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Our objective was to assess the effect of maternal intravenous immunoglobulin (IVIG) administration for severe red blood cell (RBC) alloimmunisation on fetal outcomes. This is a case-control study. Women with a history of severe early onset alloimmunisation resulting in fetal loss in a previous pregnancy and high anti-D or anti-K antibody titres received IVIG in a subsequent pregnancy. We assessed gestational age at first transfusion and fetal outcomes in the subsequent pregnancy and compared these with the outcomes in the previous pregnancy. The most responsible antibody was anti-D in 17 women and anti-K in two others, whilst seven had more than one antibody. In all, 19 women received IVIG in 22 pregnancies, two of which did not even need an intrauterine transfusion (IUT). For previous early losses despite transfusion, IVIG was associated with a relative increase in fetal haemoglobin between treated and untreated pregnancies of 36.5 g/L (95% confidence interval 19.8-53.2, p = 0.0013) and improved perinatal survival (eight of eight vs. none of six, p = 0.001). For previous losses at20 weeks, it enabled first transfusion deferral in subsequent pregnancies to at least 19.9 weeks (mean 23.2 weeks). Overall, IVIG decreases the severity of haemolytic disease of the fetus and newborn and allows deferral of the first IUT to a safer gestation in severe early-onset RBC alloimmunisation and rarely may even avoid the need for IUT entirely.

This article describes an inexpensive simulator developed for teaching intrauterine blood transfusion. The model is constructed from a boneless chicken thigh folded over a Penrose drain placed in a water-filled snap-lock lid container and covered by melted ballistic gel to simulate the fetal intrahepatic vessel. Participants valued this educational tool and reported feeling the model was practical and realistic. This low-cost, high-fidelity model provides realistic tissue resistance and represents a sonographically accurate intrahepatic fetal blood transfusion training tool.

There is little evidence evaluating angiogenic growth factor testing in real-world obstetric settings. This investigation evaluated maternal and perinatal pregnancy outcomes associated with maternal PlGF (placental growth factor) levels in real-world clinical care of high-risk pregnancies. From March 2017 to December 2019, 979 pregnant women with suspected risk of placental dysfunction, hypertensive disorders of pregnancy, or fetal growth restriction completed PlGF testing between 20+0 and 35+6 weeks of gestation. Maternal, fetal, and delivery characteristics were extracted through the electronic medical record system. The primary outcome of preterm birth was assessed using Royston-Parmar survival models and summarized with Kaplan-Meier methods. Of the 979 pregnant women, 289 had low PlGF levels (29.5%), and 690 had normal PlGF levels (70.5%). The survival probability of ongoing pregnancy free from preterm birth within 2- and 4-weeks following PlGF testing was significantly reduced in women with low PlGF levels, relative to women with normal PlGF levels (0.57 versus 0.99, standardized survival difference, −0.43 [95% CI, −0.76 to −0.09], and 0.37 versus 0.99, standardized survival difference, −0.62 [95% CI −0.87 to −0.38], respectively). Women with low PlGF levels were more likely to develop early-onset preeclampsia (adjusted odds ratio, 58.2 [95% CI, 32.1–105.4]) and have a stillbirth (adjusted odds ratio, 15.9 [95% CI, 7.6–33.3]). PlGF status distinguished placental from fetal causes of stillbirth. Low PlGF levels in high-risk pregnant women are strongly associated with increased rates of imminent preterm birth, as well as related adverse outcomes, including early-onset preeclampsia and stillbirth.

Background Attempts to reduce the current rate of antepartum stillbirth in the late third trimester have largely focused on the accurate identification of fetal growth restriction. Universal ultrasound significantly increases detection, especially when combined with maternal angiogenic growth factors, but this screening strategy is not well suited to identify umbilical cord pathology. While this poses unique challenges to pregnancy care, the recurrence risk of cord obstruction is low in comparison with many intrinsic placental diseases. Case A 30-year-old woman with normal uterine artery Doppler waveforms, fetal growth ultrasounds, and circulating placental growth factor experienced an unexpected third-trimester stillbirth. Placental pathology demonstrated fetal vascular malperfusion and cord hyper-coiling. Conclusion Despite normal placental function, the otherwise healthy fetus is at risk of antepartum stillbirth due to cord-related pathology.

OBJECTIVES To assess short- and long-term outcome in a cohort of fetuses diagnosed with hydrothorax (FHT) which underwent thoracoamniotic shunting in utero, and to examine the antenatal predictors of survival and of survival with normal neurodevelopmental outcome. METHODS This was a retrospective analysis of 132 fetuses that underwent thoracoamniotic shunting at our center between 1991 and 2014. Data were extracted from hospital obstetric and relevant neonatal intensive care and neonatal developmental follow-up databases. Outcomes included survival to discharge and survival with normal neurodevelopmental outcome beyond 18 months. Information on malformations, syndromes and genetic abnormalities were obtained from antenatal, postnatal and pediatric hospital records or by parent report. We compared pregnancy characteristics among those who survived vs non-survivors and among those with normal neurodevelopmental outcome vs those who were abnormal or died. We explored whether there was a trend in survival over the study period. RESULTS The mean gestational age at diagnosis of FHT was 25.6 weeks. The fetus was hydropic at diagnosis in 61% of cases, 69% had bilateral effusions and 55% had bilateral shunts inserted. Other diagnoses were present in 24% of cases, two-thirds of which were discovered only postnatally. There were 16 intrauterine and 30 neonatal deaths, with a 65% survival rate overall. The mean gestational age at delivery of liveborns was 35.4 (range, 26.9-41.6) weeks, and 88/116 (76%) were preterm (

Introduction: The aim of this study was to obtain expert consensus on the content of a curriculum for learning chorionic villus sampling (CVS) and amniocentesis (AC) and the items of an assessment tool to evaluate CVS and AC competence. Methods: We used a 3-round iterative Delphi process. A steering committee supervised all processes. Seven international collaborators were identified to expand the breadth of the study internationally. The collaborators invited fetal medicine experts to participate as panelists. In the first round, the panelists suggested content for a CVS/AC curriculum and an assessment tool. The steering committee organized and condensed the suggested items and presented them to the panelists in round 2. In the second round, the panelists rated and commented on the suggested items. The results were processed by the steering committee and presented to the panelists in the third round, where final consensus was obtained. Consensus was defined as support by more than 80% of the panelists for an item. Results: Eighty-six experts agreed to participate in the study. The panelists represented 16 countries across 4 continents. The final list of curricular content included 12 theoretical and practical items. The final assessment tool included 11 items, systematically divided into 5 categories: pre-procedure, procedure, post-procedure, nontechnical skills, and overall performance. These items were provided with behavioral scale anchors to rate performance, and an entrustment scale was used for the final overall assessment. Conclusion: We established consensus among international fetal medicine experts on content to be included in a CVS/AC curriculum and on an assessment tool to evaluate CVS/AC skills. These results are important to help transition current training and assessment methods from a time- and volume-based approach to a competency-based approach which is a key step in improving patient safety and outcomes for the 2 most common invasive procedures in fetal medicine.

The evolution of multidisciplinary team-based care for women with placenta accreta spectrum disorder has delivered stepwise improvements in clinical outcomes. Central to this overall goal is the ability to limit blood loss at surgery. Placement of inflatable balloons within the pelvic arteries, most commonly in the anterior divisions of the internal iliac arteries, became popular in many centers, at the expense of prolonging surgical care and with attendant risks of vascular injury. In tandem, the need to expose pelvic sidewall anatomy to safely identify the course of the ureters re-popularized the alternative strategy of ligating the same anterior divisions of the internal iliac arteries. With incremental gains in surgical expertise, described in 5 steps in this review, our teams have witnessed a steady decline in surgical blood loss. Nevertheless, a subset of women has the most severe form of placenta accreta spectrum, namely placenta previa-percreta. Such women are at risk of major hemorrhage during surgery from vessels arising outside the territories of the internal iliac arteries. These additional blood supplies, mostly from the external iliac arteries, pose significant risks of major blood loss even in experienced hands. To address this risk, some centers, principally in China, have adopted an approach of routinely placing an infrarenal aortic balloon, with both impressively low rates of blood loss and an ability to conserve the uterus by resecting the placenta with the affected portion of the uterine wall. We review these literature developments in the context of safely performing elective cesarean hysterectomy for placenta previa-percreta, the most severe placenta accreta spectrum disorder.

Red blood cell (RBC) alloimmunisation with anti-D and anti-K comprise the majority of cases of fetal haemolytic disease requiring intrauterine red cell transfusion (IUT). Few studies have investigated which haematological parameters can predict adverse fetal or neonatal outcomes. The aim of the present study was to identify predictors of adverse outcome, including preterm birth, intrauterine fetal demise (IUFD), neonatal death (NND) and/or neonatal transfusion. We reviewed the records of all pregnancies alloimmunised with anti-K and anti-D, requiring IUT over 27 years at a quaternary fetal centre. We reviewed data for 128 pregnancies in 116 women undergoing 425 IUTs. The median gestational age (GA) at first IUT was significantly earlier for anti-K than for anti-D (24·3 vs. 28·7 weeks, P = 0·004). Women with anti-K required more IUTs than women with anti-D (3·84 vs. 3·12 mean IUTs, P = 0·036) and the fetal haemoglobin (Hb) at first IUT was significantly lower (51.0 vs. 70.5 g/l, P = 0·001). The mean estimated daily decrease in Hb did not differ between the two groups. A greater number of IUTs and a slower daily decrease in Hb (g/l/day) between first and second IUTs were predictive of a longer period in utero. Earlier GA at first IUT and a shorter interval from the first IUT until delivery predicted IUFD/NND. Earlier GA and lower Hb at first IUT significantly predicted need for phototherapy and/or blood product use in the neonate. In the anti-K group, a greater number of IUTs was required in women with a higher titre. Furthermore, the higher the titre, the earlier the GA at which an IUT was required in both groups. The rate of fall in fetal Hb between IUTs decreased, as the number of transfusions increased. Our present study identified pregnancies at considerable risk of an unfavourable outcome with anti-D and anti-K RBC alloimmunisation. Identifying such patients can guide pregnancy management, facilitates patient counselling, and can optimise resource use. Prospective studies can also incorporate these characteristics, in addition to laboratory markers, to further identify and improve the outcomes of these pregnancies.

Patients at high risk of severe preeclampsia and fetal growth restriction have low circulating levels of placental growth factor and features of maternal vascular malperfusion placental pathology at delivery. Multimodal screening and commencement of aspirin prophylaxis at 11 to 13 weeks' gestation markedly reduces the risk of preterm delivery with preeclampsia. However, the additional role of low-molecular-weight heparin and mechanisms of action remain uncertain. Because low-molecular-weight heparin augments the production and release of placental growth factor in vitro by both placental villi and vascular endothelium, it may be effective to suppress the risk of severe preeclampsia in a niche group of high-risk patients with low circulating placental growth factor in the early second trimester.This study aimed to define a gestational age-specific reference range for placental growth factor and to test the hypothesis that prophylactic low-molecular-weight heparin administered in the early second trimester may restore deficient circulating placental growth factor levels and thereby prolong pregnancy.Centile curves for circulating placental growth factor levels from 12 to 36 weeks' gestation were derived using quantile regression of combined data from a published cohort of 4207 unselected nulliparous patients in Cambridge, United Kingdom, at 4 sampling time points (12, 20, 28, and 36 weeks' gestation) and the White majority (n=531) of a healthy nulliparous cohort in Toronto, Canada, at 16 weeks' gestation using the same test platform. Within a specialty high-risk clinic in Toronto, a niche group of 7 patients with a circulating placental growth factor at the10th centile in the early second trimester received daily prophylactic low-molecular-weight heparin (enoxaparin; 40 mg subcutaneously) and were followed up until delivery (group 1). Their baseline characteristics, delivery details, and placental pathologies were compared with 5 similar patients who did not receive low-molecular-weight heparin during the observation period (group 2) and further with 21 patients who delivered with severe preeclampsia (group 3) in the same institution.A gestational age-specific reference range for placental growth factor levels at weekly intervals between 12 and 36 weeks was established for White women with singleton pregnancies. Within group 1, 5 of 7 patients demonstrated a sustained increase in circulating placental growth factor levels, whereas placental growth factor levels did not increase in group 2 or group 3 patients who did not receive low-molecular-weight heparin. Group 1 patients receiving low-molecular-weight heparin therapy exhibited a later gestation at delivery, relative to groups 2 and 3 (36 weeks [33-37] vs 23 weeks [22-26] and 28 weeks [27-31], respectively), and consequently had higher birthweights (1.93 kg [1.1-2.7] vs 0.32 kg [0.19-0.39] and 0.73 kg [0.52-1.03], respectively). The incidence of stillbirth was lowest in group 1 (14% [1 of 7]), relative to groups 2 and 3 (80% [4 of 5] and 29% [6 of 21], respectively). Maternal vascular malperfusion was the most common placental pathology found in association with abnormal uterine artery Doppler.In patients at high risk of a serious adverse pregnancy outcome owing to placental disease, the addition of low-molecular-weight heparin to aspirin prophylaxis in the early second trimester may restore deficient circulating placental growth factor to mediate an improved perinatal outcome. These data support the implementation of a multicenter pilot randomized control trial where patients are recruited primarily based on the assessment of placental function in the early second trimester.

OBJECTIVES To assess the natural evolution of the size of the fetal lateral ventricles throughout pregnancy in fetuses with callosal anomalies. METHODS Cases of fetal callosal anomalies were retrospectively classified as isolated or complex based on the presence of other structural or genetic anomalies. Longitudinal ultrasound studies were reviewed, and postnatal outcomes were retrieved for isolated cases. RESULTS In 135 fetuses, those who first presented after 24 weeks' gestation were more likely to have ventriculomegaly (n = 58 of 68 [85%]) than those who presented before 24 weeks (n = 39 of 67 [58%]; P

Resume Contexte Les troubles du spectre du placenta accreta (TSPA) constituent une complication de la grossesse potentiellement mortelle et exigent une coordination des soins interdisciplinaires afin d'ameliorer la possibilite d'une issue favorable. La hausse de la frequence des cas est due a l'augmentation du nombre d'interventions chirurgicales uterines, notamment a l'augmentation de la frequence des grossesses apres cesarienne. Objectif Fournir des directives cliniques factuelles courantes sur les methodes optimales pour depister, diagnostiquer et prendre en charge les TSPA de facon efficace. Methode Les membres du comite sur les directives cliniques ont ete selectionnes en fonction de leur milieu de pratique et de leur expertise actuelle en matiere de prise en charge de cette maladie au Canada. Le comite a revu toutes les donnees probantes disponibles dans la litterature medicale en anglais, y compris des lignes directrices publiees ainsi que des tests de diagnostic, des interventions chirurgicales et les issues cliniques evaluees. Donnees probantes La litterature publiee jusqu'en mars 2018, y compris les directives cliniques, a ete puisee dans les bases de donnees Medline et Cochrane Library au moyen d'un vocabulaire controle et de mots cles. Les resultats sont limites aux analyses systematiques, aux essais cliniques randomises et aux etudes observationnelles rediges en anglais. Les recherches ont ete mises a jour regulierement, et les resultats ont ete incorpores a la directive clinique jusqu'en juillet 2018. Criteres La qualite des donnees probantes dans le present document a ete evaluee en fonction des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs. Resultats Le present document passe en revue les donnees probantes relatives aux techniques diagnostiques et chirurgicales utilisees pour favoriser la prise en charge optimale des femmes chez qui l'on suspecte un TSPA, notamment l'anesthesie et les considerations cliniques de la prestation de soins interdisciplinaires. Avantages, prejudices et couts La mise en application des recommandations de la presente directive clinique ameliorera la sensibilisation a cette maladie et augmentera la proportion des femmes atteintes recevant des soins interdisciplinaires dans des centres regionaux. Conclusion La prestation de soins par une equipe interdisciplinaire qui assure de bons services diagnostiques, la planification concertee et les interventions chirurgicales securitaires fournissent des soins qui ameliorent les issues cliniques comparativement aux autres modes de prise en charge. DECLARATIONS SOMMAIRES 1La frequence des troubles du spectre du placenta accreta est en hausse constante dans de nombreux pays, vraisemblablement en raison de l'augmentation de la proportion de femmes qui deviennent enceintes apres avoir subi une ou plusieurs interventions chirurgicales uterines, notamment des cesariennes multiples. 2Les troubles du spectre du placenta accreta dans un contexte d'antecedents de cesarienne decoulent de l'implantation de la grossesse dans la niche au niveau de la cicatrice pres de la jonction cervico-isthmique de l'uterus. Diverses methodes echographiques permettent de diagnostiquer la manifestation precoce d'une « grossesse sur cicatrice de cesarienne ». 3L'echographie peut servir a depister et a diagnostiquer les grossesses avec un placenta praevia anterieur complique par un trouble du spectre du placenta accreta. L'efficacite de l'echographie dans ce contexte depend de la connaissance des facteurs de risque cliniques, de la qualite de l'imagerie, de l'experience de l'echographiste, de l'âge gestationnel, des modalites d'imagerie et du volume vesical adequat. 4L'imagerie par resonance magnetique peut appuyer l'echographie multimodale dans le diagnostic et la classification des troubles du spectre du placenta accreta; cependant, la contre-indication relative de l'utilisation du gadolinium comme agent de contraste limite actuellement son efficacite. 5Les troubles du spectre du placenta accreta sont potentiellement mortels et necessitent la prestation de soins par une equipe interdisciplinaire regionale afin de maximiser les chances d'issue favorable pour la mere et le nourrisson. RECOMMANDATIONS 1Il y a lieu de diriger les femmes enceintes qui presentent un placenta praevia anterieur et des facteurs de risque cliniques des troubles du spectre placenta accreta a l'echographie obstetricale de 18-20 semaines vers des services d'imagerie specialisee afin de diagnostiquer ou d'exclure cette maladie (II-2A). 2Il y a lieu de diriger les femmes qui ont recu un diagnostic de troubles du spectre du placenta accreta vers un centre regional designe a la prise en charge interdisciplinaire de cette maladie (II-3A). 3Les soins interdisciplinaires rattaches a un protocole qui s'etend du diagnostic a l'intervention chirurgicale optimiseront les issues a la fois peroperatoires et postoperatoires (II-3A). 4L'admission prenatale dans un centre de prise en charge regional designe peut etre indiquee, surtout a la suite d'une hemorragie ante partum, ou en fonction de contraintes geographiques ou de transport (III-B). 5Chez les femmes autrement en sante dont l'historique de grossesse ne comporte aucun saignement vaginal, le meilleur moment pour proceder a la cesarienne planifiee se situe entre 34 et 36 semaines de grossesse (II-3B). Il convient d'envisager d'effectuer l'intervention plus tot en cas d'episodes repetes d'hemorragie ante partum ou de contractions afin de reduire le risque d'intervention chirurgicale d'urgence non planifiee; on doit aussi idealement administrer une corticotherapie pour favoriser la maturation pulmonaire fœtale si l'intervention a lieu avant 35+0 semaines de grossesse (II-2A). 6L'anesthesie regionale peut s'averer plus securitaire que l'anesthesie generale etant donne qu'elle est liee a une perte sanguine moindre et que les patientes et leur partenaire la prefere (II-2A). Un protocole de transfusion massive doit etre en place afin de pouvoir reagir en cas de perte sanguine importante (III-B). 7Il y a lieu d'administrer de l'acide tranexamique par voie intraveineuse au debut de l'intervention parce qu'elle diminue la perte sanguine peroperatoire (I-A). 8Il convient de realiser l'intervention chirurgicale en position de lithotomie modifiee, au moyen d'une incision mediane assez haute pour extraire le fœtus sans pratiquer d'incision dans le placenta; l'echographie pre- ou peroperatoire peut etre utilisee afin de determiner l'incision uterine optimale (III-B). Si le placenta ne montre aucun signe de decollement, il convient de ne pas tenter de l'extirper en raison de l'hemorragie importante qui peut en decouler (III-B). 9A l'heure actuelle, il n'y a pas suffisamment de donnees probantes pour recommander ou non l'administration de medicaments uterotoniques apres l'extraction du fœtus (III-C). 10A l'heure actuelle, il n'y a pas suffisamment de donnees probantes pour recommander une methode ou une autre (insertion preoperatoire de ballonnets ou ligature peroperatoire) visant a reduire le debit sanguin des arteres iliaques internes avant l'hysterectomie (II-1C). 11Une atteinte centrale focale peut se preter a la resection cuneiforme (wedge) avec retrait complet du placenta et reparation de l'uterus (triple-P) (II-3B). 12La cesarienne classique avec abandon du placenta envahissant constitue une methode d'accouchement acceptable, mais elle prolongerait le temps de recuperation et presente un risque persistant d'hysterectomie (II-3B). 13Il convient de recommander aux femmes qui demeurent fertiles apres un diagnostic de trouble du spectre de placenta accreta d'obtenir une echographie aupres d'un specialiste tot dans toute grossesse subsequente de sorte que toutes les options de prise en charge demeurent sur la table en cas de grossesse sur cicatrice de cesarienne (III-B). 14Le diagnostic prenatal des formes les plus graves de troubles du spectre du placenta accreta, designees comme des grossesses sur cicatrice de cesarienne, peut rendre possible une prise en charge au moyen de techniques chirurgicales a effraction minimale (II-3D). 15Bien que bon nombre de femmes presentant un trouble du spectre du placenta accreta recoivent des soins securitaires dans les pays bien outilles, il faut pousser la recherche et favoriser le transfert de connaissances encore davantage pour offrir efficacement toutes les options de prise en charge a la population (III-B).

Background Placenta accreta spectrum (PAS) disorders are a potentially life-threatening complication of pregnancy that demand coordinated interdisciplinary care to achieve safer outcomes. The rising incidence of this disease is due to a growing number of uterine surgical procedures, including the rising incidence of pregnancy following Caesarean section. Objective To provide current evidence-based guidelines on the optimal methods used to effectively screen, diagnose, and manage PAS disorders. Methods Members of the guideline committee were selected on the basis of their ongoing expertise in managing this condition across Canada and by practice setting. The committee reviewed all available evidence in the English medical literature, including published guidelines, and evaluated diagnostic tests, surgical procedures, and clinical outcomes. Evidence Published literature, including clinical practice guidelines, was retrieved through searches of Medline and The Cochrane Library to March 2018 using appropriate controlled vocabulary and key words. Results were restricted to systematic reviews, randomized controlled trials, and observational studies written in English. Searches were updated on a regular basis and incorporated in the guideline to July 2018. Values The quality of evidence in this document was graded using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Results This document reviews the evidence regarding the available diagnostic and surgical techniques used for optimal management of women with suspected PAS disorders, including anaesthesia and practical considerations for interdisciplinary care. Benefits, Harms, and Costs Implementation of the guideline recommendations will improve awareness of this disease and increase the proportion of affected women receiving interdisciplinary care in regional centres. Conclusions Interdisciplinary team-based care providing accurate diagnostic services, coordinated planning, and safer surgery deliver effective care with improved clinical outcomes in comparison with alternative management. Summary Statements 1The incidence of placenta accreta spectrum disorders is steadily rising in many countries, likely due to the increasing proportion of women becoming pregnant following a variety of surgical procedures to the uterus, including multiple Caesarean sections. 2Placenta accreta spectrum disorders in the setting of prior Caesarean section deliveries arises from pregnancy implantation within the niche created by this surgery near the cervicoisthmic junction of the uterus. This early presentation as a "Caesarean section scar pregnancy" may be diagnosed by ultrasound methods. 3Ultrasound may be used to screen for, and to diagnose, pregnancies with anterior placenta previa that are complicated by placenta accreta spectrum disorders. The effectiveness of ultrasound in this context depends upon awareness of clinical risk factors, imaging quality, operator experience, gestational age, imaging modalities, and adequate bladder filling. 4Magnetic resonance imaging may complement multimodal ultrasound in the diagnosis and staging of placenta accreta spectrum disorders, though its effectiveness is currently limited by the relative contraindication to the use of a gadolinium contrast enhancing agent. 5Placenta accreta spectrum disorders are potentially life-threatening and demand regional interdisciplinary team-based care to deliver the safest outcomes for mothers and infants. Recommendations 1Pregnant women with clinical risk factors for placenta accreta spectrum disorders and anterior placenta previa at the 18–20-week fetal anatomical ultrasound should be referred for specialist imaging to diagnose or exclude this disorder (II-2A). 2Women with a diagnosis of placenta accreta spectrum disorder should be referred to a regional centre dedicated to the interdisciplinary management of this condition (II-3A). 3Protocol-based interdisciplinary care from diagnosis to surgery will optimize both intraoperative and postoperative outcomes (II-3A). 4Antenatal admission to a designated regional management centre may be indicated, especially following an antepartum hemorrhage, or based on considerations of geography or transport conditions (III-B). 5For otherwise healthy women with no history of vaginal bleeding, the optimal timing of elective Caesarean section delivery is around 34–36 weeks gestation (II-3B). Surgery should be considered earlier for repeated episodes of antepartum hemorrhage or contractions to reduce the risks of emergent unplanned surgery and should ideally be preceded by a course of corticosteroids to enhance fetal lung maturation if prior to 35+0 weeks gestation (II-2A). 6Regional anaesthesia may be safer than general anaesthesia as it is associated with reduced blood loss and is preferred by patients and their partners (II-2A). A massive transfusion protocol should be in place to respond to significant blood loss (III-B). 7Intravenous tranexamic acid should be administered at the commencement of surgery because it reduces intraoperative blood loss (I-A). 8Surgery should be performed in the modified lithotomy position, using midline access, sufficiently high so as to deliver the fetus without incising through the placenta; preoperative or intraoperative ultrasound can be used to guide the optimal uterine incision (III-B). No attempt should be made to remove the placenta if it shows no signs of separation as this may cause substantial hemorrhage (III-B). 9Presently there is insufficient evidence to recommend giving or withholding uterotonic drugs after delivery of the fetus (III-C). 10Presently there is insufficient evidence to recommend either approach (preoperative balloon placement or intraoperative ligation) designed to arrest blood flow from the internal iliac arteries prior to hysterectomy (II-1C). 11Focal central disease may be amenable to wedge resection, with complete removal of the placenta and repair of the uterus (the triple-P procedure) (II-3B). 12Classical Caesarean section and non-removal of the invasive placenta is an acceptable method of delivery but is associated with a protracted course of recovery and a persistent risk of hysterectomy (II-3B). 13Women who retain their fertility following a diagnosis of placenta accreta spectrum disorder should be instructed to access specialist ultrasound early in any future pregnancy so that all management options are available should a Caesarean section scar pregnancy be found (III-B). 14Prenatal diagnosis of the more severe forms of placenta accreta spectrum disorder, expressed as a Caesarean section scar pregnancy, may permit management using minimally invasive surgical techniques (II-3B). 15Though many women with placenta accreta spectrum disorder in well-resourced countries receive safe care, more research and knowledge translation are needed to effectively deliver all management options at the population-based level (III-B).

Resume Objectifs Fournir des directives factuelles qui favorisent l'accouchement vaginal assiste securitaire et efficace. Resultats Conditions prealables, indications, contre-indications, ainsi que les morbidites maternelles et neonatales liees a l'accouchement vaginal assiste. Donnees probantes Des recherches ont ete effectuees dans la base de donnees Medline pour trouver des articles publies entre le 1er janvier 1985 et le 28 fevrier 2018 en utilisant les termes anglais suivants : assisted vaginal birth, instrumental vaginal birth, operative vaginal delivery, forceps delivery, vacuum delivery, ventouse delivery. La qualite des donnees probantes indiquees s'appuie sur les criteres d'evaluation des donnees decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs. Validation La presente directive a ete approuvee par le comite de pratique clinique – obstetrique et le conseil d'administration de la Societe des obstetriciens et gynecologues du Canada. RECOMMANDATIONS 1La necessite d'assister un accouchement vaginal peut etre diminuee grâce aux mesures suivantes : soutien dedie et continu durant le travail (I-A), augmentation du travail inadequat par l'administration d'ocytocine (I-A), retarder de la poussee chez les femmes sous peridurale (I-A), augmentation du temps de poussee chez les femmes nullipares sous peridurale (I-B) et optimisation du positionnement de la tete fœtale par rotation manuelle (I-A). 2Le fait de favoriser l'AVA securitaire et efficace aux mains de fournisseurs de soins competents et experimentes peut s'averer une strategie efficace pour diminuer le taux de cesarienne primaire (II-2B). 3Pour qu'un accouchement vaginal assiste s'avere securitaire et efficace, il est necessaire de detenir l'expertise requise avec la methode choisie, d'effectuer une evaluation complete de la situation clinique et de communiquer de facon claire avec la patiente, ses personnes de soutien et le personnel soignant (III-B). 4Les praticiens qui effectuent un accouchement vaginal assiste doivent avoir les connaissances, les competences et l'experience necessaires pour evaluer la situation clinique, utiliser l'instrument choisi et gerer les complications qui peuvent decouler d'un accouchement vaginal assiste (II-2B). 5Les stagiaires en obstetrique devraient recevoir une formation complete sur l'accouchement vaginal assiste; ils doivent egalement etre declares competents avant de pratiquer un accouchement vaginal assiste sans supervision (III-B). 6Lorsque l'on juge que l'accouchement vaginal assiste comporte un risque eleve d'echec, on doit le considerer comme une tentative d'accouchement vaginal assiste et l'effectuer dans un endroit ou il est possible de recourir immediatement a la cesarienne (III-B). 7Le medecin doit choisir l'instrument le mieux adapte aux circonstances cliniques en fonction de son degre de competence. La ventouse et les forceps sont associes a divers risques et avantages a court et a long termes. La ventouse est plus susceptible de conduire a l'echec de l'accouchement que les forceps (I-A). 8Il n'est pas recommande de planifier d'utiliser successivement les instruments puisque cette approche est possiblement liee a un risque accru de trauma perinatal. En cas d'echec d'une tentative d'accouchement avec ventouse, le medecin doit evaluer les risques d'une tentative avec les forceps par rapport a ceux d'une cesarienne (II-2B). 9L'utilisation restreinte de l'episiotomie mediolaterale est indiquee lors d'un accouchement vaginal assiste (II-2B). 10Un retour doit etre effectue avec la patiente et ses personnes de soutien immediatement apres une tentative d'accouchement vaginal assiste, qu'elle soit fructueuse ou non. Si ce n'est pas possible, il faut idealement le faire avant que la patiente n'obtienne son conge et lui faire part des indications pour l'accouchement vaginal assiste, du plan de prise en charge de toute complication et du pronostic pour de futurs accouchements (III-B). 11Les patientes devraient etre encouragees a envisager un accouchement vaginal spontane pour les grossesses subsequentes. Le plan de soins devrait neanmoins etre personnalise et respecter les preferences de la patiente (II-3B).

Objectives To provide evidence-based guidelines for safe and effective assisted vaginal birth. Outcomes Prerequisites, indications, contraindications, along with maternal and neonatal morbidity associated with assisted vaginal birth. Evidence Medline database was searched for articles published from January 1, 1985, to February 28, 2018 using the key words "assisted vaginal birth," "instrumental vaginal birth," "operative vaginal delivery," "forceps delivery," "vacuum delivery," "ventouse delivery." The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventive Health Care. Validation These guidelines were approved by the Clinical Practice Obstetrics Committee and the Board of the Society of Obstetricians and Gynaecologists of Canada. Recommendations 1The need for assisted vaginal birth can be reduced by: dedicated and continuous support during labour (I-A), oxytocin augmentation of inadequate labour (I-A), delayed pushing in women with an epidural (I-A), increased time pushing in nulliparous women with an epidural (I-B), as well as optimization of fetal head position through manual rotation (I-A). 2Encouraging safe and effective assisted vaginal birth by experienced and skilled care providers may be a useful strategy to reduce the rate of primary Caesarean delivery (II-2B). 3Safe and effective assisted vaginal birth requires expertise in the chosen method, comprehensive assessment of the clinical situation alongside clear communication with the patient, support people, and health care personnel (III-B). 4Practitioners performing assisted vaginal birth should have the knowledge, skills, and experience necessary to assess the clinical situation, use the selected instrument, and manage complications that may arise from assisted vaginal birth (II-2B). 5Obstetrical trainees should receive comprehensive training in assisted vaginal birth and be deemed competent prior to independent practice (III-B). 6When assisted vaginal birth is deemed to have a higher risk of not being successful, it should be considered a trial of assisted vaginal birth and be conducted in a location where immediate recourse to Caesarean delivery is available (III-B). 7The physician should determine the instrument most suitable to the clinical circumstances and their level of skill. Vacuum and forceps are associated with different short- and long-term benefits and risks. Unsuccessful delivery is more likely with vacuum than forceps (I-A). 8Planned sequential use of instruments is not recommended as it may be associated with an increased risk of perinatal trauma. If an attempted vacuum is unsuccessful, the physician should consider the risks of proceeding to an attempted forceps delivery versus Caesarean section (II-2B). 9Restrictive use of mediolateral episiotomy is supported in assisted vaginal birth (II-2B). 10A debrief should be done with the patient and support people immediately following an attempted or successful assisted vaginal birth. If this is not possible, ideally this should be done prior to hospital discharge and include the indication for assisted vaginal birth, management of any complications, and the prognosis for future deliveries (III-B). 11In a subsequent pregnancy, patients should be encouraged to consider spontaneous vaginal birth. However, care planning should be individualized and patient preference respected (II-3B).

Objective To describe the evolution and evaluation of protocol-based multidisciplinary quality improvement (QI) in women undergoing cesarean hysterectomy for radiologically suspected and pathologically confirmed placenta accreta spectrum (PAS) disorders. Methods A single-center, retrospective cohort study was conducted of all patients undergoing cesarean hysterectomy for PAS disorders between March 2009 and June 2018. Two distinct periods were defined to compare outcomes: 2009-2011 (initial period) and 2017-2018 (current period). Primary outcomes included blood loss and administration of blood products. Secondary outcomes included perioperative levels of hemoglobin, adverse events and complications, time to mobilization, and length of hospitalization. Results Among the 105 consecutive patients identified, there were 26 in the initial period and 32 in the current period. With the implementation of all QI care bundles, median estimated surgical blood loss halved from 2000 mL in the initial period to 1000 mL in the current period, and fewer patients required allogenic blood transfusion (61.5% vs 25%). Patients in the current period demonstrated improved postoperative levels of hemoglobin compared to those in the initial period (101 g/L vs 89 g/L) and had a shorter median postoperative hospital stay (3 days vs 5 days). Conclusion These results support the implementation of a multifaceted QI and patient care initiative for women with PAS disorders.

Bilateral ligation of the anterior division of the internal iliac arteries can be a lifesaving intervention for severe pelvic hemorrhage. The procedure results in decreased pelvic perfusion and promotes coagulation. The classical method of internal iliac artery ligation involved extensive retroperitoneal dissection with complete circumferential isolation of the vessel to allow the passage of a suture around the artery. This can be surgically challenging and fraught with risks of inadvertent injury to the surrounding iliac veins. We propose a contemporary technique that requires limited dissection of the anterior division of the internal iliac artery. A few millimeters of space is created on either side of the artery by spreading right-angle forceps parallel to the vessel. The artery is occluded by 2 large vascular clips. Because circumferential vessel dissection is not necessary with this technique, there is limited disruption of the delicate underlying internal iliac vein. In addition, this approach may decrease the risk of inadvertent injury to the adjacent external iliac vein. By showcasing the ease of our approach to internal iliac artery ligation, we hope to empower surgeons with an alternative approach to this lifesaving procedure.

Monoamniotic twin pregnancies are rare, but early diagnosis of such pregnancies is critical, as the incidence of complications in these pregnancies is much higher than in diamniotic or dichorionic twin pregnancies. Overall, only 70% of all monoamniotic twins will survive. Furthermore, approximately half of fetal deaths in these pregnancies are because of the high incidence of fetal anomalies (15%-25%), such as twin reversed arterial perfusion sequence and conjoined twinning. Therefore, early anatomy screening in the first trimester of pregnancy is recommended. Other causes of fetal death in these pregnancies include twin-twin transfusion syndrome, tight cord entanglement, or acute hemodynamic imbalances through the large placental vascular anastomoses. After viability, fetal surveillance can be intensified, as this decreases the risk of in utero death. Both inpatient and outpatient surveillance are reasonable. If otherwise uncomplicated, monoamniotic twins should be delivered at 33 to 34 weeks' gestation. Most centers will deliver by cesarean delivery, but some continue to advocate for vaginal delivery. Lastly, neonatal morbidity is high in monoamniotic twin pregnancies and is mainly related to prematurity.

Key points Human placental function is evaluated using non-invasive Doppler ultrasound of umbilical and uterine artery pulsatility indices as measures of resistance in placental vascular beds, while measurement of placental oxygen consumption ( V O 2 ) is only possible during Caesarean delivery. This study shows the feasibility of using magnetic resonance imaging (MRI) in utero to measure blood flow and oxygen content in uterine and umbilical vessels to calculate oxygen delivery to and V O 2 by the gravid uterus, uteroplacenta and fetus. Normal late gestational human uteroplacental V O 2 by MRI was ∼4 ml min-1 kg-1 fetal weight, which was similar to our MRI measurements in sheep and to those previously measured using invasive techniques. Our MRI approach can quantify uteroplacental V O 2 , which involves the quantification of maternal- and fetal-placental blood flows, fetal oxygen delivery and V O 2 , and the oxygen gradient between uterine- and umbilical-venous blood, providing a comprehensive assessment of placental function with clinical potential. Abstract It has not been feasible to perform routine clinical measurement of human placental oxygen consumption ( V O 2 ) and in vitro studies do not reflect true metabolism in utero. Here we propose an MRI method to non-invasively quantify in utero placental and fetal oxygen delivery ( D O 2 ) and V O 2 in healthy humans and sheep. Women (n = 20) and Merino sheep (n = 10; 23 sets of measurements) with singleton pregnancies underwent an MRI in late gestation (36 ± 2 weeks and 128 ± 9 days, respectively; mean ± SD). Blood flow (phase-contrast) and oxygen content (T1 and T2 relaxometry) were measured in the major uterine- and umbilical-placental vessels, allowing calculation of uteroplacental and fetal D O 2 and V O 2 . Maternal D O 2 (ml min-1 kg-1 fetus) to the gravid uterus was similar in humans and sheep (human = 54 ± 15, sheep = 53 ± 21, P = 0.854), while fetal D O 2 (human = 25 ± 4, sheep = 22 ± 5, P = 0.049) was slightly lower in sheep. Uteroplacental and fetal V O 2 (ml min-1 kg-1 fetus; uteroplacental: human = 4.1 ± 1.5, sheep = 3.5 ± 1.9, P = 0.281; fetus: human = 6.8 ± 1.3, sheep = 7.2 ± 1.7, P = 0.426) were similar between species. Late gestational uteroplacental:fetal V O 2 ratio did not change with age (human, P = 0.256; sheep, P = 0.121). Human umbilical blood flow (ml min-1 kg-1 fetus) decreased with advancing age (P = 0.008), while fetal V O 2 was preserved through an increase in oxygen extraction (P = 0.046). By contrast, sheep fetal V O 2 was preserved through stable umbilical flow (ml min-1 kg-1 ; P = 0.443) and oxygen extraction (P = 0.582). MRI derived measurements of uteroplacental and fetal V O 2 between humans and sheep were similar and in keeping with prior data obtained using invasive techniques. Taken together, these data confirm the reliability of our approach, which offers a novel clinical 'placental function test'.

We have developed a high-fidelity interactive "video-game" simulator in order to teach fetoscopic laser ablation of placental anastomoses for twin-twin transfusion syndrome This simulator may be used by teachers in order to provide metrics-based simulator education to multiple trainees, in both hands-on and distanced learning settings WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: The use of simulation improves training of the fetoscopic laser techniques utilized in the treatment of twin-twin transfusion syndrome A number of mannequins have been developed to aid this education WHAT DOES THIS STUDY ADD?: Two new simulators are described for twin-twin transfusion syndrome training-silicone and digital The digital simulator is a novel digital video game virtual format This new format has enhanced interactivity and has the potential to enable distance learning.

Objective: Fetal thoraco-amniotic shunts (TASs) can dislodge in utero, migrating internally into the fetal thorax or externally into the amniotic cavity. Our objective was to evaluate the perinatal and long-term outcome of fetuses with TAS dislodgement and conduct a review of the literature. Methods: This is a retrospective review of all TAS inserted for primary pleural effusions and macrocystic congenital pulmonary airway malformations (CPAMs) in a tertiary fetal medicine center (1991–2020). Antenatal history, procedural factors, and perinatal and long-term outcomes were reviewed in all fetuses with dislodged shunts and compared to fetuses with shunts that did not dislodge. Results: Of 211 TAS inserted at a mean gestational age of 27.8 weeks ± 5.47 (17.4–38.1 weeks), 187 (89%) were inserted for pleural effusions and 24 (11%) for macrocystic CPAMs. Shunts dislodged in 18 fetuses (8.5%), 17 (94%) of which were for pleural effusions. Shunts migrated into the chest wall/amniotic cavity or into the thorax among 7/18 (39%) and 11/18 (61%) fetuses, respectively. Eleven (61%) fetuses were initially hydropic, which resolved in 8 (72%) cases. Effusions were bilateral in 9 (50%), amnioreduction was required in 6 (33%), and fetal rotation in 8 cases (44%). Four (22%) fetuses underwent repeat shunting, 12 (67%) neonates required ventilatory support, and 2 (11%) neonates required chest tubes. There was no significant difference in technical factors or outcomes between infants with shunts that dislodged and those that did not. Among 11 intrathoracic shunts, 2 (18%) were removed postnatally and the remainder are in situ without any shunt-related or respiratory complications over a follow-up period of 9 months to 22 years. Conclusion: TAS dislodged antenatally in 8.5% of fetuses, with 2/3 of shunts migrating into the thorax, and nearly 25% requiring re-shunting. Retained intrathoracic shunts were well tolerated and may not necessarily require surgical removal after birth.

To determine the feasibility of a randomized controlled trial of delayed umbilical cord clamping in preterm infants.Following informed consent, women between 24 to 32 weeks gestation experiencing imminent preterm birth were randomly assigned to either an immediate cord clamping (ICC) or delayed cord clamping (DCC) group. Umbilical cord clamping directions were 0-15 s for the ICC group and 30-45 s for the DCC group. Information regarding recruitment rate and trial compliance was collected. Neonatal outcomes of intraventricular hemorrhage (IVH), sepsis, anemia, and hyperbilirubinemia were also compared between the two groups. This trial was registered at https://clinicaltrials.gov/. (ClinicalTrials.gov Identifier: NCT00562536).Thirty-eight women were recruited in total, 19 each to the ICC and DCC groups respectively. The study recruitment rate was 33% and study compliance rate was 97%. The average time for cord clamping was 5.4 s in the ICC group and 39.7 s in the DCC group (This study demonstrates that a trial of a short delay in umbilical cord clamping (30-45 s) is feasible for women and physicians. Larger scale studies of long term outcomes are warranted.

OBJECTIVE To compare surgical outcomes between women undergoing prophylactic internal iliac artery ligation or preoperative placement of balloon-occlusive devices at cesarean hysterectomy for placenta accreta spectrum (PAS) disorders. METHODS A retrospective cohort study was conducted at a tertiary-care referral center for PAS disorders in Ontario, Canada. Eligible electronic records were reviewed of women undergoing cesarean hysterectomy for PAS disorders between November 2012 and June 2018. Outcomes for the ligation and balloon groups were compared primarily on procedure-related complications and secondarily on total procedure time, bleeding and transfusion metrics, and intraoperative and postoperative complications. RESULTS Of the 79 cases of cesarean hysterectomy, 47 underwent balloon placement and 32 underwent ligation. Baseline characteristics between the groups were similar except for more emergency procedures in the ligation group (37.5% vs 12.8%, P=0.014). The balloon-related complication rate was 5/47 (10.6%), with no reported complications in the ligation group (P=0.077). Procedural time was longer in the balloon group (353 ± 14 vs 227 ± 13 minutes, P

OBJECTIVE: We report the outcome of pregnancies treated with intravenous immunoglobulin (IVIG) for severe red blood cell alloimmunization, evaluating whether IVIG defers the development of severe fetal anaemia and its consequences. BACKGROUND: Although fetal anemia can be treated very successfully with intrauterine transfusion (IUT), procedures before 20 weeks' gestation can be very challenging technically and may be hemodynamically stressful to an extremely premature and already compromised fetus. The procedure-related fetal loss rate is approximately 5.6% for IUTs performed < 20 weeks' gestation, compared to 1.6% overall. IVIG may prevent hemolysis and could therefore be a noninvasive alternative for early transfusions. STUDY DESIGN: We included consecutive pregnancies over a nineteen year period in the Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Canada, of alloimmunized women with a history of severe early onset haemolytic disease who received IVIG until intrauterine transfusion could safely be performed. Previous untreated pregnancies were used as controls. IVIG therapy was commenced between 11 and 14 weeks' gestation. Our usual protocol was IVIG 2 g/kg per week every 3 weeks, until the first IUT could be performed. Each 2g/kg dose was administered over 2 days, 1g/kg per day, to reduce the chance of severe headaches. In three pregnancies, IVIG 1g/kg was given weekly. We compared the clinical outcomes (gestation at first IUT, fetal Hb at first FBS, gestation at delivery, perinatal survival) between previous pregnancies without IVIG and the subsequent pregnancy treated with IVIG. In comparing fetal Hb's between two pregnancies, a linear relationship between fetal Hb and gestation was used to correct for variable gestations. The fetal Hb was converted to a standardized fetal Hb value (multiples of the standard deviation [SD]). Statistical analysis was performed on 'Statistical Package for Social Science Version 16.0' (SPSS Inc, Chicago, Illinois). RESULTS: Seventeen women referred to our unit for a previous pregnancy loss secondary to severe RBC alloimmunization received IVIG treatment in 20 subsequent pregnancies; all eventually requiring intrauterine transfusion. For previous early losses despite transfusion, immunoglobulin was associated with a relative increase in fetal hemoglobin between treated and untreated pregnancies of 32.6 g/L (95%CI 15.2-50.0, P=0.003) and improved perinatal survival (8/8 vs 0/6, P=0.001). For previous losses CONCLUSION: Our results show that, among severely sensitized cases with previous early fetal loss despite IUT, use of IVIG in subsequent pregnancies is associated with a significantly higher fetal Hb before first IUT, deferral of first IUT, delivery at a later gestation and increased perinatal survival. The timing of the first FBS/IUT was delayed by 3 weeks in pregnancies treated with IVIG compared to a previous untreated pregnancy. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Background: The rhesus (Rh) and Kell blood group systems are the most common of over 50 different antigens capable of causing maternal red blood cell (RBC) alloimmunization and severe fetal hemolytic disease. Anti-K and anti-D are responsible for a significant proportion of fetal anemia requiring intrauterine transfusion (IUT). Whilst IUT of packed RBCs improves neonatal survival and morbidity, clinical prognostic indicators are lacking. Our primary objective was to identify predictors of adverse outcome. Methods: We conducted a retrospective single-center study at Mount Sinai Hospital (MSH), Toronto, Canada. All pregnant patients alloimmunized with anti-K and anti-D as a single antibody, between 1991 and 2018 were included. Data were obtained from patient medical records, ultrasound reports and information from the transfusion medicine laboratory. Data included maternal demographics, antibody titers, pregnancy history, number of IUTs, hemoglobin (HB) concentration at the beginning and end of all IUTs. Neonatal outcomes included survival, mode of delivery, gestational age at delivery, birth weight, HB at birth and need for neonatal transfusion, phototherapy or intravenous immunoglobulins (IVIG). Our primary outcome was the composite outcome of stillbirth or neonatal death (SB/NND). We also constructed a secondary outcome consisting of top-up neonatal transfusion, exchange transfusion, phototherapy, or use of IVIG. Medians and interquartile ranges (IQR) or mean±SD were used as summary statistics and compared by Mann-Whitney or t-test; p Results: 116 women with 128 pregnancies and 425 IUTs with anti-K or anti-D as a single antibody were identified. Median maternal age was 31 years (27.0-35.0) for anti-K and 32 years (23.6-40.6) for anti-D. The gestational age at 1st IUT differed significantly between anti-K and anti-D (24.3 vs 28.7 weeks respectively, p=0.004). Women with anti-K antibodies required more IUTs than women with anti-D (3.84 vs 3.12 IUTs, p=0.036) and HB at 1st IUT was significantly lower in the anti-K group (5.10 vs 7.05 g/dL, p=0.001) (Table 1). Following initiation of IUT, the time from 1st IUT to delivery was 69.6 days in the anti-K group and 54.6 in the anti-D group (p=0.06). The daily decrease of HB between 1st and 2nd IUT (as a marker of disease severity), development of fetal hydrops and severe preterm birth did not differ significantly between the two groups. Mean gestation age at delivery was 35.0 weeks in the anti-K and 36.0 weeks in the anti-D group (p=0.28), with 87.1% and 93.9% survival (p=0.37), respectively. The proportion of neonates requiring phototherapy, IVIG and exchange/top-up transfusion was comparable across the two antibody groups (Table 1). Regression analysis showed that delivery occurred sooner if HB dropped more rapidly between the first two IUTs (p=0.01). Each additional transfusion gained on average 22.5 days in utero (Table 2). In multivariable analysis, gestational age at 1st IUT was the only predictor of a SB/NND outcome (adjusted OR 0.79 [95%CI 0.67-0.93]; p=0.006). With 1st IUT at 23 weeks, the risk of SB/NND was 8%, but only 2.5% at 28 weeks and Conclusion: The earlier in gestation that IUTs are implemented, the higher the odds of a SB/NND; however the later the gestation at delivery, the greater the odds of the neonate requiring blood products post-partum. The greater the HB drop between the 1st and 2nd IUT, the shorter the 'time between the first IUT and delivery', which increases the odds of a SB/NND outcome. Disclosures Garbowski: Vifor Pharma: Consultancy, Membership on an entity's Board of Directors or advisory committees; Imara: Consultancy. Shehata:Ferring: Honoraria.

To describe/analyse a novel, community-based prenatal monitoring protocol for opioid-exposed pregnancies developed by our centre in 2014 to optimize prenatal care for this population. A literature review of published monitoring protocols for this population is also presented.Retrospective comparison of pre-protocol (n = 215) and post-protocol (n = 251) cohorts. Medline and Embase were searched between 2000-2016 using MeSH terms: [fetal monitoring OR prenatal care] AND [opioid-related disorders OR substance-related disorders] in Medline and [fetal monitoring OR prenatal care] AND [opiate addiction OR substance abuse] in Embase, producing 518 results. Thirteen studies included protocols for monitoring opioid-exposed pregnancies. No comprehensive monitoring protocols with high-quality supporting evidence were found.We evaluated 466 opioid-exposed pregnancies, 215 before and 251 after introduction of the protocol. Since implementation, there was a significant increase in the number of opioid-exposed patients who have underwent urine drug screening (72.6% to 89.2%, P0.0001); a significant reduction in the number of urine drug screenings positive for illicit opioids (50.2% to 29.1%, P 0.0001); and a significant increase in the number of patients who discontinued illicit opioid use by the time of delivery (24.7% to 39.4%, P0.01). There was no difference in the CS rate (27.4% vs. 26.3%, P0.05). There were no observed differences in the rate of preterm birth, birth weight2500 g, or Apgar score7 (P0.05).Care of women with increased opioid use during pregnancy is an important but under-studied health issue. A novel protocol for focused antenatal care provision for women with opioid-exposed pregnancies improves standard of care and maternal/fetal outcomes.

To compare the use of simulator-based and patient-based obstetric ultrasound training.This was a prospective, randomized, single-blinded trial. Eighteen consenting obstetric trainees with minimal previous ultrasound exposure were recruited. Enrolled patients were also fully consenting. Mid-trimester fetal brain anatomy in the standard planes (i.e., biparietal diameter and head circumference, cavum septum pellucidum, posterior fossa, and lateral ventricle) was chosen as a surrogate for all fetal anatomy ultrasound training. Trainees were randomized into two groups according to training method: simulator group (n = 9) or patient group (n = 9). All participating trainees went through the following sequence: a didactic session regarding the required planes; a "real" patient 15-minute pretest; a 45-minute training session with a dedicated ultrasound educator, using either a simulator or a "real" patient (according to the randomized group assignment); and a 15-minute post-test to obtain and label the standard four planes on a "real" patient. All images were stored and then scored by two blinded Maternal Fetal Medicine staff, according to 3 set criteria: image quality, landmarks, and measurements. Each criterion was scored 0 to 15 for a total score of 0 to 60.Pretest competence was similar between the two groups. For each of the two groups there was a significant score improvement following training: real patient (mean score pretest 13.3 vs. post-test 24.6; P0.04) and simulator group (mean score pretest 15.9 vs. post-test 28.9; P0.05). All trainees demonstrated significant overall score improvements (mean score pretest 14.6 vs. post-test 26.6; P0.04) regardless of training method. Trainees were further divided by their initial level of confidence (pretest score ≤5: very unconfident; pretest5: unconfident). The improvement was similar for both groups, but "very unconfident" trainees' performance improved more in the simulator group (mean pretest vs. post-test score 3.5 to 35) compared with the patient group (mean pretest vs. post-test score 2.3 to 25.6) CONCLUSION: Simulator-based obstetric ultrasound training performed as well as real patient training and was found to be especially beneficial for beginner trainees. Simulator-based ultrasound training has a high rate of acceptance by trainees, does not require investment of patient or clinic resources, and warrants consideration as an educational tool for the safe and effective teaching of obstetric ultrasound.

Fournir des directives factuelles qui favorisent l'accouchement vaginal assisté sécuritaire et efficace. RéSULTATS: Conditions préalables, indications, contre-indications, ainsi que les morbidités maternelles et néonatales liées à l'accouchement vaginal assisté. DONNéES PROBANTES: Des recherches ont été effectuées dans la base de données Medline pour trouver des articles publiés entre le 1La présente directive a été approuvée par le comité de pratique clinique - obstétrique et le conseil d'administration de la Société des obstétriciens et gynécologues du Canada. RECOMMANDATIONS.

OBJECTIVE To evaluate the impact of introduction of noninvasive prenatal testing (NIPT) on the uptake of invasive testing in pregnancies complicated by fetal central nervous system (CNS) anomalies. METHODS Retrospective review of all singleton pregnancies complicated by fetal CNS anomalies seen at a single tertiary center between 2010 and 2017. Cases who had undergone invasive testing or NIPT prior to the diagnosis of the CNS anomaly were excluded. Cases were segregated according to whether they were seen prior to introduction of NIPT (group A, 2010-2013) or thereafter (group B, 2014-2017). We examined the rate of invasive and noninvasive genetic testing in each group. RESULTS We retrieved 500 cases: 308 (62%) were isolated CNS anomalies, and 192 (38%) had additional structural anomalies. In the total cohort, 165 women (33%) underwent expectant management with no further prenatal genetic testing, 166 (33%) had invasive testing, 52 (10%) had NIPT, and 117 pregnancies (23%) were terminated without further prenatal investigations. The introduction of NIPT significantly decreased the number of pregnancies having no testing (44% group A vs 22% in group B, p

Objective Caesarean section at full cervical dilatation is a challenging procedure with a higher risk of fetal and maternal morbidity. We wished to elicit the essential clinical components of a CS at full dilatation performed skilfully and safely. Methods We conducted a prospective study with both qualitative (individual interviews) and quantitative (questionnaire) components. In the qualitative components, senior clinicians were interviewed using open-ended questions regarding techniques used for performance of CS at full cervical dilatation. Interviews were recorded and thematic analysis was performed until saturation was achieved. In the second (quantitative) component of the study, clinicians completed a questionnaire regarding tips and techniques to perform a CS at full cervical dilatation. Results For the qualitative component, 15 clinicians agreed to participate. There was a 90% (n=27) response rate to the questionnaire. Common themes from both components of the study included the advice to routinely re-examine the patient (with abdominal and vaginal examinations) in the operating room after induction of anaesthesia to determine pelvic architecture, fetal size, and the station of the presenting part, and especially to assess for progress since the initial decision to perform a CS in the labour room. When the decision is made to proceed with CS, the following modifications to a standard CS technique were suggested: first, to make a more superior transverse uterine incision than usual, and second, to secure each uterine angle separately before uterine closure is commenced in order to identify and manage angle extension and thereby minimize blood loss. Other modifications, such as vaginal disimpaction of the fetal head before beginning the operation, were more controversial. Participants developed their own techniques by combining teaching from senior obstetricians, watching others operate, and learning from their own clinical experience. Conclusion There is an increasing role for good quality clinical training programs on how best to perform complex deliveries such as CS at full cervical dilatation. After identifying the essential components of CS at full cervical dilatation reported by multiple skilled clinicians, these can then be translated into a useful educational tool.

This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.

Objective Achieving clinical competence in managing safe vaginal breech delivery (VBD) is challenging in contemporary obstetrics. Novel educational strategies are required, as exposure of obstetric trainees to VBD remains limited. The aim of this study was to identify the verbal and non-verbal skills required to manage VBD through filmed demonstration by experts. Methods Labour and delivery nursing staff at three large university-affiliated hospitals identified clinicians whom they considered skilled in VBD. Obstetricians consistently identified were invited to participate in the study. Participants were filmed performing a VBD on a birth simulator while discussing their assessment, technique, and providing clinical pearls based on their experience. Two study members reviewed all videos and documented verbal and non-verbal components of the assessment, grouped them into common themes, and produced an integrated summary. This was circulated to all participants and reviewed by senior obstetricians from outside Canada. Results Seventeen clinicians were identified; 12 (70%) consented to participation. Themes identified were meticulous assessment and pre-pregnancy counselling; roles of the multidisciplinary team; need for careful and appropriate communication with parents; specific techniques of the delivery; and postpartum care and documentation. A clinical task list was generated based on this analysis. Conclusion Derived from clinicians with extensive experience, we have developed a comprehensive task list outlining the important features involved in safe VBD. Common themes in the experts' teaching for safe VBD included rigorous antepartum selection and counselling, appreciation for when to convert to Caesarean section, and a "hands off" delivery technique.

Background: The risk factors determining the frequency of intrauterine transfusions (IUTs) for severely affected red blood cell alloimmunized singleton pregnancies are not well known. Objective: To assess factors associated with IUT frequency and adverse pregnancy outcomes in transfused pregnancies.Methods: Retrospective cohort analysis of 246 consecutive cases between 1991 and 2014. Time-to-event survival analysis for repeated events was used to evaluate risk of subsequent IUT. Multivariable logistic regression assessed odds of a composite adverse pregnancy outcome (intrauterine fetal death, termination of pregnancy, neonatal death, preterm birth Results: Full information was available on232 cases (94.3%) and 716 IUTs. Fetal hydrops was associated with increased frequency (hazard ratio [HR] 1.29 [95% CIs 1.15–1.47, p < 0.001]) while higher fetal hemoglobin (Hb) pre-IUT (HR) 0.99 (95% CI 0.99–1.00, p = 0.021) and post-IUT (HR 0.99 [95% CI 0.99–1.00] p = 0.042), and higher transfused blood volume (HR 0.98 [95% CI 0.97–0.99] p < 0.001) were associated with reduced IUT frequency. Adverse pregnancy outcomes were more likely with lower gestational age (GA) at initial IUT. Antibody type was not associated with IUT frequency or adverse pregnancy outcomes. Conclusions: Hydrops is associated with increased IUT frequency while lower GA at initial IUT is associated with higher adverse pregnancy outcomes in alloimmunized pregnancies.Higher transfused blood volumes, pre- and post-IUT Hb are associated with lower IUT frequency.

Microcystic congenital cystic adenomatoid malformations (CCAM), when associated with hydrops, carry a dismal prognosis. Options for treatment are limited and experimental, including antenatal corticosteroids, open fetal surgery, laser ablation and, more recently, sclerotherapy. We describe a case of a large, predominantly microcystic CCAM in a hydropic fetus treated successfully with direct interstitial injection of a sclerosant agent (3% sodium tetradecyl sulfate) at 23+3 weeks gestation, after multiple failed courses of steroids. Elective thoracoscopic right lower lobectomy was performed at 1 year of life and there have been no respiratory or other medical morbidities since. A literature review of fetal lung masses treated with sclerosants antenatally reveals that sclerotherapy may represent a novel treatment option for large hydropic microcystic CCAMs, which are unresponsive to corticosteroids. Further studies are required to evaluate the utility and safety of fetal sclerotherapy, as this may represent an alternative minimally invasive treatment option to fetal lobectomy.

Background: Kell and Rhesus (Rh) maternal red blood cell (RBC) alloimmunization are the most common causes of severe fetal haemolytic disease. Widespread use of anti-D immune globulin has dramatically reduced the incidence of Rh(D) alloimmunization, leaving K alloimmunization responsible for a significant proportion of cases of fetal anemia requiring intrauterine transfusion ( ). K antigens are expressed on fetal erythrocytes at 10-11 weeks and k antigens at 6-7 weeks gestation (Tovey et al, 1986). In alloimmunized women, erythroid specific antibodies traverse the placenta, causing immune destruction of fetal erythroid cells leading to progressive haemolytic anaemia. The mechanism of fetal anaemia in K alloimmunization differs somewhat from that in Rh-D, in that anti-K antibodies cause suppression of fetal erythropoiesis (Gariod et al, 2004; Weiner et al, 1996). Whilst IUT of RBCs has improved fetal and neonatal survival, important information such as the critical anti-K titres to guide appropriate timing and frequency of IUT, is somewhat conflicting. Currently anti-K alloimmunized pregnancies do not have a standardized protocol for titer monitoring throughout pregnancy and, once alloimmunized, patients are usually referred to a regional fetal center for close ultrasound (US) surveillance. Our primary objective is to determine from a retrospective analysis of our population whether there is a critical anti-K titer that should trigger intensive US monitoring or intervention and to investigate the rate of progression of fetal anemia following IUTs. Methods: This is a retrospective single-center study at Mount Sinai Hospital (MSH), Toronto, Canada, of all pregnant patients with anti-K as the primary alloimmunizing antibody, between 1991 and 2018. MSH is the largest fetal medicine center in Canada and the largest referral center for IUTs. Ethical approval was granted by the Research Ethics Board (REB # 12-0113-C). Data were obtained from a database of patient medical records, US reports and the transfusion medicine laboratory, including maternal demographics, pregnancy history, presence of other alloantibodies and hemoglobin concentration before and after all IUTs. Neonatal outcomes included survival, mode of delivery, gestational age (GA) at delivery, birth weight and need for neonatal exchange transfusion, phototherapy or IVIG. Data were analyzed using GraphPad Prism 6 and linear correlations are expressed as a p-value. Results: Thirty-eight women underwent 163 IUTs in 44 pregnancies where K was the predominant antibody. Two patients in whom anti-K was a secondary antibody were excluded. In 5 of these pregnancies, 2 had a total of three alloantibodies and 5 had 2 alloantibodies each. The median maternal age was 31 (29 - 35) years. Four women had a history of intrauterine fetal death (IUFD) and 9 of neonatal haemolytic disease. The median GA at 1st IUT was 24.2 weeks (14.9-34.7), and there was a median of 4 IUTs per patient. There were seven cases of hydrops fetalis. The number of IUTs a patient received throughout pregnancy was correlated directly with the anti-K titer (Figure 1). Every 4-fold dilution resulted in a further increase in the IUT number by 2.2 above the mean of 2.5 at a titer of 1:32 (p=0.0137). Figure 2 illustrates the correlation between the GA at 1st IUT and antibody titer. IUTs were required at earlier GAs if the titers were higher. Following a 1:32 titer, every 2-fold titer increase reduced the mean gestational age at 1st IUT by 2 weeks (p Conclusion: Our data support a critical anti-K titer of 1:32 and support a role for anti-K titer monitoring as a predictor of disease severity, counselling women appropriately and establishing a balance between paternal K antigen typing, US middle cerebral artery peak systolic velocity monitoring of the fetus and IUTs. Disclosures Garbowski: Vifor Pharma: Consultancy; Imara: Consultancy.

Objective Increased rates of delivery by Caesarean section have resulted in a reduction in rates of instrumental deliveries This has led to a new educational challenge for teaching and development of skills. In teaching trainees, there are subconscious tasks that the supervising staff may not review because they are automatic. This study aimed to create a new tool to meet this challenge: to identify the core steps required to perform a non-rotational forceps delivery safely and successfully. Methods Labour and delivery nursing staff of three large teaching hospitals were asked to identify clinicians they considered to be particularly skilled in non-rotational forceps deliveries Obstetricians who were identified consistently in this way were invited to participate in the study. After providing written consent, participants were then filmed performing a non-rotational forceps delivery on a model. Two clinicians reviewed all videos and documented verbal and non-verbal components of the assessment. Thematic analysis combined findings into an integrated summary The initial summary was then circulated to all participants for their approval. Results Seventeen clinicians were identified and consented Themes identified included the need for careful assessment of suitability for operative delivery, the role of the multidisciplinary team, the need for careful and appropriate communication with the parents, the technique of delivery itself, and postpartum care and documentation. Conclusion In the core steps identified, the clinicians balanced respect for the "elegant technique" of non-rotational forceps deliveries with careful assessment and knowing when to stop if safety criteria were not met.

Effective detection and management of fetal growth restriction is relevant to all obstetric care providers. Models of best practice to care for these patients and their families continue to evolve. Since much of the disease burden in fetal growth restriction originates in the placenta, the concept of a multidisciplinary placenta clinic program, managed primarily within a maternal-fetal medicine division, has gained popularity. In this context, fetal growth restriction is merely one of many placenta-related disorders that can benefit from an interdisciplinary approach, incorporating expertise from specialist perinatal ultrasound and magnetic resonance imaging, reproductive genetics, neonatal pediatrics, internal medicine subspecialties, perinatal pathology, and nursing. The accurate diagnosis and prognosis for women with fetal growth restriction is established by comprehensive clinical review and detailed sonographic evaluation of the fetus, combined with uterine artery Doppler and morphologic assessment of the placenta. Diagnostic accuracy for placenta-mediated fetal growth restriction may be enhanced by quantification of maternal serum biomarkers including placenta growth factor alone or combined with soluble fms-like tyrosine kinase-1. Uterine artery Doppler is typically abnormal in most instances of early-onset fetal growth restriction and is associated with coexistent preeclampsia and underlying maternal vascular malperfusion pathology of the placenta. By contrast, rare but potentially more serious underlying placental diagnoses, such as massive perivillous fibrinoid deposition, chronic histiocytic intervillositis, or fetal thrombotic vasculopathy, may be associated with normal uterine artery Doppler waveforms. Despite minor variations in placental size, shape, and cord insertion, placental function remains, largely normal in the general population. Consequently, morphologic assessment of the placenta is not currently incorporated into current screening programs for placental complications. However, placental ultrasound can be diagnostic in the context of fetal growth restriction, for example in Breus' mole and triploidy, which in turn may enhance diagnosis and management. Several examples are illustrated in our figures and supplementary videos. Recent advances in the ability of multiparameter screening and intervention programs to reduce the risk of severe preeclampsia will likely increase efforts to deliver similar improvements for women at risk of fetal growth restriction. Placental pathology is important because the underlying pathologies associated with fetal growth restriction have a wide range of recurrence risks. Rare conditions such as massive perivillous fibrinoid deposition or chronic histolytic intervillositis may recur in >50% of subsequent pregnancies. Postpartum care in a placenta-focused program can provide effective counseling for modifiable maternal risk factors, and can assist in planning future pregnancy care based on the pathologic basis of fetal growth restriction.

OBJECTIVE The objective of this study was to develop a synthetic high-fidelity simulator for teaching chorionic villus sampling. METHODS Working with a medical sculptor, the authors developed a simulator, constructed from various synthetic rubber materials, of a gravid female pelvis, including the vulva, vagina, cervix, and a 13-week-sized uterus with a gestational sac. RESULTS This simulator is high fidelity and durable, and it does not require any organic materials. Maternal-fetal medicine trainees valued this educational tool. CONCLUSION This novel, high-fidelity simulator is an additional tool for educators involved in teaching chorionic villus sampling.