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Objective The aim of the study is to evaluate whether pathologic severity of placenta accreta spectrum (PAS) is correlated with the incidence of small for gestational age (SGA) and neonatal birthweight. Study Design This was a multicenter cohort study of viable, non-anomalous, singleton gestations delivered with histology-proven PAS. Data including maternal history, neonatal birthweight, and placental pathology were collected and deidentified. Pathology was defined as accreta, increta, or percreta. The primary outcome was rate of SGA defined by birth weight less than the 10th percentile. The secondary outcomes included incidence of large for gestational age (LGA) babies as defined by birth weight greater than the 90th percentile as well as incidence of SGA and LGA in preterm and term gestations. Statistical analysis was performed using Chi-square, Kruskal–Wallis, and log-binomial regression. Increta and percreta patients were each compared with accreta patients. Results Among the cohort of 1,008 women from seven United States centers, 865 subjects were included in the analysis. The relative risk (RR) of SGA for increta and percreta did not differ from accreta after adjusting for confounders (adjusted RR = 0.63, 95% confidence interval [CI]: 0.36–1.10 for increta and aRR = 0.72, 95% CI: 0.45–1.16 for percreta). The results were stratified by placenta previa status, which did not affect results. There was no difference in incidence of LGA (p = 1.0) by PAS pathologic severity. The incidence of SGA for all PAS patients was 9.2% for those delivered preterm and 18.7% for those delivered at term (p = 0.004). The incidence of LGA for all PAS patients was 12.6% for those delivered preterm and 13.2% for those delivered at term (p = 0.8203). Conclusion There was no difference in incidence of SGA or LGA when comparing accreta to increta or percreta patients regardless of previa status. Although we cannot suggest causation, our results suggest that PAS, regardless of pathologic severity, is not associated with pathologic fetal growth in the preterm period. Key Points

Placenta accreta spectrum (PAS) refers to the range of pathologic adherence of the placenta to the uterine myometrium, including the placenta accreta, increta, and percreta. The incidence of PAS is rising primarily because of an increase in related risk factors, such as the rate of cesarean deliveries and pregnancies resulting from assisted reproductive technology. The maternal risks associated with PAS are significant, including hemorrhage, hysterectomy, and death. Fetal and neonatal risks are primarily the result of premature delivery. Antenatal diagnosis via ultrasonography and magnetic resonance imaging remains imperfect. Management of PAS varies, however, and there is a clear improvement in maternal outcomes with an antenatal diagnosis compared with unexpected diagnosis at the time of delivery. Studies that evaluate the balance between maternal and fetal/neonatal risks of expectant management versus preterm delivery have found that planned delivery between 34 and 35 weeks’ gestation optimizes outcomes. Multidisciplinary PAS care teams have become the norm and recommended approach to management, given the complexity of caring for this obstetrical condition. Although significant advances have been made over the years, large knowledge gaps remain in understanding the pathophysiology, diagnosis, and clinical management.

Objective While evidence-based guidelines exist for placenta accreta spectrum (PAS) diagnosis and management, there is a paucity of data on PAS practice patterns worldwide. The objective of this study was to describe global geographic variations in the diagnosis and management of PAS. Methods An international cross-sectional study was conducted among PAS experts practicing at medical institutions in member states of the United Nations. Survey questions focused on diagnostic evaluation and management strategies for PAS. Results A total of 136 centers participated. Participating centers represented each of the United Nations' designated regions. Of those, 88% reported practicing in a medium or high volume center. First trimester PAS screen was reported in 26.1% of centers. Respondents consistently implement guideline-supported care practices, including utilization of ultrasound as the primary diagnostic modality (100%) and implementation of multidisciplinary care teams (85.8%). Less than 10% of respondents reported routinely managing PAS without hysterectomy; these centers were predominantly located in Europe and Africa. Antepartum management and availability of mental health support for PAS patients varied widely. Conclusion Worldwide, there is a strong adherence to PAS care guidelines; however, regional variations do exist. Comparing variations in care to outcomes will provide insight into the clinically significant practice variability.

Objective Placenta accreta spectrum (PAS) is an obstetric diagnosis that carries significant risks. However, little is known about patient perceptions of care. This study was conducted to describe the patient experience, reported outcomes, and assess geographical variation in PAS care in the United States. Study Design Partnering with a PAS patient advocacy organization, we conducted an online survey of PAS patients. Perceptions of care and outcomes, and geographic variation were described. Results We received 108 responses (69% response rate); 103 respondents delivered in the United States. Demographic characteristics were similar across each region. Most (67%) reported at least one prior cesarean delivery and 53% reported placenta previa in the PAS pregnancy. Over half (63%) reported an antenatal suspicion of PAS and 66% of those respondents reported changing their delivery hospital as a result of their antenatal diagnosis. Though not statistically significant, both showed variability across regions (both p ≥0.60). Seventy-five percent of respondents with antenatal diagnosis reported their pregnancy was managed by a dedicated PAS care team, which did not differ by region (p = 0.80). A majority of respondents (75%) felt their PAS care team was prepared for their delivery; this too did not vary across regions (p = 0.97). Many respondents reported at least one physical (63%) or mental health (17%) adverse outcome as a result of their PAS pregnancy. Conclusion As reported by prior PAS patients, perception of care and outcomes are overall favorable. There are long-term physical and mental adverse consequences reported. Geographical variation is mixed, however, national guidelines are predominately followed. Key Points

The terminology and diagnostic criteria presently used by pathologists to report invasive placentation is inconsistent and does not reflect current knowledge of the pathogenesis of the disease or the needs of the clinical care team. A consensus panel was convened to recommend terminology and reporting elements unified across the spectrum of PAS specimens (i.e., delivered placenta, total or partial hysterectomy with or without extrauterine tissues, curetting for retained products of conception). The proposed nomenclature under the umbrella diagnosis of placenta accreta spectrum (PAS) replaces the traditional categorical terminology (placenta accreta, increta, percreta) with a descriptive grading system that parallels the guidelines endorsed by the International Federation of Gynaecology and Obstetrics (FIGO). In addition, the nomenclature for hysterectomy specimens is separated from that for delivered placentas. The goal for each element in the system of nomenclature was to provide diagnostic criteria and guidelines for expected use in clinical practice.

The ideal time for birth in pregnancies diagnosed with vasa previa remains unclear. We conducted a systematic review aiming to identify the gestational age at delivery that best balances the risks for prematurity with that of pregnancy prolongation in cases with prenatally diagnosed vasa previa.Ovid MEDLINE, PubMed, CINAHL, Embase, Scopus, and Web of Science were searched from inception to January 2022.The intervention analyzed was delivery at various gestational ages in pregnancies prenatally diagnosed with vasa previa. Cohort studies, case series, and case reports were included in the qualitative synthesis. When summary figures could not be obtained directly from the studies for the quantitative synthesis, authors were contacted and asked to provide a breakdown of perinatal outcomes by gestational age at birth.Study appraisal was completed using the National Institutes of Health quality assessment tool for the respective study types. Statistical analysis was performed using a random-effects meta-analysis of proportions.The search identified 3435 studies of which 1264 were duplicates. After screening 2171 titles and abstracts, 140 studies proceeded to the full-text screen. A total of 37 studies were included for analysis, 14 of which were included in a quantitative synthesis. Among 490 neonates, there were 2 perinatal deaths (0.4%), both of which were neonatal deaths before 32 weeks' gestation. In general, the rate of neonatal complications decreased steadily from32 weeks' gestation (4.6% rate of perinatal death, 91.2% respiratory distress, 11.4% 5-minute Apgar score7, 23.3% neonatal blood transfusion, 100% neonatal intensive care unit admission, and 100% low birthweight) to 36 weeks' gestation (0% perinatal death, 5.3% respiratory distress, 0% 5-minute Apgar score7, 2.9% neonatal blood transfusion, 29.2% neonatal intensive care unit admission, and 30.9% low birthweight). Complications then increased slightly at 37 weeks' gestation before decreasing again at 38 weeks' gestation.Prolonging pregnancies until 36 weeks' gestation seems to be safe and beneficial in otherwise uncomplicated pregnancies with antenatally diagnosed vasa previa.

Background: Hemoperitoneum in pregnancy requires urgent evaluation. While spontaneous intraperitoneal bleeding is rare, ectopic endometrial tissue is a frequent cause of this event. Case: A 38-year-old woman with a history of endometriosis presented at 26 weeks gestation with 1 week of vague abdominal pain. Vital signs were within normal limits, and physical exam was notable for left-sided abdominal tenderness. Imaging demonstrated simple free fluid in her pelvis, concern for a uterine fundal defect and an adjacent hematoma. Exploratory laparotomy revealed hemoperitoneum secondary to highly vascularized stage 4 endometriosis. After classical cesarean delivery, a supracervical hysterectomy with bilateral oophorectomy was performed due to ongoing global pelvic hemorrhage. Conclusion: Consider endometriosis as a cause of spontaneous hemoperitoneum in pregnancy. Obstetricians should be prepared for significant maternal morbidity when encountering such pathology.

To characterize the immune cell infiltrate associated with maternal vascular remodeling in 12 cases of cesarean hysterectomy from women with placenta accreta spectrum (PAS) disorder. Myometrial vessels were evaluated by hematoxylin and eosin and immunohistochemistry stains on tissue microarrays that included samples from the myometrium, deep to the implantation site. Vessels were quantified based on physiologic conversion and immune cell infiltrates. Placental bed biopsies from cases of repeat cesarean section, and decidual vessels from delivered non-PAS placentas were used as controls. Immune cells, predominantly macrophages and T-cells, were present as a band along the placental-myometrial interface in PAS cases. However, within the myometrium, the infiltrate showed a perivascular accentuation. The infiltrates around and within vessel walls were composed of T-cells (CD3) and macrophages (CD68), with fewer NK (CD56), Treg (FoxP3) and rare B-cells (CD20). Plasma cells (CD138) were absent. The majority of vessels with immune cell infiltrates had undergone complete or partial physiologic conversion by trophoblast. However, a subset of unconverted vessels in the myometrium had a similar immune cell infiltration. Control blood vessels showed a similar pattern of leukocytes infiltration in the decidua and placental bed biopsies, but with a lower density. Our findings suggest that myometrial vascular changes in PAS resemble the physiological changes of vessels noted in the implantation site of normal pregnancies. The presence of perivascular immune cell infiltrates in the absence of adjacent trophoblast suggests that the process may be initiated by paracrine effects rather than direct contact or endovascular growth of trophoblast.

Lymphopenia does not identify severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among asymptomatic patients admitted to an obstetrics unit or among obstetric patients under investigation for coronavirus disease 2019 (COVID-19).

Objective: Our objective was to compare women with and without invasive placentation for whom the massive transfusion protocol (MTP) was activated. In addition, we evaluated the differences in clinical management and blood product utilization between the two groups and described the activation of MTP over time.Study design: This is a retrospective cohort study of women for whom the MTP was activated from January 2012 through July 2016. Two groups were compared, those with invasive placentation (accreta, increta, percreta) and those without.Results: We identified 87 women for whom the MTP was activated, the majority (62.1%) did not have invasive placentation. Women with invasive placentation were more likely to have had a prior cesarean delivery and placenta previa (both p < .001). Women with invasive placentation were more likely to undergo hysterectomy, experience more blood loss, and receive cell salvage (all p ≤ .04). Blood product utilization was similar between the two groups, with the exception of cell-salvage, which was more commonly used for women with invasive placentation. The proportion of deliveries necessitating MTP activation ranged from 1.4 to 2.6 per 1000 deliveries.Conclusion: Invasive placentation accounts for less than half of the cases complicated by activation of an MTP. Cases with invasive placentation were more likely to result in a vertical uterine and skin incision or a hysterectomy. With the exception of cell-salvage, blood product utilization was similar.

INTRODUCTION: MR relaxometry has been used to assess placental exchange function, but methods to date are not sufficiently fast to be robust to placental motion. Magnetic resonance fingerprinting (MRF) permits rapid, voxel-wise, intrinsically co-registered T(1) and T(2) mapping. After characterizing measurement error, we scanned pregnant women during air and oxygen breathing to demonstrate MRF’s ability to detect placental oxygenation changes. METHODS: The accuracy of FISP-based, sliding-window reconstructed MRF was tested on phantoms.MRF scans in 9-s breath holds were acquired at 3T in 31 pregnant women during air and oxygen breathing. A mixed effects model was used to test for changes in placenta relaxation times between physiological states, to assess the dependency on gestational age (GA), and the impact of placental motion. RESULTS: MRF estimates of known phantom relaxation times resulted in mean absolute errors for T(1) of 92 ms (4.8%), but T(2) was less accurate at 16 ms (13.6%). During normoxia, placental T(1)=1825±141 ms (avg±standard deviation) and T(2)=60±16 ms (gestational age range 24.3-36.7, median 32.6 weeks). In the statistical model, placental T(2) rose and T(1) remained contant after hyperoxia, and no GA dependency was observed for T(1) or T(2). DISCUSSION: Well-characterized, motion-robust MRF was used to acquire T(1) and T(2) maps of the placenta. Changes with hyperoxia are consistent with a net increase in oxygen saturation. Toward the goal of whole-placenta quantitative oxygenation imaging over time, we aim to implement 3D MRF with integrated motion correction to improve T(2) accuracy.

Placenta accreta spectrum includes the full range of abnormal placental attachment to the uterus or other structures, encompassing placenta accreta, placenta increta, placenta percreta, morbidly adherent placenta, and invasive placentation. The incidence of placenta accreta spectrum has increased in recent years, largely driven by increasing rates of cesarean delivery. Prenatal detection of placenta accreta spectrum is primarily made by ultrasound and is important to reduce maternal morbidity associated with the condition. Despite a large body of research on various placenta accreta spectrum ultrasound markers and their screening performance, inconsistencies in the literature persist. In response to the need for standardizing the definitions of placenta accreta spectrum markers and the approach to the ultrasound examination, the Society for Maternal-Fetal Medicine convened a task force with representatives from the American Institute of Ultrasound in Medicine, the American College of Obstetricians and Gynecologists, the American College of Radiology, the International Society of Ultrasound in Obstetrics and Gynecology, the Society for Radiologists in Ultrasound, the American Registry for Diagnostic Medical Sonography, and the Gottesfeld-Hohler Memorial Ultrasound Foundation. The goals of the task force were to assess placenta accreta spectrum sonographic markers on the basis of available data and expert consensus, provide a standardized approach to the prenatal ultrasound evaluation of the uterus and placenta in pregnancies at risk of placenta accreta spectrum, and identify research gaps in the field. This manuscript provides information on the Placenta Accreta Spectrum Task Force process and findings.

This volume constitutes a selection of 50 studies that changed the modern practice of obstetrics and gynecology. Studies were reviewed and summarized by national experts in the field and have been compiled in a simple, readable fashion that distills these works into the most salient points, placing them within the context of practice. This volume can be used by general practitioners as well as clinicians and academicians who have an interest in the state of evidence in obstetrics and gynecology.

Supplemental Digital Content is available in the text., BACKGROUND: Care of the pregnant patient during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic presents many challenges, including creating parallel workflows for infected and noninfected patients, minimizing waste of materials, and ensuring that clinicians can seamlessly transition between types of anesthesia. The exponential community spread of disease limited the time for development and training. METHODS: The goals of our workflow and process development were to maximize safety for staff and patients, minimize therisk of contamination, and reduce the waste of unused supplies and materials. We used a cyclical improvement system and the plus/delta debriefing method to rapidly develop workflows consisting of sequential checklists and procedure-specific packs. RESULTS: We designed independent workflows for labor analgesia, neuraxial anesthesia for cesarean delivery, conversion of labor analgesia to cesarean anesthesia, and general anesthesia. In addition, we created procedure-specific material packs to optimize supplies and prevent wastage. Finally, we generated sequential checklists to allow staff to perform standard operating procedures without extensive training. CONCLUSIONS: Collectively, these workflows and tools allowed our staff to urgently care for patients in high-risk situations without prior experience. Over time, we refined the workflows using a cyclical improvement system. We present our checklists and workflows as well as the system we used for their development, so that others may use them to their benefit.

The terminology and diagnostic criteria presently used by pathologists to report placenta accreta spectrum is inconsistent and does not reflect current knowledge of the pathogenesis of this disease.In 2020, the perinatal subcommittee of the Society for Pediatric Pathology Placenta Accreta Task Force proposed a new pathologic grading system for placenta accreta spectrum. We sought to correlate the clinical outcomes with the classification into each group in the new placenta accreta spectrum grading system.The pathology reports of patients with histopathologic confirmation of placenta accreta spectrum were reviewed in 2 academic referral centers by placental pathologists. Pathologic grading was assigned based on the new grading system according to which placenta accreta spectrum is categorized into 5 groups depending on the depth of invasion, from grade p1 with no invasion into the uterine wall to grade p3E with invasion beyond the uterine wall to the adjacent organs. Patient characteristics and clinical outcomes were compared among these groups. A univariate analysis was performed, and a multivariate linear or binomial regression was employed when needed.A total of 683 patients with placenta accreta spectrum were identified. Of those, 407 were included for histology review. There were 92 patients (23%) categorized into the grade p1 group, 74 (18%) in the grade p2 group, 84 (20%) in the grade p3A group, 121 (30%) in the grade p3D group, and 36 (9%) in the grade p3E group. There was a significant association between the pathology grading and the number of red blood cells transfused (β=1.14; 95% confidence interval, 0.48-1.79) and the postoperative complications including the rate of readmission (risk ratio, 1.93; 95% confidence interval, 1.26-2.94) and bladder injury (risk ratio, 1.81; 95% confidence interval, 1.23-2.68) after adjustment for antenatal diagnosis and other variables. The pathology grading was not associated with the estimated blood loss (P=.072).The new pathology grading system accurately reflects maternal outcomes and complications of placenta accreta spectrum. We encourage the utilization of this new pathologic grading system because it is designed to omit discrepancies in placenta accreta spectrum reporting and to standardize communication.

Background The COVID-19 pandemic caused by the SARS-CoV-2 has increased the demand for inpatient healthcare resources; however, approximately 80% of patients with COVID-19 have a mild clinical presentation and can be managed at home. Objective This study aimed to describe the feasibility and clinical and process outcomes associated with a multidisciplinary telemedicine surveillance model to triage and manage obstetrical patients with known exposures and symptoms of COVID-19. Study Design We implemented a multidisciplinary telemedicine surveillance model with obstetrical physicians and nurses to standardize ambulatory care for obstetrical patients with confirmed or suspected COVID-19 based on the symptoms or exposures at an urban academic tertiary care center with multiple hospital-affiliated and community-based practices. All pregnant or postpartum patients with COVID-19 symptoms, exposures, or hospitalization were eligible for inclusion in the program. Patients were assessed by means of regular nursing phone calls and were managed according to illness severity. Patient characteristics and clinical and process outcomes were abstracted from the electronic medical record. Results A total of 135 patients were enrolled in the multidisciplinary telemedicine model from March 17 to April 19, 2020, of whom 130 were pregnant and 5 were recently postpartum. In this study, 116 of 135 patients (86%) were managed solely in the outpatient setting and did not require an in-person evaluation; 9 patients were ultimately admitted after ambulatory or urgent evaluations, and 10 patients were observed after hospital discharge. Although only 50% of the patients were tested secondary to limitations in ambulatory testing, 1 in 3 of those patients received positive results for SARS-CoV-2 (N=22, 16% of entire cohort). Patients were enrolled in the telemedicine model for a median of 7 days (interquartile range, 4–8) and averaged 1 phone call daily, resulting in 891 nursing calls and 20 physician calls over 1 month. Conclusion A multidisciplinary telemedicine surveillance model for outpatient management of obstetrical patients with COVID-19 symptoms and exposures is feasible and resulted in rates of ambulatory management similar to those seen in nonpregnant patients. A centralized model for telemedicine surveillance of obstetrical patients with COVID-19 symptoms may preserve inpatient resources and prevent avoidable staff and patient exposures, particularly in centers with multiple ambulatory practice settings.

Background: Preparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe the rapid cycle implementation of a comprehensive perioperative checklist for care of the COVID-19 parturient and a retrospective analysis of the factors which influenced implementation success.Methods: A newly designed workflow for COVID-19 parturients requiring perioperative care was produced as a checklist, intended for use as a cognitive aid. Implementation and refinement of the workflow was accomplished through rapid-cycling, debriefing and on-site walkthroughs. Retrospective evaluation of the implementation experience was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR). Results: Post-implementation, consistent use of the workflow was reported for all obstetric COVID-19 perioperative cases (100% compliance). Evaluation of our implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting and characteristic of individuals (external pressures, baseline culture, and personal attributes) were felt to act as barriers. Constructs such as communication, shifted in influence over time.Conclusion: We describe the implementation of a comprehensive obstetric workflow checklist for care of the COVID-19 perioperative patient. A retrospective evaluation of our implementation experience was possible using CFIR, which enabled identification of barriers and facilitators for change within our unit. Furthermore, we observed that implementation success was possible, despite facilitation being perceived within only two domains at baseline. Emerging themes from this study highlight the importance of thoughtful innovation design, careful implementation planning and the establishment of a long-standing culture of improvement, in order to facilitate implementation of change during a time of crisis.

Background Preparedness efforts for a COVID-19 outbreak required redesign and implementation of a perioperative workflow for the management of obstetric patients. In this report we describe factors which influenced rapid cycle implementation of a novel comprehensive checklist for the perioperative care of the COVID-19 parturient. Methods Within our labour and delivery unit, implementation of a novel checklist for the COVID-19 parturient requiring perioperative care was accomplished through rapid cycling, debriefing and on-site walkthroughs. Post-implementation, consistent use of the checklist was reported for all obstetric COVID-19 perioperative cases (100% workflow checklist utilization). Retrospective analysis of the factors influencing implementation was performed using a group deliberation approach, mapped against the Consolidated Framework for Implementation Research (CFIR). Results Analysis of factors influencing implementation using CFIR revealed domains of process implementation and innovation characteristics as overwhelming facilitators for success. Constructs within the outer setting, inner setting, and characteristic of individuals (external pressures, baseline culture, and personal attributes) were perceived to act as early barriers. Constructs such as communication culture and learning climate, shifted in influence over time. Conclusion We describe the influential factors of implementing a novel comprehensive obstetric workflow for care of the COVID-19 perioperative parturient during the first surge of the pandemic using the CFIR framework. Early workflow adoption was facilitated primarily by two domains, namely thoughtful innovation design and careful implementation planning in the setting of a long-standing culture of improvement. Factors initially assessed as barriers such as communication, culture and learning climate, transitioned into facilitators once a perceived benefit was experienced by healthcare teams. These results provide important information for the implementation of rapid change during a time of crisis.

The United States is facing a national crisis related to increasing rates of maternal morbidity and mortality. Over the past few years, significant focus has been turned to initiatives that aim to address maternal morbidity and mortality rates. In parallel, the United States has seen a significant increase in restrictive abortion access state laws. The link between abortion restrictions and worsening maternal outcomes has been proposed. This review article outlines the national crisis of maternal morbidity and mortality, the potential role of limiting abortion access in this crisis, and the significant racial, socioeconomic, and geographical disparities that exist.

Objective The incidence of placenta accreta spectrum (PAS) has been increasing in the United States. In addition, there has also been an increase in the utilization of in vitro fertilization (IVF). The IVF pregnancies confer an increased risk of adverse obstetric and neonatal outcomes, but there is limited data on whether IVF is associated with PAS. The aim of this study is to assess the association between IVF and the risk of PAS. Study Design This was a retrospective cohort study of deliveries from January 1, 2013 to August 1, 2018 at a tertiary hospital in the Massachusetts. IVF pregnancies were compared with non-IVF pregnancies, and PAS diagnosis was confirmed by histopathology reports. Hospital administrative data and medical record review were used, and supplemented with data from birth certificates from the Massachusetts Department of Public Health. Results We identified 28,344 pregnancies that met inclusion criteria, of which 1,418 (5.0%) were IVF pregnancies. The overall incidence of PAS was 0.4% (2.2% in the IVF group and 0.3% in the non-IVF group). Women who underwent IVF had 5.5 times the risk of PAS (95% confidence interval [CI]: 3.4–8.7) compared with women in the non-IVF group, adjusted for maternal age, nulliparity, and year of delivery (Table 5). Compared with women in the non-IVF group, the IVF group had fewer prior cesarean deliveries (22.6 vs. 64.2%) and a lower prevalence of placenta previa (19.4 vs. 44.4%). Conclusion Women with an IVF pregnancy carry an increased risk of PAS compared with non-IVF. Among women who underwent IVF, there was a lower prevalence of prior cesarean deliveries and placenta previa. Future work is needed to identify the mechanism of association for this increased risk as well as a reliable tool for antenatal detection in this cohort of women. Key Points

Introduction Placenta Accreta Spectrum (PAS) disorder is one of the leading causes of maternal morbidity and mortality due to uncontrollable hemorrhage. The greatest risk factor for development of PAS is prior uterine surgery, frequently cesarean delivery. Despite considerable clinical knowledge, animal models of PAS are lacking. To address this, we used two surgical approaches to create uterine scarring in peripartum and non-pregnant CD-1 mice. Il10−/− mice, with a pro-inflammatory phenotype were also studied. Methods In peripartum mice, a hysterotomy was performed to simulate a cesarean section. The second approach utilized endometrial curettage in non-pregnant mice. Sham-operated mice served as control. Following recovery, females were mated. On gestation day 16, pregnant females were euthanized, and the uterus was excised. Tissue was fixed, sectioned, and stained with H&E or cytokeratin immunohistochemistry. The cytokeratin-positive area extending beyond the trophoblast giant cells was measured by quantitative image analysis. Disruption of the circular (inner myometrium) smooth muscle was scored semi-quantitatively. Results In surgically scarred mice, trophoblast invasion was deeper relative to control mice, regardless of surgical method. The myometrium in experimental mice showed significant disruption compared to sham controls. Results from CD-1 and Il10−/− mice were similar, with the latter showing more severe pathology. Discussion While further refinement of surgical method is required, our data indicate that surgical uterine scarring in mice represents a promising model of PAS.

Aims Pregnancy is a known risk factor for arterial dissection, which can result in significant morbidity and mortality in the peripartum period. However, little is known about the risk factors, timing, distribution, and outcomes of arterial dissections associated with pregnancy. Methods and results We included all women ≥12 years of age with hospitalizations associated with pregnancy and/or delivery in the Nationwide Readmissions Database between 2010 and 2015. The primary outcome was any dissection during pregnancy, delivery, or the postpartum period (42-days post-delivery). Secondary outcomes included timing of dissection, location of dissection, and in-hospital mortality. Among 18 151 897 pregnant patients, 993 (0.005%) patients were diagnosed with a pregnancy-related dissection. Risk factors included older age (32.8 vs. 28.0 years), multiple gestation (3.6% vs. 1.9%), gestational diabetes (14.3% vs. 0.2%), gestational hypertension (6.0% vs. 0.6%), and pre-eclampsia/eclampsia (2.7% vs. 0.4%), in addition to traditional cardiovascular risk factors. Of the 993 patients with dissection, 150 (15.1%) dissections occurred in the antepartum period, 232 (23.4%) were diagnosed during the admission for delivery, and 611 (61.5%) were diagnosed in the postpartum period. The most common locations for dissections were coronary (38.2%), vertebral (22.9%), aortic (19.8%), and carotid (19.5%). In-hospital mortality was 3.7% among pregnant patients with a dissection vs. Conclusion Arterial dissections occurred in 5.5/100 000 hospitalized pregnant or postpartum women, most frequently in the postpartum period, and were associated with high mortality risk. The coronary arteries were most commonly involved. Pregnancy-related dissections were associated with traditional risk factors, as well as pregnancy-specific conditions.

BACKGROUND Reasons for the increased incidence of cesarean delivery among women with inflammatory bowel disease remain unclear. We assessed cesarean delivery incidence and factors influencing mode of delivery in women with inflammatory bowel disease. METHODS We performed a 10-year retrospective cohort study of nulliparous women who delivered a singleton infant at our institution. We compared the risk of each mode of delivery in women with Crohn's disease and ulcerative colitis with women without inflammatory bowel disease. We assessed mode of delivery indications for patients with inflammatory bowel disease and whether cesarean deliveries were planned. RESULTS The overall incidence of cesarean delivery among women with Crohn's disease (24/59; 40.7%) was similar to that among women without inflammatory bowel disease (7868/21,805; 36.1%) (risk ratio 1.1 [95% confidence interval, 0.83, 1.5]; P = 0.46), but was increased in the subgroups with active and inactive perianal disease (risk ratio 2.3; P < 0.01). Women with ulcerative colitis had a 1.8-fold increased relative risk of cesarean delivery (41/65; 63.1%) (95% confidence interval, 1.5, 2.1; P < 0.01), with highest incidence in patients with ileal pouch-anal anastomosis. Forty-nine percent of ulcerative colitis and 66.7% of Crohn's disease cesarean deliveries were unplanned, with only 1 unplanned delivery performed for active inflammatory bowel disease. Most unplanned deliveries were for arrest of descent/dilation and nonreassuring fetal heart tracings. Seventy-five percent of planned cesarean deliveries were for inflammatory bowel disease-related indications. CONCLUSIONS Women with ulcerative colitis and perianal Crohn's disease have an increased incidence of cesarean delivery. At least half of cesarean deliveries are unplanned.

Background The World Maternal Antifibrinolytic trial demonstrated that tranexamic acid administered during postpartum hemorrhage reduces hemorrhage-related mortality and laparotomies. The World Health Organization has thus recommended early use of tranexamic acid in the treatment of postpartum hemorrhage. This recommendation has not been universally adopted in the United States, in part because of concerns about cost-effectiveness. Objective We aim to demonstrate the cost-effectiveness of routine tranexamic acid administration in the treatment of postpartum hemorrhage in the United States, where the rate of hemorrhage-related mortality is lower than that described in the World Maternal Antifibrinolytic trial. Study Design We constructed a decision tree comparing 3 strategies in women with a clinical diagnosis of postpartum hemorrhage: no tranexamic acid, tranexamic acid given at any time, and ideal use of tranexamic acid given within 3 hours of delivery. The study was performed from a health care institution perspective with a time horizon of delivery until 6 weeks postpartum. We included interventions that differed by arm in the World Maternal Antifibrinolytic trial (hemorrhage-related mortality, laparotomies, and brace or compression sutures) and incorporated probabilities and costs based on available data for a population of women with postpartum hemorrhage in the United States. In our base case, the rate of postpartum hemorrhage–related mortality was 0.0388%, and the cost of tranexamic acid was $37.80. We assumed that the relative risk reduction in death and laparotomy with tranexamic acid would be similar to the World Maternal Antifibrinolytic trial (19% and 36%, respectively). The primary outcome was incremental cost per hemorrhage-related death averted, and a main secondary outcome was incremental cost per laparotomy avoided under each strategy. Another planned secondary outcome was cost per quality-adjusted life-year. We anticipated that the risk reduction (benefit) because of tranexamic acid in the United States may be less than in the World Maternal Antifibrinolytic trial; thus, we performed 1-way and 2-way sensitivity analyses to explore the parameter uncertainty across a wide range of data-supported estimates. Probabilistic sensitivity analyses with Monte Carlo simulation were performed. Results Tranexamic acid strategies were dominant (more effective and cost saving) compared with no tranexamic acid for patients with postpartum hemorrhage in the United States. One-way analyses showed that tranexamic acid is cost saving as long as the relative risk reduction of death with tranexamic acid is greater than 4.7%; the model was not sensitive to any other variables. Threshold analyses outside the bounds defined in the model showed that tranexamic acid is cost saving as long as the relative risk reduction of laparotomy with tranexamic acid is greater than 7% or the cost of tranexamic acid is less than $194. A 2-way sensitivity analysis of the risk reduction of death because of tranexamic acid and the baseline risk of postpartum hemorrhage–related death confirmed that tranexamic acid is cost saving across a wide range of plausible estimates. Furthermore, probabilistic sensitivity analysis demonstrated that the tranexamic acid strategies are cost saving in >99.9% of 10,000 Monte Carlo simulations. Despite the initial cost of administration, the annual net cost savings expected from routine use of tranexamic acid for the treatment of postpartum hemorrhage in the United States is $11.3 million, and we estimate that 9 maternal deaths would be averted in 1 year with this strategy. Giving tranexamic acid within 3 hours would almost triple the cost savings and improve maternal outcomes much further. Conclusion A policy of routine tranexamic acid early in the treatment of postpartum hemorrhage is likely to be cost saving in the United States. This conclusion holds true even when the relative risk reduction with tranexamic acid is significantly less than reported in the World Maternal Antifibrinolytic trial and when tranexamic acid is significantly more expensive than currently reported.

1. A woman is pregnant at 31 weeks’ gestation with Rh (D)–negative, antibody-negative blood type. She develops a placental abruption, prompting delivery of a viable preterm infant with Rh (D)–positive blood type. Which of the following is recommended after delivery to prevent D-alloimmunization in the mother? 2. Unfortunately she does not receive the appropriate treatment. She then has a miscarriage while traveling and has an extremely elevated anti-D antibody titer in her next pregnancy 2 years later. She is diagnosed with fetal anemia at 22 weeks’ gestation and ultimately has a procedure ( Video 1). What procedure is being shown in this video? Video 1. Click here to view the video. Fetal intraperitoneal transfusion. Alloimmunization is the development of antibodies to foreign red blood cell antigens. Fetal red blood cell antigens are determined by maternal and paternal red blood cell phenotypes. If the fetus expresses antigens foreign to the pregnant woman, the woman can develop immunoglobulin G (IgG) antibodies to this …

To characterize the immune cell infiltrate associated with maternal vascular remodeling in 12 cases of cesarean hysterectomy from women with placenta accreta spectrum (PAS) disorder.Myometrial vessels were evaluated by hematoxylin and eosin and immunohistochemistry stains on tissue microarrays that included samples from the myometrium, deep to the implantation site. Vessels were quantified based on physiologic conversion and immune cell infiltrates. Placental bed biopsies from cases of repeat cesarean section, and decidual vessels from delivered non-PAS placentas were used as controls.Immune cells, predominantly macrophages and T-cells, were present as a band along the placental-myometrial interface in PAS cases. However, within the myometrium, the infiltrate showed a perivascular accentuation. The infiltrates around and within vessel walls were composed of T-cells (CD3) and macrophages (CD68), with fewer NK (CD56), Treg (FoxP3) and rare B-cells (CD20). Plasma cells (CD138) were absent. The majority of vessels with immune cell infiltrates had undergone complete or partial physiologic conversion by trophoblast. However, a subset of unconverted vessels in the myometrium had a similar immune cell infiltration. Control blood vessels showed a similar pattern of leukocytes infiltration in the decidua and placental bed biopsies, but with a lower density.Our findings suggest that myometrial vascular changes in PAS resemble the physiological changes of vessels noted in the implantation site of normal pregnancies. The presence of perivascular immune cell infiltrates in the absence of adjacent trophoblast suggests that the process may be initiated by paracrine effects rather than direct contact or endovascular growth of trophoblast.