy and lactation. However, mycophenolic acid is associated with higher risks of birth defects and should be avoided in pregnancy. Tacrolimus, the commonly used drug in transplantation medicine and autoimmune disorders, requires monitoring of serum levels for dose adjustment, particularly during pregnancy. Although no pregnancy-specific therapeutic range exists, the general target range is 5-15 ng/mL, and pregnant patients may require higher doses to achieve therapeutic levels. Adherence to prescribed immunosuppressive regimens is crucial to prevent graft rejection and autoimmune disorder flare-ups. This review aims to provide essential information about the use of immunosuppressant medications in pregnant individuals. With a rising number of pregnant patients undergoing organ transplantations or having autoimmune disorders, it is important to understand the implications of the use of these medications during pregnancy., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2024 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)
- Published
- 2024
- Full Text
- View/download PDF
15. Peripartum Abdominal Compartment Syndrome Following Extracorporeal Hemodynamic Support.
- Author
-
Lozovyy V, Saoud F, and Pacheco LD
- Abstract
In massive pulmonary embolism (PE), anticoagulation and thrombolytics may increase the risk of retroperitoneal bleeding following vascular cannulation for extracorporeal hemodynamic support resulting in abdominal compartment syndrome (ACS). A 27-year-old women at 33 weeks of gestation presented with acute chest pain and shortness of breath. Massive PE was diagnosed. Intravenous unfractionated heparin was started together with catheter-directed tissue plasminogen activator (tPA) infusion and mechanical thrombectomy. During the procedure, cardiac arrest developed. Cardiopulmonary resuscitation, intravenous tPA, and urgent perimortem cesarean delivery were performed. After return of spontaneous circulation, profound right ventricular failure required venoarterial membrane oxygenation. Six hours afterward, ACS secondary to retroperitoneal bleeding developed, requiring surgical intervention. ACS may result from retroperitoneal bleeding following cannulation for extracorporeal hemodynamic support., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)
- Published
- 2024
- Full Text
- View/download PDF
16. Management of pregnant women who have bleeding disorders.
- Author
-
James AH, Pacheco LD, and Konkle BA
- Subjects
- Child, Infant, Newborn, Female, Pregnancy, Male, Humans, Pregnant Women, Placenta, Hemorrhage therapy, Blood Coagulation Factors therapeutic use, Hemophilia A diagnosis, Hemophilia A therapy, von Willebrand Diseases diagnosis, von Willebrand Diseases therapy
- Abstract
Bleeding disorders, including von Willebrand disease (VWD), hemophilia, other coagulation factor deficiencies, platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal implications. Successful management of bleeding disorders in pregnant women requires not only an understanding of bleeding disorders but also an understanding of when and how bleeding occurs in pregnancy. Bleeding does not occur during a normal pregnancy with a healthy placenta. Bleeding occurs during pregnancy when there is an interruption of the normal utero-placental interface, during miscarriage, during an ectopic pregnancy, or at the time of placental separation at the conclusion of pregnancy. Although mild platelet defects may be more prevalent, the most commonly diagnosed bleeding disorder among women is VWD. Other bleeding disorders are less common, but hemophilia carriers are unique in that they are at risk of bleeding themselves and of giving birth to an affected male infant. General guidance for maternal management of a woman who is moderately or severely affected includes obtaining coagulation factor levels at a minimum in the third trimester; planning for delivery at a center with hemostasis expertise; and anticipating the need for hemostatic agents. General guidance for fetal management includes pre-pregnancy counseling; the option of preimplantation genetic testing for hemophilia; delivery at a tertiary care center with pediatric hematology and newborn intensive care; consideration of cesarean delivery of a potentially severely affected infant; and avoidance of invasive procedures such as scalp electrodes and operative vaginal delivery in any potentially affected infant., (Copyright © 2023 by The American Society of Hematology.)
- Published
- 2023
- Full Text
- View/download PDF
17. Care and Monitoring of Pregnant Patients With Left Ventricular Assist Devices.
- Author
-
Pacheco LD, Saad AF, Lick SD, Iturrizaga JC, and Saade GR
- Subjects
- Female, Pregnancy, Humans, Adult, Hemodynamics, Heart-Assist Devices adverse effects, Cardiomyopathies, Cardiovascular Diseases, Heart Failure therapy
- Abstract
Cardiovascular disease is one of the leading causes of maternal mortality in the United States. Although still rare, pregnancy in patients with left ventricular assist devices (LVADs) is becoming more common. Typical indications for the use of LVADs in reproductive-aged females include ischemic cardiomyopathy, nonischemic (familial) dilated cardiomyopathy, peripartum cardiomyopathy, and some forms of myocarditis. An LVAD drains blood through a cannula placed into the apex of the left ventricle and then returns it to the proximal aorta bypassing the aortic valve allowing hemodynamic support in parallel with the native circulation. The physiologic changes associated with pregnancy, mainly increased blood volume and hypercoagulability, may adversely affect patients with LVADs, leading to many experts recommending against pregnancy. Maternal-fetal medicine specialists should have a central role within a multidisciplinary team required to provide optimal care for this high-risk group of patients., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)
- Published
- 2023
- Full Text
- View/download PDF
18. 2023 HRS expert consensus statement on the management of arrhythmias during pregnancy.
- Author
-
Joglar JA, Kapa S, Saarel EV, Dubin AM, Gorenek B, Hameed AB, Lara de Melo S, Leal MA, Mondésert B, Pacheco LD, Robinson MR, Sarkozy A, Silversides CK, Spears D, Srinivas SK, Strasburger JF, Tedrow UB, Wright JM, Zelop CM, and Zentner D
- Subjects
- Pregnancy, Female, Humans, Tachycardia diagnosis, Anti-Arrhythmia Agents therapeutic use, Arrhythmias, Cardiac therapy, Arrhythmias, Cardiac drug therapy
- Abstract
This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified., (Copyright © 2023 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)
- Published
- 2023
- Full Text
- View/download PDF
19. Alliance for Innovation on Maternal Health: Consensus Bundle on Sepsis in Obstetric Care.
- Author
-
Bauer ME, Albright C, Prabhu M, Heine RP, Lennox C, Allen C, Burke C, Chavez A, Hughes BL, Kendig S, Le Boeuf M, Main E, Messerall T, Pacheco LD, Riley L, Solnick R, Youmans A, and Gibbs R
- Subjects
- Female, Pregnancy, Humans, Maternal Health, Consensus, Advisory Committees, Sepsis diagnosis, Sepsis prevention & control
- Abstract
Sepsis in obstetric care is one of the leading causes of maternal death in the United States, with Black, Asian/Pacific Islander, and American Indian/Alaska Native obstetric patients experiencing sepsis at disproportionately higher rates. State maternal mortality review committees have determined that deaths are preventable much of the time and are caused by delays in recognition, treatment, and escalation of care. The "Sepsis in Obstetric Care" patient safety bundle provides guidance for health care teams to develop coordinated, multidisciplinary care for pregnant and postpartum people by preventing infection and recognizing and treating infection early to prevent progression to sepsis. This is one of several core patient safety bundles developed by AIM (the Alliance for Innovation on Maternal Health) to provide condition- or event-specific clinical practices that should be implemented in all appropriate care settings. As with other bundles developed by AIM, the "Sepsis in Obstetric Care" patient safety bundle is organized into five domains: Readiness, Recognition and Prevention, Response, Reporting and Systems Learning, and Respectful, Equitable, and Supportive Care. The Respectful, Equitable, and Supportive Care domain provides essential best practices to support respectful, equitable, and supportive care to all patients. Further health equity considerations are integrated into the elements of each domain., Competing Interests: Financial Disclosure Melissa E. Bauer is a consultant for Institute for Healthcare Innovation. Catherine Albright reports receiving payment from the Seattle Foundation. Malavika Prabhu receives royalties from UpToDate, Inc. and is a consultant for Medscape. Laura Riley is on the Maven Clinic Co. Advisory Board, the New England Journal of Medicine Editorial Board, and the Contemporary OB/GYN advisory board. She received payment from Pfizer for a one-time consultation about an RSV vaccine. Melissa E. Bauer, Catherina Albright, Malavika Prabhu, Carol Burke, April Chavez, Maile Le Boeuf, Tiffany Messerall, and Ronald S. Gibbs received payment for contributions to the development of the Sepsis in Obstetric Care Change Package created by Alliance for Innovation on Maternal Health and the Institute for Healthcare Improvement. Brenna L. Hughes received payment from UpToDate, Johns Hopkins for DSMB, and the NIH for grants. Susan Kendig received payment from ACOG as a consultant to bundle development. The other authors did not report any potential conflicts of interest., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)
- Published
- 2023
- Full Text
- View/download PDF
20. Society for Maternal-Fetal Medicine Consult Series #67: Maternal sepsis.
- Author
-
Shields AD, Plante LA, Pacheco LD, and Louis JM
- Subjects
- Pregnancy, Female, Humans, Perinatology, Shock, Septic diagnosis, Shock, Septic therapy, Venous Thromboembolism, Sepsis diagnosis, Sepsis therapy, Pregnancy Complications, Infectious diagnosis, Pregnancy Complications, Infectious therapy, Pre-Eclampsia
- Abstract
Maternal sepsis is a significant cause of maternal morbidity and mortality, and is a potentially preventable cause of maternal death. This Consult aims to summarize what is known about sepsis and provide guidance for the management of sepsis during pregnancy and the postpartum period. Most studies cited are from the nonpregnant population, but where available, pregnancy data are included. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend that clinicians consider the diagnosis of sepsis in pregnant or postpartum patients with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever (GRADE 1C); (2) we recommend that sepsis and septic shock in pregnancy be considered medical emergencies and that treatment and resuscitation begin immediately (Best Practice); (3) we recommend that hospitals and health systems use a performance improvement program for sepsis in pregnancy with sepsis screening tools and metrics (GRADE 1B); (4) we recommend that institutions develop their own procedures and protocols for the detection of maternal sepsis, avoiding the use of a single screening tool alone (GRADE 1B); (5) we recommend obtaining tests to evaluate for infectious and noninfectious causes of life-threatening organ dysfunction in pregnant and postpartum patients with possible sepsis (Best Practice); (6) we recommend that an evaluation for infectious causes in pregnant or postpartum patients in whom sepsis is suspected or identified includes appropriate microbiologic cultures, including blood, before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics (Best Practice); (7) we recommend obtaining a serum lactate level in pregnant or postpartum patients in whom sepsis is suspected or identified (GRADE 1B); (8) in pregnant or postpartum patients with septic shock or a high likelihood of sepsis, we recommend administration of empiric broad-spectrum antimicrobial therapy, ideally within 1 hour of recognition (GRADE 1C); (9) after a diagnosis of sepsis in pregnancy is made, we recommend rapid identification or exclusion of an anatomic source of infection and emergency source control when indicated (Best Practice); (10) we recommend early intravenous administration (within the first 3 hours) of 1 to 2 L of balanced crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (11) we recommend the use of a balanced crystalloid solution as a first-line fluid for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1B); (12) we recommend against the use of starches or gelatin for resuscitation in pregnant and postpartum patients with sepsis or septic shock (GRADE 1A); (13) we recommend ongoing, detailed evaluation of the patient's response to fluid resuscitation guided by dynamic measures of preload (GRADE 1B); (14) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period with septic shock (GRADE 1C); (15) we suggest using intravenous corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B); (16) because of an increased risk of venous thromboembolism in sepsis and septic shock, we recommend the use of pharmacologic venous thromboembolism prophylaxis in pregnant and postpartum patients in septic shock (GRADE 1B); (17) we suggest initiating insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis (GRADE 2C); (18) if a uterine source for sepsis is suspected or confirmed, we recommend prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age (GRADE 1C); and (19) because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, we recommend ongoing comprehensive support for pregnant and postpartum sepsis survivors and their families (Best Practice)., (Copyright © 2023. Published by Elsevier Inc.)
- Published
- 2023
- Full Text
- View/download PDF
21. Pregnancy outcomes in patients with suspected SARS-CoV-2 infection before delivery.
- Author
-
Berry M, Wang AM, Moutos CP, Younes L, Meilchen C, Pacheco LD, Saade GR, and Saad AF
- Subjects
- Pregnancy, Female, Humans, Pregnancy Outcome epidemiology, SARS-CoV-2, COVID-19 diagnosis, COVID-19 epidemiology, Pregnancy Complications, Infectious diagnosis, Pregnancy Complications, Infectious epidemiology, Pregnancy Complications, Infectious prevention & control, Premature Birth
- Published
- 2023
- Full Text
- View/download PDF
22. Tranexamic acid for the prevention of postpartum bleeding: Protocol for a systematic review and individual patient data meta-analysis.
- Author
-
Ker K, Shakur-Still H, Sentilhes L, Pacheco LD, Saade G, Deneux-Tharaux C, Brenner A, Mansukhani R, Ageron FX, Prowse D, Chaudhri R, Olayemi O, and Roberts I
- Abstract
Background: Tranexamic acid (TXA) reduces the risk of death and is recommended as a treatment for women with severe postpartum bleeding. There is hope that giving TXA shortly before or immediately after birth could prevent postpartum bleeding. Extending the use of TXA to prevent harmful postpartum bleeding could improve outcomes for millions of women; however we must carefully consider the balance of benefits and potential harms. This article describes the protocol for a systematic review and individual patient data (IPD) meta-analysis to assess the effectiveness and safety of TXA for preventing postpartum bleeding in all women giving birth, and to explore how the effects vary by underlying risk and other patient characteristics. Methods: We will search for prospectively registered, randomised controlled trials involving 500 patients or more assessing the effects of TXA in women giving birth. Two authors will extract data and assess risk of bias. IPD data will be sought from eligible trials. Primary outcomes will be life-threatening bleeding and thromboembolic events. We will use a one-stage model to analyse the data. Subgroup analyses will be conducted to explore whether the effectiveness and safety of TXA varies by underlying risk, type birth, maternal haemoglobin (Hb), and timing of TXA. This protocol is registered on PROSPERO (CRD42022345775). Conclusions: This systematic review and IPD meta-analysis will address important clinical questions about the effectiveness and safety of the use of TXA for the prevention of postpartum bleeding that cannot be answered reliably using aggregate data and will inform the decision of who to treat. PROSPERO registration: CRD42022345775 Keywords Anti-fibrinolytics; Tranexamic acid; childbirth; postpartum haemorrhage; meta-analysis., Competing Interests: Competing interests: LS reports receiving lecture and consulting fees from Ferring. No competing interests were disclosed for any other author., (Copyright: © 2023 The Anti-fibrinolytics Trialists Collaborators – Obstetric Trialists Group et al.)
- Published
- 2023
- Full Text
- View/download PDF
23. Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery.
- Author
-
Pacheco LD, Clifton RG, Saade GR, Weiner SJ, Parry S, Thorp JM Jr, Longo M, Salazar A, Dalton W, Tita ATN, Gyamfi-Bannerman C, Chauhan SP, Metz TD, Rood K, Rouse DJ, Bailit JL, Grobman WA, Simhan HN, and Macones GA
- Subjects
- Child, Female, Humans, Pregnancy, Blood Loss, Surgical mortality, Blood Loss, Surgical prevention & control, Hemoglobins analysis, Maternal Death, Blood Transfusion, Chemoprevention, Antifibrinolytic Agents adverse effects, Antifibrinolytic Agents therapeutic use, Tranexamic Acid adverse effects, Tranexamic Acid therapeutic use, Postpartum Hemorrhage blood, Postpartum Hemorrhage etiology, Postpartum Hemorrhage mortality, Postpartum Hemorrhage prevention & control, Cesarean Section adverse effects
- Abstract
Background: Prophylactic use of tranexamic acid at the time of cesarean delivery has been shown to decrease the calculated blood loss, but the effect on the need for blood transfusions is unclear., Methods: We randomly assigned patients undergoing cesarean delivery at 31 U.S. hospitals to receive either tranexamic acid or placebo after umbilical-cord clamping. The primary outcome was a composite of maternal death or blood transfusion by hospital discharge or 7 days post partum, whichever came first. Key secondary outcomes were estimated intraoperative blood loss of more than 1 liter (prespecified as a major secondary outcome), interventions for bleeding and related complications, the preoperative-to-postoperative change in the hemoglobin level, and postpartum infectious complications. Adverse events were assessed., Results: A total of 11,000 participants underwent randomization (5529 to the tranexamic acid group and 5471 to the placebo group); scheduled cesarean delivery accounted for 50.1% and 49.2% of the deliveries in the respective groups. A primary-outcome event occurred in 201 of 5525 participants (3.6%) in the tranexamic acid group and in 233 of 5470 (4.3%) in the placebo group (adjusted relative risk, 0.89; 95.26% confidence interval [CI], 0.74 to 1.07; P = 0.19). Estimated intraoperative blood loss of more than 1 liter occurred in 7.3% of the participants in the tranexamic acid group and in 8.0% of those in the placebo group (relative risk, 0.91; 95% CI, 0.79 to 1.05). Interventions for bleeding complications occurred in 16.1% of the participants in the tranexamic acid group and in 18.0% of those in the placebo group (relative risk, 0.90; 95% CI, 0.82 to 0.97); the change in the hemoglobin level was -1.8 g per deciliter and -1.9 g per deciliter, respectively (mean difference, -0.1 g per deciliter; 95% CI, -0.2 to -0.1); and postpartum infectious complications occurred in 3.2% and 2.5% of the participants, respectively (relative risk, 1.28; 95% CI, 1.02 to 1.61). The frequencies of thromboembolic events and other adverse events were similar in the two groups., Conclusions: Prophylactic use of tranexamic acid during cesarean delivery did not lead to a significantly lower risk of a composite outcome of maternal death or blood transfusion than placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT03364491.)., (Copyright © 2023 Massachusetts Medical Society.)
- Published
- 2023
- Full Text
- View/download PDF
24. Von Willebrand Disease, Hemophilia, and Other Inherited Bleeding Disorders in Pregnancy.
- Author
-
Pacheco LD, Saade GR, and James AH
- Subjects
- Infant, Newborn, Pregnancy, Female, Humans, Male, Child, Hemorrhage etiology, Parturition, von Willebrand Factor, von Willebrand Diseases complications, von Willebrand Diseases diagnosis, von Willebrand Diseases genetics, Hemophilia A complications, Hemophilia A diagnosis, Hemophilia A genetics, Hemostatics
- Abstract
Inherited bleeding disorders, which comprise von Willebrand disease (VWD), hemophilia, other congenital clotting factor deficiencies, inherited platelet disorders, defects of fibrinolysis, and connective tissue disorders, have both maternal and fetal implications. Although mild platelet defects may actually be more prevalent, the most common diagnosed bleeding disorder among women is VWD. Other bleeding disorders, including hemophilia carriership, are much less common, but hemophilia carriers are unique in that they are at risk of giving birth to a severely affected male neonate. General guidance for maternal management of inherited bleeding disorders includes obtaining clotting factor levels in the third trimester, planning for delivery at a center with hemostasis expertise if factor levels do not meet the minimum threshold (eg, less than 0.50 international units/1 mL [50%] for von Willebrand factor, factor VIII, or factor IX), and using hemostatic agents such as factor concentrates, desmopressin, or tranexamic acid. General guidance for fetal management includes prepregnancy counseling, the option of preimplantation genetic testing for hemophilia, and consideration of delivery of potentially affected male neonates with hemophilia by cesarean delivery to reduce the risk of neonatal intracranial hemorrhage. In addition, delivery of possibly affected neonates should occur in a facility where there is newborn intensive care and pediatric hemostasis expertise. For patients with other inherited bleeding disorders, unless a severely affected neonate is anticipated, mode of delivery should be dictated by obstetric indications. Nonetheless, invasive procedures such as fetal scalp clip or operative vaginal delivery should be avoided, if possible, in any fetus potentially affected with a bleeding disorder., Competing Interests: Financial Disclosure Andra H. James disclosed that money was paid to her institution from Coagulant Therapeutics, Cerus, and Octapharma. Dr. James received payment from Tremeau. The other authors did not report any potential conflicts of interest., (Copyright © 2023 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)
- Published
- 2023
- Full Text
- View/download PDF
25. Extracorporeal Membrane Oxygenation During Pregnancy.
- Author
-
Pacheco LD and Shamshirsaz AA
- Subjects
- Female, Humans, Pregnancy, COVID-19 epidemiology, COVID-19 therapy, Pandemics, Respiration, Artificial, Treatment Failure, Respiratory Distress Syndrome therapy, Extracorporeal Membrane Oxygenation methods, Extracorporeal Membrane Oxygenation statistics & numerical data
- Abstract
In the last 2 decades, the use of venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) during pregnancy and the postpartum period has increased, mirroring the increased utilization in nonpregnant individuals worldwide. VV ECMO provides respiratory support for patients with acute respiratory distress syndrome (ARDS) who fail conventional mechanical ventilation. With the COVID-19 pandemic, the use of VV ECMO has increased dramatically and data during pregnancy and the postpartum period are overall reassuring. In contrast, VA ECMO provides both respiratory and cardiovascular support. Data on the use of VA ECMO during pregnancy are extremely limited., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)
- Published
- 2023
- Full Text
- View/download PDF
26. Foreword: Critical Care Obstetrics.
- Author
-
Pacheco LD
- Subjects
- Female, Pregnancy, Humans, Critical Care, Obstetrics, Gynecology
- Published
- 2023
- Full Text
- View/download PDF
27. Treatment of Arrhythmias During Pregnancy.
- Author
-
Pacheco LD, Eyada M, and Saade GR
- Subjects
- Pregnancy, Female, Humans, Prenatal Care, Perinatology, Fetus, Arrhythmias, Cardiac diagnosis, Arrhythmias, Cardiac therapy, Anti-Arrhythmia Agents therapeutic use
- Abstract
Cardiac disease is the most common cause of maternal mortality in developed nations. Cardiac arrhythmias are frequent among patients with structural heart disease and may require immediate treatment to prevent hemodynamic instability leading to acute maternal and fetal decompensation. Antiarrhythmic therapy during pregnancy should follow the same principles recommended for nonpregnant individuals. Although multidisciplinary management is recommended, obstetricians, and maternal-fetal medicine specialists may sometimes need to emergently recognize and treat rhythm anomalies before support services become available., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)
- Published
- 2023
- Full Text
- View/download PDF
28. Emerging technology for early detection and management of postpartum hemorrhage to prevent morbidity.
- Author
-
Lord MG, Calderon JA, Ahmadzia HK, and Pacheco LD
- Subjects
- Pregnancy, Female, Humans, United States epidemiology, Blood Transfusion methods, Morbidity, Maternal Mortality, Postpartum Hemorrhage diagnosis, Postpartum Hemorrhage epidemiology, Postpartum Hemorrhage etiology, Maternal Death
- Abstract
Despite advances in hemorrhage detection and management, postpartum hemorrhage remains the single leading cause of maternal death worldwide. Within the United States, hemorrhage is the leading cause of maternal death on the day of delivery and within the first week after delivery. Blood transfusion after hemorrhage represents a large proportion of severe maternal morbidity during and after delivery. Blood loss during delivery has historically been assessed visually by inspecting soiled pads, linens, and laparotomy sponges. These methods underestimate the volume of blood loss by as much as 40%, becoming increasingly inaccurate as blood loss increases. Young, healthy obstetrical patients compensate for blood loss via peripheral vasoconstriction, maintaining heart rate and blood pressure in a normal range until over 1 L of blood has been lost. A significant decrease in blood pressure along with marked tachycardia (>120 bpm) may not be seen until 30% to 40% of blood volume has been lost, or 2.0 to 2.6 L in a healthy term pregnant patient, after which the patient may rapidly decompensate. In resource-poor settings especially, the narrow window between the emergence of significant vital sign abnormalities and clinical decompensation may prove catastrophic. Once hemorrhage is detected, decisions regarding blood product transfusion are routinely made on the basis of inaccurate estimates of blood loss, placing patients at risk of underresuscitation (increasing the risk of hemorrhagic shock and end-organ damage) or overresuscitation (increasing the risk of transfusion reaction, fluid overload, and alloimmunization). We will review novel technologies that have emerged to assist both in the early and accurate detection of postpartum hemorrhage and in decisions regarding blood product transfusion., (Published by Elsevier Inc.)
- Published
- 2023
- Full Text
- View/download PDF
29. Intrahepatic Cholestasis of Pregnancy: Toward Improving Perinatal Outcome.
- Author
-
Saad AF, Pacheco LD, Chappell L, and Saade GR
- Subjects
- Pregnancy, Infant, Newborn, Female, Humans, Bile Acids and Salts, Ursodeoxycholic Acid therapeutic use, Pregnancy Outcome, Cholestasis, Intrahepatic diagnosis, Cholestasis, Intrahepatic drug therapy, Pregnancy Complications diagnosis, Pregnancy Complications drug therapy
- Abstract
Intrahepatic cholestasis of pregnancy (ICP) is associated with poor perinatal outcomes in some women such as preterm delivery and fetal demise. Ursodeoxycholic acid (UDCA) is the main therapeutic agent for ICP, but recent evidence failed to show an impact on most perinatal outcomes. Our objective is to summarize the latest evidence in the management of ICP, with a focus on perinatal outcome. We propose a practical approach that combines pharmacotherapy with biochemical and fetal testing, as well as delivery planning., (© 2021. Society for Reproductive Investigation.)
- Published
- 2022
- Full Text
- View/download PDF
30. Septic Shock and Cardiac Arrest in Obstetrics: A Practical Simplified Clinical View.
- Author
-
Pacheco LD, Shepherd MC, and Saade GS
- Subjects
- Female, Humans, Pregnancy, Heart Arrest therapy, Obstetrics, Shock, Septic diagnosis, Shock, Septic therapy
- Abstract
Septic shock and cardiac arrest during pregnancy, despite being uncommon, carry a high mortality rate among pregnant individuals. Basic initial management strategies are fundamental to improve clinical outcomes; obstetricians and maternal-fetal medicine specialists need to be familiar with such interventions., (Copyright © 2022 Elsevier Inc. All rights reserved.)
- Published
- 2022
- Full Text
- View/download PDF
31. Society for Maternal-Fetal Medicine Consult Series #61: Anticoagulation in pregnant patients with cardiac disease.
- Author
-
Pacheco LD, Saade G, Shrivastava V, Shree R, and Elkayam U
- Subjects
- Anticoagulants therapeutic use, Arrhythmias, Cardiac, Female, Humans, Perinatology, Pregnancy, Pregnancy Complications, Cardiovascular chemically induced, Pregnancy Complications, Cardiovascular drug therapy, Pregnancy Complications, Cardiovascular prevention & control, Thromboembolism prevention & control
- Abstract
Pregnancy in individuals with a mechanical heart valve has been classified as very high risk because of a substantially increased risk of maternal mortality or severe morbidity. Lifelong therapeutic anticoagulation is a principal component of the medical management of mechanical heart valves to prevent valve thrombosis. Anticoagulation regimens indicated outside of pregnancy for patients with mechanical valves should be continued during pregnancy with the possibility of modifications based on the type of valve, the trimester of pregnancy, individual risk tolerance, and circumstances around the time of delivery. The purpose of this document is to provide recommendations regarding the management of anticoagulation for common cardiac conditions complicating pregnancy, including mechanical heart valves, atrial fibrillation, systolic heart failure, and congenital heart disease., (Copyright © 2022. Published by Elsevier Inc.)
- Published
- 2022
- Full Text
- View/download PDF
32. The Golden Hour: Early Interventions for Medical Emergencies during Pregnancy.
- Author
-
Pacheco LD, Lozada MJ, and Saade GR
- Subjects
- Female, Humans, Pregnancy, United States, Emergencies, Maternal Mortality
- Abstract
Maternal mortality has increased in the last decades in the United States as a result of increased prevalence of coexisting medical diseases such as hypertension, diabetes, and both acquired and congenital heart diseases. Obstetricians and maternal-fetal medicine physicians should have the basic medical knowledge to initiate appropriate diagnostic and early therapeutic interventions since they may be the only provider available at the time of presentation. The goal of this article is not to extensively discuss the management of complex medical diseases during pregnancy, rather we provide a concise review of key early medical interventions that will likely result in improved clinical outcomes. KEY POINTS: · Obstetricians and maternal-fetal medicine physicians must be familiar with initial basic management of common medical emergencies.. · Management of these complex cases is ideally multidisciplinary.. · Residency/fellowship programs should include common disease management to improve maternal outcomes.., Competing Interests: None declared., (Thieme. All rights reserved.)
- Published
- 2022
- Full Text
- View/download PDF
33. Association of the Delta (B.1.617.2) Variant of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) With Pregnancy Outcomes.
- Author
-
Wang AM, Berry M, Moutos CP, Omere C, Clark SM, Harirah HM, Jain S, Olson GL, Pacheco LD, Saade GR, and Saad AF
- Subjects
- Adolescent, Adult, Cohort Studies, Female, Humans, Pregnancy, Pregnancy Outcome, Retrospective Studies, Young Adult, COVID-19 virology, Pregnancy Complications, Infectious virology, SARS-CoV-2
- Abstract
Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest.
- Published
- 2021
- Full Text
- View/download PDF
34. Coagulation assessment with viscoelastic testing in asymptomatic postpartum patients with SARS-CoV-2 infection: a pilot study.
- Author
-
Pacheco LD, Berry M, Saad AF, Yates SG, and Saade GR
- Subjects
- Blood Viscosity, Cohort Studies, Female, Humans, Pilot Projects, Postpartum Period, Pregnancy, Asymptomatic Infections, Blood Coagulation, COVID-19 blood, Pregnancy Complications, Infectious blood, SARS-CoV-2
- Published
- 2021
- Full Text
- View/download PDF
35. A Practical Approach to Antibiotic Use in Critically Ill Obstetric Patients.
- Author
-
Pacheco LD, Saad AF, and Saade GR
- Subjects
- Female, Humans, Pregnancy, Anti-Bacterial Agents therapeutic use, Critical Illness, Pregnancy Complications, Infectious drug therapy, Prenatal Care, Sepsis drug therapy
- Abstract
In recent years, several new antimicrobials have become available that are safer and more effective compared with older agents commonly used in obstetrics. Basic knowledge of these agents is of paramount importance to obstetricians and maternal fetal medicine specialists, as administration of early adequate broad-spectrum empiric antibiotic coverage plays a pivotal role in the management of septic patients. Of particular importance is the critically ill pregnant patient with life-threatening infectious processes in whom poor initial antibiotic selection may result in higher mortality and significant side effects from antibiotics themselves. In this article we aim to provide a guide for clinicians to select an adequate empirical antibiotic regimen for the most common severe infections that may affect pregnant individuals., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)
- Published
- 2021
- Full Text
- View/download PDF
36. Clinical Stratification of Pregnant COVID-19 Patients based on Severity: A Single Academic Center Experience.
- Author
-
Berry M, Wang A, Clark SM, Harirah HM, Jain S, Olson GL, Pacheco LD, Saade GR, and Saad AF
- Subjects
- Adolescent, Adult, Body Mass Index, Female, Gestational Age, Humans, Oxygen Inhalation Therapy, Pregnancy, Pregnancy Trimester, Third, Retrospective Studies, Risk Factors, SARS-CoV-2 isolation & purification, Young Adult, Asymptomatic Diseases, COVID-19 therapy, Patient Acuity, Pregnancy Complications, Infectious therapy, Pregnancy Outcome
- Abstract
Objective: This study aimed to describe baseline characteristics of a cohort of pregnant women infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and determine if these correlate with disease severity and perinatal outcomes., Study Design: This was a retrospective cohort trial conducted at the University of Texas Medical Branch Galveston, Texas. All pregnant women presented to our medical center, who were screened and tested positive for SARS-CoV-2 virus, were included. We stratified our study population in three groups: asymptomatic, symptomatic not requiring oxygen therapy, and patients requiring oxygen support to maintain oxygen saturation >94%. Relevant population characteristics, laboratory data, and maternal and neonatal outcomes were abstracted. A p -value <0.05 was considered statistically significant., Results: Between March and July 2020, 91 women tested positive for SARS-CoV-2 upon admission to our labor and delivery unit. Among these, 61.5% were asymptomatic, 34.1% were symptomatic, and 4.4% required oxygen support. Our population was mainly Hispanic (80.2%), multiparous (76.9%), obese (70.3%), and with a median age of 27 years. Median gestational age at symptom onset or diagnosis was 36 weeks. Significant differences were found between gestational age and disease severity. Maternal characteristics including age, body mass index (BMI), and presence of comorbid conditions did not appear to influence severity of SARS-CoV-2 infection. Significant laboratory findings associated with increasing disease severity included decreasing hemoglobin and white blood cell count, lymphopenia, and increasing levels of inflammatory markers including CRP, ferritin, and procalcitonin. Maternal and neonatal outcomes did not differ among groups. No SARS-CoV-2 was detected by polymerase chain reaction testing in neonates of mothers with COVID-19., Conclusion: Pregnant patients with COVID-19 infection are predominantly asymptomatic. Patients appear to be at increased risk for more severe infection requiring oxygen support later in pregnancy., Key Points: · The majority of pregnant patients with COVID-19 are asymptomatic and <1 in 20 require oxygen support.. · Women in the later stages of pregnancy may be at increased risk for severe infection.. · Anemia, leukopenia, CRP, ferritin, and procalcitonin are associated with increasing severity.., Competing Interests: None declared., (Thieme. All rights reserved.)
- Published
- 2021
- Full Text
- View/download PDF
37. In Reply.
- Author
-
Saad AF, Chappell L, Saade GR, and Pacheco LD
- Subjects
- Adrenal Cortex Hormones, Female, Humans, Pregnancy, SARS-CoV-2, COVID-19, Coronavirus
- Abstract
Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest.
- Published
- 2021
- Full Text
- View/download PDF
38. Corticosteroids in the Management of Pregnant Patients With Coronavirus Disease (COVID-19).
- Author
-
Saad AF, Chappell L, Saade GR, and Pacheco LD
- Subjects
- Betacoronavirus isolation & purification, COVID-19, Drug Monitoring methods, Female, Fetal Organ Maturity drug effects, Humans, Infant, Newborn, Oxygen Inhalation Therapy methods, Pregnancy, Respiration, Artificial methods, Risk Assessment, SARS-CoV-2, Coronavirus Infections epidemiology, Coronavirus Infections therapy, Critical Care methods, Glucocorticoids classification, Glucocorticoids pharmacology, Medication Therapy Management standards, Pandemics, Pneumonia, Viral epidemiology, Pneumonia, Viral therapy, Pregnancy Complications, Infectious epidemiology, Pregnancy Complications, Infectious therapy, Pregnancy Complications, Infectious virology
- Abstract
Recent evidence supports the use of an early, short course of glucocorticoids in patients with COVID-19 who require mechanical ventilation or oxygen support. As the number of coronavirus disease 2019 (COVID-19) cases continues to increase, the number of pregnant women with the disease is very likely to increase as well. Because pregnant women are at increased risk for hospitalization, intensive care unit admission, and mechanical ventilation support, obstetricians will be facing the dilemma of initiating maternal corticosteroid therapy while weighing its potential adverse effects on the fetus (or neonate if the patient is postpartum and breastfeeding). Our objective is to summarize the current evidence supporting steroid therapy in the management of patients with acute respiratory distress syndrome and COVID-19 and to elaborate on key modifications for the pregnant patient.
- Published
- 2020
- Full Text
- View/download PDF
39. Intra-abdominal pressure as an ignored parameter in the pathophysiology of preeclampsia.
- Author
-
Gyselaers W, Lozada MJ, Pacheco LD, Tayebi S, and Malbrain MLNG
- Subjects
- Female, Humans, Pregnancy, Pre-Eclampsia
- Published
- 2020
- Full Text
- View/download PDF
40. Society for Maternal-Fetal Medicine Consult Series #51: Thromboembolism prophylaxis for cesarean delivery.
- Author
-
Pacheco LD, Saade G, and Metz TD
- Subjects
- Anticoagulants therapeutic use, Female, Fibrinolytic Agents therapeutic use, Heparin therapeutic use, Humans, Postoperative Complications etiology, Postoperative Complications prevention & control, Pregnancy, Venous Thromboembolism etiology, Cesarean Section adverse effects, Venous Thromboembolism prevention & control
- Abstract
Venous thromboembolism is a major cause of maternal morbidity and mortality. The risk of venous thromboembolism is particularly elevated during the postpartum period and especially after cesarean delivery. There is considerable variation in the approach to prophylaxis of venous thromboembolism in pregnancy, including after cesarean delivery. This Consult discusses the different guidelines on prophylaxis of venous thromboembolism after cesarean delivery and provides recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend that all women who undergo cesarean delivery receive sequential compression devices starting before surgery and that the compression devices be used continuously until the patient is fully ambulatory (GRADE 1C); (2) we suggest that women with a previous personal history of deep venous thrombosis or pulmonary embolism who undergo cesarean delivery receive both mechanical (starting preoperatively and continuing until ambulatory) and pharmacologic (for 6 weeks postoperatively) prophylaxis (GRADE 2C); (3) we suggest that women with a personal history of an inherited thrombophilia (high-risk or low-risk) but no previous thrombosis who undergo cesarean delivery receive both mechanical (starting preoperatively and continuing until ambulatory) and pharmacologic (for 6 weeks postoperatively) prophylaxis (GRADE 2C); (4) we recommend the use of low-molecular-weight heparin as the preferred thromboprophylactic agent in pregnancy and the postpartum period (GRADE 1C); (5) when pharmacologic thromboprophylaxis is needed in pregnant women with class III obesity, we suggest the use of intermediate doses of enoxaparin (GRADE 2C); and (6) we recommend that each institution develop a patient safety bundle with an institutional protocol for venous thromboembolism prophylaxis among women who undergo cesarean delivery (Best Practice)., (Copyright © 2020. Published by Elsevier Inc.)
- Published
- 2020
- Full Text
- View/download PDF
41. Early Acute Respiratory Support for Pregnant Patients With Coronavirus Disease 2019 (COVID-19) Infection.
- Author
-
Pacheco LD, Saad AF, and Saade G
- Subjects
- COVID-19, Coronavirus Infections virology, Female, Humans, Pandemics, Pneumonia, Viral virology, Pregnancy, Pregnancy Complications, Infectious virology, SARS-CoV-2, Betacoronavirus, Coronavirus Infections therapy, Pneumonia, Viral therapy, Pregnancy Complications, Infectious therapy, Prenatal Care methods, Respiratory Therapy methods
- Abstract
The present coronavirus disease 2019 (COVID-19) pandemic is affecting pregnant patients worldwide. Although it appears that the severity of disease is reduced in pregnant patients, some are likely to develop severe disease. Our objective is to summarize the basic initial respiratory support interventions recommended for pregnant patients with infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
- Published
- 2020
- Full Text
- View/download PDF
42. The Carit Maneuver: A Novel Approach for the Relief of Shoulder Dystocia-A Case Series.
- Author
-
Gei AF, Mastache JS, Pacheco LD, and Villanueva M
- Abstract
Objective The main purpose of this article is to describe the technique and mechanism of action of a novel intervention for the relief of shoulder dystocia we are labeling Carit maneuver. Methods We report a cohort study of eight cases of shoulder dystocia not relieved by the combination of McRobert's maneuver and suprapubic pressure treated with the Carit maneuver. This intervention involves the use of the fetal head and neck as the grasping point of the fetus to exert a ventral rotation of the fetal trunk, reduce the bi-acromial diameter, and deliver the posterior shoulder by passive displacement. In all these cases, the direction of the original head restitution, direction of exerted rotation, and side and location of delivery of the first shoulder were recorded. Maternal and neonatal outcomes were reviewed and reported. Results In all cases, the Carit rotational maneuver resulted in the delivery of the posterior shoulder in the transverse (4), oblique anterior (2), or direct anterior (2) diameters. No instances of neonatal depression or fetal acidemia were noted in this cohort. Conclusion The Carit maneuver is an original and successful intervention in the management of shoulder dystocia unresponsive to McRobert's maneuver and suprapubic pressure., Competing Interests: Conflict of Interest None.
- Published
- 2020
- Full Text
- View/download PDF
43. Lower Extremity Blood Flow Velocity in Obese versus Nonobese Pregnant Women.
- Author
-
Dutta EH, Burns RN, Pacheco LD, Marrs CC, Koutrouvelis A, and Koutrouvelis GLO
- Subjects
- Adult, Blood Volume, Case-Control Studies, Chi-Square Distribution, Female, Humans, Lower Extremity diagnostic imaging, Obesity, Maternal complications, Pregnancy, Prospective Studies, Statistics, Nonparametric, Ultrasonography, Doppler, Duplex, Venous Insufficiency etiology, Venous Thromboembolism etiology, Young Adult, Blood Flow Velocity, Lower Extremity blood supply, Obesity, Maternal physiopathology
- Abstract
Objective: Obesity and pregnancy are risk factors for venous thromboembolism (VTE). In nonpregnant individuals, abdominal obesity is associated with venous insufficiency. This study aimed to compare venous Doppler volume flow and velocity in the lower extremities of obese versus nonobese women., Study Design: A prospective cohort study was performed. Duplex ultrasound examined bilateral lower extremity venous flow and velocity (time-averaged mean velocity, TAMV). Flow was analyzed at the superficial femoral (SFV), distal external iliac (DEI), common femoral, profunda femoris, and popliteal veins. Mann-Whitney U -test, Spearman's correlation, and chi-square tests were used, with a significance of p < 0.05., Results: Left SFV TAMV and volume flow were higher in the obese group (5.1 [4.1-5.7] vs. 2.8 [1.7-3.4] cm/second; p < 0.001) and (89 [73-119] vs. 48 [26-62] cm/minute; p = 0.005). Significant differences were noted for right DEI flow (obese 326 [221-833] vs. nonobese 182 [104-355] cm/minute; p = 0.049). The right femoral profunda flow was also higher in obese (49 [40-93] cm/minute) compared with nonobese (31 [22-52] cm/minute; p = 0.041)., Conclusion: Volume flow and TAMV in the lower extremities of obese gravidas are higher compared with nonobese ones. Thus, the increased risk of VTE among obese pregnant women may not be caused by venous stasis., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)
- Published
- 2020
- Full Text
- View/download PDF
44. Aspiration Pneumonitis Causing Respiratory Collapse in a Pregnant Patient Not in Labor.
- Author
-
Lozada MJ, Goyal VK, Kiczek MP, and Pacheco LD
- Subjects
- Female, Humans, Pregnancy, Labor, Obstetric, Pneumonia, Aspiration, Shock
- Published
- 2020
- Full Text
- View/download PDF
45. Zika Virus Infection - After the Pandemic.
- Author
-
Pacheco LD, Weaver SC, and Saade GR
- Subjects
- Female, Humans, Pandemics, Pregnancy, Pregnancy Complications, Infectious epidemiology, Zika Virus, Zika Virus Infection epidemiology
- Published
- 2020
- Full Text
- View/download PDF
46. Amniotic fluid embolism: principles of early clinical management.
- Author
-
Pacheco LD, Clark SL, Klassen M, and Hankins GDV
- Subjects
- Blood Coagulation Disorders etiology, Echocardiography, Embolism, Amniotic Fluid diagnostic imaging, Erythrocyte Transfusion, Factor VIII therapeutic use, Female, Fibrinogen therapeutic use, Heart Arrest etiology, Heart Failure diagnosis, Heart Failure etiology, Heart Failure therapy, Humans, Hypertension, Pulmonary diagnosis, Hypertension, Pulmonary etiology, Hypertension, Pulmonary therapy, Plasma, Platelet Transfusion, Pregnancy, Vasoconstrictor Agents therapeutic use, Blood Coagulation Disorders therapy, Blood Component Transfusion, Cardiopulmonary Resuscitation methods, Embolism, Amniotic Fluid therapy, Extracorporeal Membrane Oxygenation methods, Heart Arrest therapy
- Abstract
Amniotic fluid embolism is an uncommon, but potentially lethal, complication of pregnancy. Because amniotic fluid embolism usually is seen with cardiac arrest, the initial immediate response should be to provide high-quality cardiopulmonary resuscitation. We describe key features of initial treatment of patients with amniotic fluid embolism. Where available, we recommend performing transthoracic or transesophageal echocardiography as soon as possible because this is an easy and reliable method of identifying a failing right ventricle. If such failure is identified, treatment that is tailored at improving right ventricular performance should be initiated with the use of inotropic agents and pulmonary vasodilators. Blood pressure support with vasopressors is preferred over fluid infusion in the setting of severe right ventricular compromise. Amniotic fluid embolism-related coagulopathy should be managed with hemostatic resuscitation with the use of a 1:1:1 ratio of packed red cells, fresh frozen plasma, and platelets (with cryoprecipitate as needed to maintain a serum fibrinogen of >150-200 mg/dL). In cases that require prolonged cardiopulmonary resuscitation or, after arrest, severe ventricular dysfunction refractory to medical management, consideration for venoarterial extracorporeal membrane oxygenation should be given., (Copyright © 2019 Elsevier Inc. All rights reserved.)
- Published
- 2020
- Full Text
- View/download PDF
47. The Effect of Distraction during Labor Induction on Timing of Analgesia Request: A Randomized Clinical Trial.
- Author
-
Dixon CL, Monsivais L, Chamseddine P, Olson G, Pacheco LD, Saade GR, and Costantine MM
- Subjects
- Adult, Analgesia, Epidural, Analgesics, Opioid therapeutic use, Female, Humans, Kaplan-Meier Estimate, Pain drug therapy, Pain etiology, Pain Measurement, Patient Satisfaction, Pregnancy, Statistics, Nonparametric, Time Factors, Young Adult, Analgesia, Obstetrical, Labor, Induced adverse effects, Music, Pain prevention & control, Video Games
- Abstract
Objective: To assess whether distraction using music and/or video games influences timing of analgesia request and improves pain outcomes in women undergoing labor induction., Study Design: A total of 219 pregnant women with singleton gestation undergoing labor induction with a Foley bulb (FB) at term were randomized to distraction with music and video games via iPod ( n = 109) or no iPod ( n = 110). The primary outcome was the time from FB placement to request for pain medication. Secondary outcomes included number of patients requesting pain medication within 6 and 12 hours, type of pain medication received, pain visual analog scale scores, and patient satisfaction. Mann-Whitney's, chi-square, Kaplan-Meier's curves, and Pearson's product moment correlation were used for statistical analysis (significance: p < 0.05)., Results: Baseline characteristics were similar between the two groups. There was no difference in the time from FB placement until pain medication request between the groups. There were no significant differences in secondary outcomes. Increased per cent time of iPod use correlated with a longer time until pain medication request ( R
2 = 0.22, p = 0.03)., Conclusion: We were not able to show that distraction using music and video games delays timing of analgesia request or improve pain outcomes in pregnant women undergoing mechanical labor induction at term., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)- Published
- 2019
- Full Text
- View/download PDF
48. Management of peripartum intra-abdominal hypertension and abdominal compartment syndrome.
- Author
-
Lozada MJ, Goyal V, Levin D, Walden RL, Osmundson SS, Pacheco LD, and Malbrain MLNG
- Subjects
- Adult, Compartment Syndromes diagnosis, Compartment Syndromes epidemiology, Critical Illness mortality, Critical Illness therapy, Female, Humans, Incidence, Intra-Abdominal Hypertension diagnosis, Intra-Abdominal Hypertension epidemiology, Maternal Mortality, Needs Assessment, Pregnancy, Pregnancy Complications physiopathology, Pregnancy Complications therapy, Prognosis, Risk Assessment, Treatment Outcome, Abdominal Cavity physiopathology, Compartment Syndromes therapy, Fetal Monitoring methods, Intra-Abdominal Hypertension therapy, Peripartum Period, Pregnancy Outcome
- Abstract
Normal pregnancy leads to a state of chronically increased intra-abdominal pressure. Obstetric and non-obstetric conditions may increase intra-abdominal pressure further, causing intra-abdominal hypertension and abdominal compartment syndrome, which leads to maternal organ dysfunction and a compromised fetal state. Limited medical literature exists to guide treatment of pregnant women with these conditions. In this state-of-the-art review, we propose a diagnostic and treatment algorithm for the management of peripartum intra-abdominal hypertension and abdominal compartment syndrome, informed by newly available studies., (© 2019 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)
- Published
- 2019
- Full Text
- View/download PDF
49. It's high time for intra-abdominal hypertension guidelines in pregnancy after more than 100 years of measuring pressures.
- Author
-
Lozada MJ, Goyal V, Osmundson SS, Pacheco LD, and Malbrain MLNG
- Subjects
- Female, Humans, Peripartum Period, Pregnancy, Hypertension, Intra-Abdominal Hypertension
- Published
- 2019
- Full Text
- View/download PDF
50. Performance of Risk Assessment Models for Peripartum Thromboprophylaxis.
- Author
-
Tran JP, Stribling SS, Ibezim UC, Omere C, McEnery KA, Pacheco LD, Hankins GD, Saade GR, and Saad AF
- Subjects
- Adult, Female, Humans, Peripartum Period, Pregnancy, Retrospective Studies, Risk Assessment, Risk Factors, Anticoagulants therapeutic use, Pregnancy Complications prevention & control, Venous Thromboembolism prevention & control
- Abstract
Objective: There is no consensus on which risk stratification approach to use for thromboprophylaxis in pregnancy, and most available risk assessment models (RAMs) for venous thromboembolism (VTE) events have not been validated in pregnancy. Our objective was to compare the performance of some of the most commonly used VTEs RAMs in our patient population in the peripartum period., Study Design: This is a retrospective cohort of women who delivered at our institution in 2015 and 2016. We excluded patients with history of prior or current VTEs or those already receiving anticoagulants. Antepartum, intrapartum, and postpartum records were reviewed. Data were collected on known risk factors for VTEs in order to calculate scores for 3 RAMs on admission for delivery: Padua, Caprini, and Royal College of Obstetricians and Gynaecologists (RCOG). The primary objective was to the estimate the performance of the various RAMs in preventing postpartum VTEs. We calculated the proportion of women who would have been high risk, determined the number of VTEs cases within high- and low-risk categories, as well as calculated the number needed to treat (NNT) for each RAM. We performed analyses using different RAM scores cutoffs, VTEs outcome rates, and effectiveness of anticoagulation to prevent VTEs. The P value <.05 was considered statistically significant., Results: A total of 6094 women were included. Three women had VTEs for an overall rate of 0.04% (N = 3; 95% confidence interval [CI]: 0.01-0.15). The proportion of women categorized as high risk for VTEs were 62% (95% CI: 61-64) for RCOG, 0.8% (95% CI: 0.6-1.0) for Padua, and 94% (95% CI: 94-95) for Caprini. Of the 3 VTEs, the RCOG model classified 1 woman as high risk and Padua model classified 3 women as high risk; whereas the Caprini did not identify any women as high risk. Assuming 100% effectiveness of thromboprophylaxis, the observed NNT was 3838 using RCOG, not able to calculate using Padua (no VTEs cases occurred in the high-risk group, thus none were prevented), and 1927 using Caprini., Conclusion: The rates of VTEs in pregnancy are very low and the available RAMs do not identify most of them. The RCOG and Caprini RAMs would categorize a large proportion of women as high risk and are associated with high NNTs. The Padua RAM appears to have the lowest NNT but missed all the VTEs in our cohort.
- Published
- 2019
- Full Text
- View/download PDF
Catalog
Discovery Service for Jio Institute Digital Library
For full access to our library's resources, please sign in.