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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

Objective To evaluate the relationship between umbilical artery cord gas values and fetal tolerance of labor, as reflected by Apgar score. We hypothesized the existence of wide biological variability in fetal tolerance of metabolic acidemia, which, if present, would weaken one fundamental assumption underlying the use of electronic fetal heart rate (FHR) monitoring. Methods We conducted a retrospective cohort study of term, singleton, nonanomalous fetuses delivered in our institution between March 2012 and July 2020. Universally obtained umbilical cord gas values and Apgar scores were extracted. We calculated Spearman correlation coefficients and receiver operating characteristic curves for various levels of umbilical artery pH, base excess, and Apgar scores. Results We analyzed data from 29,787 deliveries. The statistical correlation between umbilical artery pH and base excess and both 1- and 5-minute Apgar scores was weak or nonexistent in all pH range subgroups (range 0.064-0.213). Receiver operating characteristic curve analysis suggested umbilical artery pH value of 7.22 yields the best discrimination for prediction of a severely depressed newborn (5-minute Apgar score less than 4), but sensitivity and specificity for this predictive value remains poor to moderate. Conclusion The use of electronic FHR monitoring is predicated on a documented relationship between FHR patterns and umbilical artery pH, and an assumed correlation between pH and fetal outcomes, reflecting fetal tolerance of labor and delivery. Our data demonstrate a weak-to-absent correlation between metabolic acidemia and even short-term fetal condition, thus significantly weakening this latter assumption. No amount of future modification of FHR pattern interpretation to better predict newborn pH is likely to lead to improved newborn outcomes, given this weakness in a fundamental assumption on which FHR monitoring is based.

Our understanding and management of gestational hypertension and its variants are substantially hindered by a reliance on antiquated terminology and on practice recommendations based largely on tradition rather than outcomes-based evidence. Unsurprisingly, gestational hypertension remains a major contributor to maternal and neonatal morbidity and mortality rates, with little improvement seen over the past half century except as it relates to better newborn care. Reliance on a binary classification of vastly disparate types and degrees of organ dysfunction (severe or not severe) and the use of nonphysiological and largely arbitrary gestational age cutoffs are particularly problematic. If this situation is to improve, it will be necessary to abandon current misleading terminology and non-evidence-based traditional practice patterns and start again, building on management approaches validated by outcomes-based data.

Objective Placenta accreta spectrum (PAS) covers a wide spectrum of placental adherence/invasion with varied clinical significance. Histopathologic examination is considered the confirmatory gold standard, but is only obtained sometime after definitive treatment. The International Federation of Gynecology and Obstetrics (FIGO) has published a new clinical classification that can be assigned at delivery, and we aimed to investigate the association between this new FIGO classification and histopathology and also to assess its correlation with maternal outcomes. Study Design We studied a retrospective cohort of 185 patients with histopathologically proven PAS managed at our referral center between September 2012 and January 2019. Two experienced surgeons retrospectively reviewed charts and assigned the FIGO grading based on findings reported at delivery. A third experienced reviewer adjudicated to determine the classification used for final analysis. Categorical outcomes were compared with the use of chi-squared and the Fisher exact test, as appropriate. A multivariate model was designed to adjust outcomes in different FIGO groups for the involvement of a formal multidisciplinary management team. Results Among 185 patients, there were 41 (22%) placenta accreta, 44 (24%) placenta increta, and 100 (54%) placenta percreta on histopathology. The inter-rater reliability was found to be substantial with Kappa = 0.661 (p Conclusion The new FIGO clinical classification is strongly associated with histopathologic findings. A better understanding of the depth and extent of invasion as afforded by the clinical classification system will help standardize reporting and future research. Key Points

Preeclampsia and eclampsia are hypertensive disorders of pregnancy associated with abnormal placental vascular development. The systemic angiogenic imbalance, endothelial dysfunction and proinflammatory state caused by abnormal placental development results in abnormalities in renal, hepatic, pulmonary and neurologic function. Neurosensory symptoms related to pregnancy induced hypertension (PIH), the most devastating of which are intracranial hemorrhage and seizure, are among the leading causes of maternal and perinatal morbidity and mortality globally, yet risk stratification strategies and targeted therapies remain elusive. Current treatment for preeclampsia with severe features is limited to delivery, antihypertensive therapy, and magnesium sulfate seizure prophylaxis. Magnesium sulfate reduces seizure rates among severe preeclamptics, but predisposes patients to weakness, uterine atony, pulmonary edema and respiratory depression. Therefore, this drug should ideally be administered only to the subset of preeclamptics who are at increased risk for neurologic complications. While there are no objective methods validated to predict eclampsia, we hypothesize that measurement of optic nerve sheath diameters, optic disc height and middle cerebral artery transcranial doppler resistance indices may be useful in identifying subclinical cerebral edema, potentially allowing us to recognize those patients at highest risk for seizures. This summary of the current literature provides an initial framework for developing more sophisticated and noninvasive methods for identifying, monitoring and treating parturients who are at highest risk for neurologic complications from preeclampsia.

Introduction Rotational thromboelastometry (ROTEM) rapidly identifies deficits underlying coagulopathy during massive hemorrhage. Prompt coagulopathy correction is balanced with the risk of blood product overutilization, making the ability to quickly target therapy highly desirable. However, data about ROTEM reference ranges in pregnancy are limited. We hypothesized that ROTEM parameters change across trimesters of pregnancy and differ from the nonpregnant state. Also, we sought to identify which hemostatic test best predicts coagulation activation during pregnancy. Methods A prospective cohort study in healthy pregnant patients in the first (n = 34), second (n = 34), and third trimesters (n = 41) against healthy, nonpregnant controls (n = 33) was performed. Citrated blood was collected, and ROTEM, complete blood count, and plasma-based assays of coagulation were performed. Mean ± SD or median [IQR] were compared across trimesters and between each trimester against the nonpregnant state. ROTEM parameters vs. plasma-based assays were also compared. Results Maximum clot firmness and A10 in FIBTEM correlated strongly with fibrinogen level. INTEM and EXTEM values demonstrated only weak to modest correlation with corresponding tests using plasma assays. Thrombin antithrombin complex (TAT) increased from the first trimester onward, whereas other coagulation activation markers did not show difference compared with control group. Conclusion Rotational thromboelastometry parameters differ variably across trimesters of pregnancy and compared with the nonpregnant state. The development and use of pregnancy-specific values are critical to the proper clinical interpretation of ROTEM in women with serious hemorrhage during different stages in pregnancy. TAT was the earliest laboratory marker for coagulation activation among others.

Amniotic fluid embolism is an uncommon, but potentially lethal, complication of pregnancy. Because amniotic fluid embolism usually is seen with cardiac arrest, the initial immediate response should be to provide high-quality cardiopulmonary resuscitation. We describe key features of initial treatment of patients with amniotic fluid embolism. Where available, we recommend performing transthoracic or transesophageal echocardiography as soon as possible because this is an easy and reliable method of identifying a failing right ventricle. If such failure is identified, treatment that is tailored at improving right ventricular performance should be initiated with the use of inotropic agents and pulmonary vasodilators. Blood pressure support with vasopressors is preferred over fluid infusion in the setting of severe right ventricular compromise. Amniotic fluid embolism-related coagulopathy should be managed with hemostatic resuscitation with the use of a 1:1:1 ratio of packed red cells, fresh frozen plasma, and platelets (with cryoprecipitate as needed to maintain a serum fibrinogen of >150-200 mg/dL). In cases that require prolonged cardiopulmonary resuscitation or, after arrest, severe ventricular dysfunction refractory to medical management, consideration for venoarterial extracorporeal membrane oxygenation should be given.

Objective Antenatal diagnosis of placenta accreta spectrum (PAS) is critical to reduce maternal morbidity. While clinical outcomes of women with PAS have been extensively described, little information is available regarding the women who undergo cesarean delivery with a presumptive PAS diagnosis that is not confirmed by histopathologic examination. We sought to examine resource utilization and clinical outcomes of this group of women with a false-positive diagnosis of PAS. Study Design This is a retrospective analysis of patients with prenatally diagnosed PAS cared for between 2015 and 2020 by our multidisciplinary PAS team. Maternal outcomes were examined. Univariate analysis was performed and a multivariate model was employed to compare outcomes between women with and without histopathologically confirmed PAS. Results A total of 162 patients delivered with the preoperative diagnosis of PAS. Of these, 146 (90%) underwent hysterectomy and had histopathologic confirmation of PAS. Thirteen women did not undergo the planned hysterectomy. Three women underwent hysterectomy but pathologic examination did not confirm PAS. In comparing women with and without pathologic confirmation of PAS, the false-positive PAS group delivered later in pregnancy (34 vs. 33 weeks of gestation, p = 0.015) and had more planned surgery (88 vs. 47%, p = 0.002). There was no difference in skin incision type or hysterotomy placement for delivery. No significant difference in either the estimated blood loss or blood components transfused was noted between groups. Conclusion Careful intraoperative evaluation of women with preoperatively presumed PAS resulted in a 3/149 (2%) retrospectively unnecessary hysterectomy. Management of women with PAS in experienced centers benefits patients in terms of both resource utilization and avoidance of unnecessary maternal morbidity, understanding that our results are produced in a center of excellence for PAS. We also propose a management protocol to assist in the avoidance of unnecessary hysterectomy in women with the preoperative diagnosis of PAS. Key Points

A sustained increase in the maternal death rate in the U.S. remains one of the most challenging issues of the twenty-first century. Ten years ago, we investigated the major conditions contributing to the maternal death rate between the years 2000 and 2006. The leading causes of death in the U.S. at that time were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage and cardiac disease. Venous thromboembolism accounted for 9% of all maternal death, and an overall pregnancy-related mortality risk of 0.9 maternal deaths per 100,000 live births. VTE was the most common preventable cause of maternal death noted during that time period. In this paper, we will review and summarize changes in obstetric health care over the last ten years implemented to prevent VTE and its related morbidity. We will then examine opportunities for hospitals and hospital systems to improve VTE prophylaxis.

Objective The calculation of HCO3 and base excess in current blood gas analysis is based on the Siggaard–Andersen equation. One of the constants in this equation is dependent on the known buffering capacity of hemoglobin A. We sought to investigate differences in buffering capacity between adult hemoglobin A and fetal hemoglobin F as a potential explanation for the observed poor correlation between calculated base excess in umbilical cord blood and newborn outcomes. Such differences would influence a key constant in the Van Slyke/Siggaard–Andersen equation used to calculate HCO3 and base excess and could be an explanation of these observations. Study Design This was a prospective observational study. We analyzed umbilical cord blood bicarbonate levels both as calculated values from a traditional blood gas analyzer and as measured values in 20 women giving birth at term. Since the calculated value is dependent upon the concentration and known buffering capacity of hemoglobin A, significant differences in these two analyses would imply differences in the buffering capacity of hemoglobins A and F. Results The mean calculated HCO3 value was 25 mEq/L (25.3 ± 1.9) compared with a mean measured value of 25 mEq/L (24.6 ± 1.7) over a range of pH levels of 7.16 to 7.42. This difference was not significant (p = 0.07). Conclusion The buffering capacity of hemoglobin F, for clinical purposes, is not different than that of hemoglobin A and is not an explanation for the recognized poor correlation between base excess and neonatal outcome.

Massive transfusion protocols are widely implemented in obstetrical practice in case of severe hemorrhage; however, different recommendations exist regarding the appropriate ratios of blood product components to be transfused. We report our extensive experience with massive component transfusion in a referral center in which the standard massive transfusion protocol is modified by ongoing clinical and laboratory evaluation. A retrospective chart review of all patients who had massive transfusion protocol activation in a level 4 referral center for obstetrical practice was performed from January 2014 to January 2020. Data collected included the etiology of obstetrical hemorrhage, number of blood products of each type transfused, crystalloid infusion, and several indices of maternal morbidity and mortality. Data are presented with descriptive statistics. A total of 62 patients had massive transfusion protocol activation, of which 97% received blood products. Uterine atony was found to be the most common etiology for massive hemorrhage (34%), followed by placenta accreta spectrum (32%). The mean estimated blood loss was 1,945 mL. A mean of 6.5 units of packed red blood cells, 14.8 units of fresh frozen plasma and cryoprecipitate, and 8.3 units of platelets were transfused per patient. No maternal deaths were seen. The ratios of transfused packed red blood cell to fresh frozen plasma/cryoprecipitate and of packed red blood cell to platelet units varied significantly from the fixed initial infusion ratio called for by our massive transfusion protocol resulting in universally favorable maternal outcomes. When rapid laboratory evaluation of hematologic and clotting parameters is available, careful use of this information may facilitate safe modification of an initial fixed transfusion ratio based on etiology of the hemorrhage and individual patient response.· Massive transfusion protocols in obstetrics follow fixed ratios of blood products.. · Actual usage of blood components is different than the standardized protocols.. · We recommend to modify the initial fixed transfusion ratio according to clinical response..

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.

Objective To compare neonatal and maternal outcomes among twin pregnancies conceived as a result of different types of fertility treatments with those of spontaneously conceived twin pregnancies. Design Retrospective Cohort. Setting Population-based analysis. Patient(s) Population-based analysis of twin pregnancies in the United States based on their mode of conception using the natality data from the National Center for Health Statistics from the Centers for Disease Control and Prevention (from January 2015 through December 2017). Intervention(s) None. Main Outcome Measure(s) Adverse neonatal and maternal outcomes. Result(s) The overall prevalence of early adverse maternal outcomes and medical complications and obstetric complications including the risk of unplanned hysterectomy, intensive care unit admission, maternal blood transfusion, and perineal laceration were significantly higher in the fertility treatment group (including both ovulation induction/intrauterine insemination and assisted reproductive technology groups) compared with those of the spontaneous conception group, even after adjusting for several potential confounders. The risk of adverse composite neonatal outcomes was slightly lower in the spontaneous conception live twin birth group even after adjustment for several potential confounders. Conclusion(s) The rate of maternal and neonatal morbidity in twins conceived via different fertility treatments was slightly increased compared with those of twins conceived spontaneously. Because the absolute risks of maternal and neonatal morbidity were low, overall reassurance regarding these outcomes can be provided to the patients undergoing all types of fertility treatments.

Objective To analyze the origins and consequences of cases of brachial plexus injuries and their relationship to shoulder dystocia. Methods We conducted a retrospective cohort study and identified all neonates with brachial plexus injury delivered at our institution between March 2012 and July 2019. A review was performed of the maternal and neonatal records of each neonate to identify obstetric antecedents, including the occurrence of shoulder dystocia and persistence of the injury. Experience of the delivering clinician was also examined. Statistical analysis was performed with the Fisher exact test, χ test for trends, and two-tailed t tests. Results Thirty-three cases of brachial plexus injury were identified in 41,525 deliveries (0.08%). Fourteen (42%) of these cases were not associated with shoulder dystocia; three (9%) followed cesarean delivery. Brachial plexus injury without shoulder dystocia was related to the absence of maternal diabetes, lower birth weights, and a longer second stage of labor. Persistent brachial plexus injury at the time of discharge was seen with equal frequency among neonates with (17/19, 89%, 95% CI 0.52-100%) and without shoulder dystocia (10/14, 71%, 95% CI 34-100%), P=.36). Whether brachial plexus injury was transient or persistent after shoulder dystocia was unrelated to the years of experience of the delivering clinician. Despite ongoing training and simulation, the already low incidence of brachial plexus injury did not decrease over time at our institution. Conclusion Brachial plexus injury and shoulder dystocia represent two complications of uterine forces driving a fetus through the maternal pelvis in the presence of disproportion between the passage and the shoulder girdle of the passenger. Either or both of these complications may occur, but often are not causally related.

A surgical disease occurring during pregnancy can present a diagnostic dilemma due to the desire to make a timely and accurate diagnosis within the constraints of limiting radiation exposure to the fetus. However, required diagnostic imaging should be pursued when indicated and attempts made to minimize the radiation dose by utilizing abdominal shielding and low-dose protocols when feasible. When surgery is indicated due to disease processes, treatment should not be altered or delayed due to pregnancy as the evidence for adverse pregnancy outcomes including early pregnancy loss and preterm delivery are overall of low quality due to substantial confounding by the disease process itself.

Background Placenta accreta spectrum is well known for its association with catastrophic maternal outcomes. However, its pathophysiology is not well defined. There have been emerging data that in vitro fertilization may be a risk factor for placenta accreta spectrum. Objective We investigated the hypothesis that in vitro fertilization is an independent risk factor for placenta accreta spectrum. Study Design A retrospective analysis of all deliveries in a prospective, population-based cohort (2012–2019) was performed in a tertiary academic center. Primary outcome variable was placenta accreta spectrum. Univariate analysis was performed on potential risk factors for predicting placenta accreta spectrum, and a multivariate model was designed to best fit the prediction of placenta accreta spectrum adjusted for risk factors such as cesarean delivery, placenta previa, age, and parity. History of previous cesarean delivery was known as a risk factor for both placenta previa and placenta accreta spectrum; hence, the interaction between “placenta previa” and “previous cesarean delivery” was included in the final model. Odds ratios were calculated as exponential of beta coefficients from the multivariate regression analysis. Results A total of 37,461 deliveries were included in this analysis, 5464 (15%) of which had a history of cesarean delivery, 281 (0.7%) had placenta previa in their index pregnancy, and 571 (1.5%) had in vitro fertilization pregnancy. The frequency of placenta accreta spectrum was 230 (0.6%). Independent risk factors for placenta accreta spectrum were in vitro fertilization pregnancy (adjusted odds ratio, 8.7; 95% confidence interval, 3.8–20.3), history of previous cesarean delivery (adjusted odds ratio, 21.1; 95% confidence interval, 11.4–39.2), and presence of placenta previa (adjusted odds ratio, 94.6; 95% confidence interval, 29.3–305.1). After adjustment for number of previous cesarean deliveries, the correlation persisted for in vitro fertilization (adjusted odds ratio, 6.7; 95% confidence interval, 2.9–15.6). Conclusion Our data suggested that in vitro fertilization is an independent risk factor for placenta accreta spectrum, although its relative clinical importance compared with that of the presence of placenta previa and history of cesarean delivery is small. The pathophysiology behind this relationship remains to be investigated.

Objective This study aimed to investigate the diagnostic performance of transperineal ultrasound–measured angles of progression at the onset of the second stage of labor for the prediction of spontaneous vaginal delivery in singleton term pregnancies with cephalic presentation. Data Sources We performed a predefined systematic search in PubMed, Embase, Scopus, Web of Science, and Google Scholar from inception to February 5, 2021. Study Eligibility Criteria Prospective cohort studies that evaluated the diagnostic performance of transperineal ultrasound–measured angles of progression (index test) at the onset of the second stage of labor (ie, when complete cervical dilation is diagnosed) for the prediction of spontaneous vaginal delivery (reference standard) were eligible for inclusion. Eligible studies were limited to those published as full-text articles in the English language and those that included only parturients with a singleton healthy fetus at term with cephalic presentation. Study Appraisal and Synthesis Methods Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Summary receiver operating characteristic curves, pooled sensitivities and specificities, area under the curve, and summary likelihood ratios were calculated using the Stata software. Subgroup analyses were done based on angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°. Results A total of 8 studies reporting on 887 pregnancies were included. Summary estimates of the sensitivity and specificity of transperineal ultrasound–measured angle of progression at the onset of the second stage of labor for predicting spontaneous vaginal delivery were 94% (95% confidence interval, 88%–97%) and 47% (95% confidence interval, 18%–78%), respectively, for an angle of progression of 108° to 119°, 81% (95% confidence interval, 70%–89%) and 73% (95% confidence interval, 57%–85%), respectively, for an angle of progression of 120° to 140°, and 66% (95% confidence interval, 56%–74%) and 82% (95% confidence interval, 66%–92%), respectively, for an angle of progression of 141° to 153°. Likelihood ratio syntheses gave overall positive likelihood ratios of 1.8 (95% confidence interval, 1–3.3), 3 (95% confidence interval, 2–4.7), and 3.7 (95% confidence interval, 1.7–8.1) and negative likelihood ratios of 0.13 (95% confidence interval, 0.07–0.22), 0.26 (95% confidence interval, 0.18–0.38), and 0.42 (95% confidence interval, 0.29–0.60) for angle of progression ranges of 108° to 119°, 120° to 140°, and 141° to 153°, respectively. Conclusion Angle of progression measured by transperineal ultrasound at the onset of the second stage of labor may predict spontaneous vaginal delivery in singleton, term, cephalic presenting pregnancies and has the potential to be used along with physical examinations and other clinical factors in the management of labor and delivery.

Background Hysterectomy for placenta accreta spectrum may be associated with urologic morbidity, including intentional or unintentional cystostomy, ureteral injury, and bladder fistula. Although previous retrospective studies have shown an association between placenta accreta spectrum and urologic morbidities, there is still a paucity of literature addressing these urologic complications. Objective We sought to report a systematic description of such morbidity and associated factors. Study Design This was a retrospective study of all histology-proven placenta accreta spectrum deliveries in an academic center between 2011 and 2020. Urologic morbidity was defined as the presence of at least one of the following: cystotomy, ureteral injury, or bladder fistula. Variables were reported as median (interquartile range) or number (percentage). Analyses were made using appropriate parametric and nonparametric tests. Multinomial regression analysis was performed to assess the association of adverse urologic events with the depth of placental invasion. Results In this study, 58 of 292 patients (19.9%) experienced urologic morbidity. Patients with urologic morbidity had a higher rate of placenta percreta (compared with placenta accreta and placenta increta) than those without such injuries. Preoperative ureteral stents were placed in 54 patients (93.1%) with and 146 patients (62.4%) without urologic injury (P=.003). After adjusting for confounding variables, multinomial regression analysis revealed that the odds of having adverse urologic events was 6.5 times higher in patients with placenta percreta than in patients with placenta accreta. Conclusion Greater depth of invasion in placenta accreta spectrum was associated with more frequent and severe adverse urologic events. Whether stent placement confers any protective benefit requires further investigation.

One percent to 2% of pregnant women undergo nonobstetric surgery during pregnancy. Historically, there has been a reluctance to operate on pregnant women based on concerns for teratogenesis, pregnancy loss, or preterm birth. However, a careful review of published data suggests four major flaws affecting much of the available literature. Many studies contain outcomes data from past years in which diagnostic testing, surgical technique, and perioperative maternal-fetal care were so different from current experience as to make these data of limited utility today. This issue is further compounded by a tendency to combine experience from vastly disparate types of surgery into a single report. In addition, reports in nonobstetric journals often focus on maternal outcomes and contain insufficient detail regarding perinatal outcomes to allow distinction between complications associated with surgical disease and those attributable to surgery itself. Finally, most series are either uncontrolled or use the general population of pregnant women as controls rather than women with surgical disease who are managed nonsurgically. Consideration of these factors as well as our own extensive experience suggests that when the risks of maternal hypotension or hypoxia are minimal, or can be adequately mitigated, indicated surgery during any trimester does not appear to subject either the mother or fetus to risks significantly beyond those associated with the disease itself or the complications of surgery in nonpregnant individuals. In some cases, reluctance to operate during pregnancy becomes a self-fulfilling prophecy in which delay in surgery contributes to adverse perinatal outcomes traditionally attributed to surgery itself.

To quantitate the contribution of various demographic factors to the U.S. maternal mortality ratio.This was a retrospective observational study. We analyzed data from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics database and the Detailed Mortality Underlying Cause of Death database (CDC WONDER) from 2005 to 2014 that contains mortality and population counts for all U.S. counties. Bivariate correlations between the maternal mortality ratio and all maternal demographic, lifestyle, health, and medical service utilization characteristics were calculated. We performed a maximum likelihood factor analysis with varimax rotation retaining variables that were significant (P.05) in the univariate analysis to deal with multicollinearity among the existing variables.The United States has experienced an increase in maternal mortality ratio since 2005 with rates increasing from 15 per 100,00 live births in 2005 to 21-22 per 100,000 live births in 2013 and 2014. (P.001) This increase in mortality was most pronounced in non-Hispanic black women, with ratios rising from 39 to 49 per 100,000 live births. A significant correlation between state mortality ranking and the percentage of non-Hispanic black women in the delivery population was demonstrated. Cesarean deliveries, unintended births, unmarried status, percentage of deliveries to non-Hispanic black women, and four or fewer prenatal visits were significantly (P.05) associated with the increased maternal mortality ratio.The current U.S. maternal mortality ratio is heavily influenced by a higher rate of death among non-Hispanic black or unmarried patients with unplanned pregnancies. Racial disparities in health care availability and access or utilization by underserved populations are important issues faced by states seeking to decrease maternal mortality.

OBJECTIVE To compare outcomes between planned and urgent cesarean hysterectomy for morbidly adherent placenta managed by a multidisciplinary team. METHODS This is a retrospective case-control study of women with singleton pregnancies with antenatally suspected and pathologically confirmed morbidly adherent placenta who underwent cesarean hysterectomy between January 1, 2011, and February 30, 2017. Timing of delivery was classified as either planned (delivery at 34-35 weeks of gestation) or urgent (need for urgent delivery as a result of uterine contractions, bleeding, or both). The primary outcome variable was composite maternal morbidity. Logistic regression analysis was used to evaluate risk factors for urgent delivery. RESULTS One hundred thirty patients underwent hysterectomy. Sixty (46.2%) required urgent delivery. Composite maternal morbidity was identified in 34 (56.7%) of the urgent and 26 (37.1%) of the planned deliveries (P=.03). Fewer units of red blood cells and fresh frozen plasma were transfused in the planned delivery group (red blood cells, median interquartile range 3 [0-8] versus 1 [0-4], P=.02; fresh frozen plasma, median interquartile range 1 [0-2] versus 0 [0-0], P=.001). Rates of low Apgar score and respiratory distress syndrome were higher in the urgent compared with the planned delivery group (5-minute Apgar score less than 7, 34 [59.6%] versus 14 [23.3%], P

Pregnancy-related deaths in the United States are increasing. Medical, social, economic, and cultural issues have all been implicated in this trend, but few data exist to differentiate the relative contributions of these various factors.The objective of the study was to examine trends in US pregnancy-related mortality by place of death and maternal race and age. We hypothesized that such an analysis may allow some distinction between deaths related to medical performance and those more closely related to social, cultural, or environmental issues.We conducted a retrospective, cross-sectional study for the years 2003-2016 using multiple cause-of-death mortality data provided by the Centers for Disease Control and Natality Data provided by National Vital Statistics System of the National Center for Health Statistics. Temporal trends analyses for the place of death, race/ethnicity, and age at the time of death were performed using joinpoint regression over the study period.Approximately one third of pregnancy-related deaths occurred outside a medical facility. The fraction of maternal deaths occurring in inpatient facilities fell by 20% over the study period, from 53% to 44% of all maternal deaths (P.0001). Maternal deaths in an outpatient facility or emergency room demonstrated a similar decline (24%) in relative frequency (P.0001). In contrast, there was a significant increase in the relative frequency of maternal mortality in other settings, particularly within the descendant's home, with a doubling over this time period. However, overall pregnancy-related deaths continued to increase in all settings. These increases were particularly striking in non-Hispanic black and white women and among women in the youngest and oldest age groups.Against a background of rising US pregnancy-related mortality, stratification of such deaths by place of death and maternal age and race highlights both the need for ongoing improvements in the quality of medical care and the potential contribution of events occurring outside a medical facility to the overall morality ratio. Current trends in pregnancy-related mortality in the United States are, in part, driven by social, cultural, and financial issues beyond the direct control of the medical community.

ObjectiveTo examine the risk for cyanotic congenital heart diseases (CCHDs) among live births in the USA, resulting from various forms of infertility treatments.MethodsThis study is a cross-sectional analysis of live births in the USA from 2011 to 2014. Infertility treatments are categorised into two of the following groups on birth certificates: assisted reproductive technology (ART) fertility treatment (surgical egg removal; eg, in vitro fertilisation and gamete intrafallopian transfer) and non-ART fertility treatment (eg, medical treatment and intrauterine insemination). We compared the risk for CCHD in ART and non-ART fertility treatment groups with those infants whose mothers received no documented fertility treatment and were naturally conceived (NC).ResultsAmong 14 242 267 live births from 2011 to 2014, a total of 101 494 live births were in the ART and 81 242 resulted from non-ART fertility treatments. CCHD prevalence in ART, non-ART and NC groups were 393/100 892 (0.39%), 210/80 884 (0.26%) and 10 749/14 020 749 (0.08%), respectively. As compared with naturally conceiving infants, risk for CCHD was significantly higher among infants born in ART (adjusted relative risk (aRR) 2.4, 95% CI 2.1 to 2.7) and non-ART fertility treatment groups (aRR 1.9, 95% CI 1.6 to 2.2). Absolute risk increase in CCHD due to ART and non-ART treatments were 0.03% and 0.02%, respectively. A similar pattern was observed when the analysis was restricted to twins, newborns with birth weights under 1500 g and gestational age of less than 32 weeks.ConclusionsOur findings suggest an increased risk for CCHD in infants conceived after all types of infertility treatment.

The United States has the highest maternal mortality ratio of any high-resource country; the 2014 ratio of 22 per 100,000 live births is in fact four to five times higher than that of the best-performing nations, and recent data suggest that this ratio may be increasing. The causes of this disparity are unknown and may be related to social, economic, cultural, or medical issues or a combination of factors. Repeated counts of categories of maternal death are of little assistance in determining the actual cause of death or in identifying preventive measures. Furthermore, when based on administrative data, such tallies may themselves be inaccurate. We propose the creation of a national maternal mortality review committee, modeled after those in other high-resource nations, to assist in addressing the problem of maternal mortality in the United States.

Objective This study aims to describe the subsequent reproductive outcomes in women who either correctly or incorrectly were diagnosed with amniotic fluid embolism (AFE). Study design Medical records were obtained, abstracted and reviewed by authors with extensive experience in critical care obstetrics. Telephone interviews of all survivors were conducted to determine obstetrical and contraceptive history. A subgroup underwent further telephone interview to address subsequent reproductive decisions. Results By November 2015, 116 medical records of patients diagnosed with AFE were reviewed. Patients who had undergone hysterectomy (n=26), died (n=9), or developed Sheehan's syndrome (n=1) at the time of the original event were excluded from the present analysis. Of the remaining 80 women, 30% (24/80) had subsequently conceived and 32.5% (26/80) patients or their partners had undergone permanent sterilization. At the time of this report, 66% (21/32) of registry participants were categorized to have had AFE and 34% (11/32) as not likely AFE or indeterminate. Conclusions The syndrome of AFE is over-diagnosed. Women diagnosed with AFE who survive conceive another pregnancy less frequently than US women over similar time intervals and often choose a permanent sterilization method, whether or not they actually had AFE, largely out of fear of AFE recurrence.

Zika virus is an emerging mosquito-borne ( Aedes genus) arbovirus of the Flaviviridae family. Following epidemics in Micronesia and French Polynesia during the past decade, more recent Zika virus infection outbreaks were first reported in South America as early as May 2013 and spread to now 50 countries throughout the Americas. Although no other flavivirus has previously been known to cause major fetal malformations following perinatal infection, reports of a causal link between Zika virus and microcephaly, brain and ocular malformations, and fetal loss emerged from hard-hit regions of Brazil by October 2015. Among the minority of infected women with symptoms, clinical manifestations of Zika virus infection may include fever, headache, arthralgia, myalgia, and maculopapular rash; however, only 1 of every 4–5 people who are infected have any symptoms. Thus, clinical symptom reporting is an ineffective screening tool for the relative risk assessment of Zika virus infection in the majority of patients. As previously occurred with other largely asymptomatic viral infections posing perinatal transmission risk (such as HIV or cytomegalovirus), we must develop and implement rapid, sensitive, and specific screening and diagnostic testing for both viral detection and estimation of timing of exposure. Unfortunately, despite an unprecedented surge in attempts to rapidly advance perinatal clinical testing for a previously obscure arbovirus, there are several ongoing hindrances to molecular- and sonographic-based screening and diagnosis of congenital Zika virus infection. These include the following: (1) difficulty in estimating the timing of exposure for women living in endemic areas and thus limited interpretability of immunoglobulin M serologies; (2) cross-reaction of immunoglobulin serologies with other endemic flaviruses, such as dengue; (3) persistent viremia and viruria in pregnancy weeks to months after primary exposure; and (4) fetal brain malformations and anomalies preceding the sonographic detection of microcephaly. In this commentary, we discuss screening and diagnostic considerations that are grounded not only in the realities of current obstetrical practice in a largely global population but also in basic immunology and virology. We review recent epidemiological data pertaining to the risk of congenital Zika virus malformations based on trimester of exposure and consider side by side with emerging data demonstrating replication of Zika virus in placental and fetal tissue throughout gestation. We discuss limitations to ultrasound based strategies that rely largely or solely on the detection of microcephaly and provide alternative neurosonographic approaches for the detection of malformations that may precede or occur independent of a small head circumference. This expert review provides information that is of value for the following: (1) obstetrician, maternal-fetal medicine specialist, midwife, patient, and family in cases of suspected Zika virus infection; (2) review of the methodology for laboratory testing to explore the presence of the virus and the immune response; (3) ultrasound-based assessment of the fetus suspected to be exposed to Zika virus with particular emphasis on the central nervous system; and (4) identification of areas ready for development.

OBJECTIVE: In a 2015 Maternal-Fetal Medicine Units Network study, only half of placenta accreta spectrum cases were suspected before delivery, and the outcomes in the anticipated cases were paradoxically poorer than in unanticipated placenta accreta spectrum cases. This was possibly because the antenatally suspected cases were of greater severity. We sought to compare the outcomes of expected vs unexpected placenta accreta spectrum in a single large US center with multidisciplinary management protocol. STUDY DESIGN: This was a retrospective cohort study carried out between Jan. 1, 2011, and June 30, 2018, of all histology-proven placenta accreta spectrum deliveries in an academic referral center. Patients diagnosed at the time of delivery were cases (unexpected placenta accreta spectrum), and those who were antentally diagnosed were controls (expected placenta accreta spectrume). The primary and secondary outcomes were the estimated blood loss and the number of red blood cell units transfused, respectively. Variables are reported as median and interquartile range or number (percentage). Analyses were made using appropriate parametric and nonparametric tests. RESULTS: Fifty-four of the 243 patients (22.2%) were in the unexpected placenta accreta spectrum group. Patients in the expected placenta accreta spectrum group had a higher rate of previous cesarean delivery (170 of 189 [89.9%] vs 35 of 54 [64.8%]; P < .001) and placenta previa (135 [74.6%] vs 19 [37.3%]; P < .001). There was a higher proportion of increta/percreta in expected placenta accreta spectrum vs unexpected placenta accreta spectrum (125 [66.1%] vs 9 [16.7%], P < .001). Both primary outcomes were higher in the unexpected placenta accreta spectrum group (estimated blood loss, 2.4 L [1.4–3] vs 1.7 L [1.2–3], P = .04; red blood cell units, 4 [1–6] vs 2 [0–5], P = .03). CONCLUSION: Our data contradict the Maternal-Fetal Medicine Units results and instead show better outcomes in the expected placenta accreta spectrum group, despite a high proportion of women with more severe placental invasion. We attribute this to our multidisciplinary approach and ongoing process improvement in the management of expected cases. The presence of an experienced team appears to be a more important determinant of maternal morbidity in placenta accreta spectrum than the depth of placental invasion.

To investigate factors associated with differential state maternal mortality ratios and to quantitate the contribution of various demographic factors to such variation.In a population-level analysis study, we analyzed data from the Centers for Disease Control and Prevention National Center for Health Statistics database and the Detailed Mortality Underlying Cause of Death database (CDC WONDER) that contains mortality and population counts for all U.S. counties. Bivariate correlations between maternal mortality ratio and all maternal demographic, lifestyle, health, and medical service utilization characteristics were calculated. We performed a maximum likelihood factor analysis with varimax rotation retaining variables that were significant (P.05) in the univariate analysis to deal with multicollinearity among the existing variables.The United States has experienced a continued increase in maternal mortality ratio since 2007 with rates of 21-22 per 100,000 live births in 2013 and 2014. This increase in mortality was most dramatic in non-Hispanic black women. There was a significant correlation between state mortality ranking and the percentage of non-Hispanic black women in the delivery population. Cesarean deliveries, unintended births, unmarried status, percentage of non-Hispanic black deliveries, and four or less prenatal visits were significantly (P.05) associated with increased maternal mortality ratio.Interstate differences in maternal mortality ratios largely reflect a different proportion of non-Hispanic black or unmarried patients with unplanned pregnancies. Racial disparities in health care availability, access, or utilization by underserved populations are an important issue faced by states in seeking to decrease maternal mortality.

Both resident training in the use of obstetric forceps and forceps deliveries are experiencing precipitous declines in the United States. Current minimum training requirements are insufficient to ensure competency in this skill. These trends bear striking similarities to observations regarding the decline and ultimate extinction of biologic species and portend the inevitable disappearance of this valuable skill from the obstetric armamentarium. Attempts by experienced teaching faculty to provide residents with experience in a few forceps deliveries are of little value and may do more harm than good. There would seem to be only two viable solutions to this dilemma: 1) abandon attempts to teach forceps and prepare residents for a real-world practice setting in which management of second-stage labor does not include the availability forceps delivery; or 2) prioritize the development of high-fidelity simulation models in which fetal head size and attitude and pelvic size and architecture can be continuously varied to allow residents to obtain sufficient experience to know both how and when to proceed with forceps delivery. We believe this latter approach is the sole alternative to inevitable extinction of this species.

Uterine atony remains the major cause of postpartum hemorrhage, and of death from postpartum hemorrhage in the United States. While existing guidelines outlining a general approach to postpartum hemorrhage are useful, recent data suggest that greater specificity may be necessary to significantly impact mortality. We present a highly specific and methodical approach to the management of uterine atony, which addresses what we believe to be the most common cause of preventable maternal hemorrhagic death in the US—lack of an intensive, focused approach to atony and perseverance with therapies that are not working. This protocol should result in cessation of hemorrhage by medical or surgical means within 1 hour of diagnosis. We then apply this protocol to a number of illustrative cases of maternal death due to atony. An approach involving the active management of uterine atony may assist clinicians in avoiding severe morbidity and mortality from uterine atony.

Background Morbidly adherent placenta (MAP) is a serious obstetric complication causing mortality and morbidity. Objective To evaluate whether outcomes of patients with MAP improve with increasing experience within a well-established multidisciplinary team at a single referral center. Study Design All singleton pregnancies with pathology-confirmed MAP (including placenta accreta, increta, or percreta) managed by a multidisciplinary team between January 2011 and August 2016 were included in this retrospective study. Turnover of team members was minimal, and cases were divided into 2 time periods so as to compare 2 similarly sized groups: T1 = January 2011 to April 2014 and T2 = May 2014 to August 2016. Outcome variables were estimated blood loss, units of red blood cell transfused, volume of crystalloid transfused, massive transfusion protocol activation, ureter and bowel injury, and neonatal birth weight. Comparisons and adjustments were made by use of the Student t test, Mann-Whitney U test, χ 2 test, analysis of covariance, and multinomial logistic regression. Results A total of 118 singleton pregnancies, 59 in T1 and 59 in T2, were managed during the study period. Baseline patient characteristics were not statistically significant. Forty-eight of 59 (81.4%) patients in T1 and 42 of 59 (71.2%) patients in T2 were diagnosed with placenta increta/percreta. The median [interquartile range] estimated blood loss (T1: 2000 [1475-3000] vs T2: 1500 [1000-2700], P = .04), median red blood cell transfusion units (T1: 2.5 [0-7] vs T2: 1 [0-4], P = .02), and median crystalloid transfusion volume (T1: 4200 [3600-5000] vs T2: 3400 [3000-4000], P P Conclusion Our study shows that patient outcomes are improved over time with increasing experience within a well-established multidisciplinary team performing 2−3 cases per month. This suggests that small, collective changes in team dynamics lead to continuous improvement of clinical outcomes. These findings support the development of centers of excellence for MAP staffed by stable, core multidisciplinary teams, which should perform a significant number of these procedures on an ongoing basis.

Background Pregnant women with preeclampsia have been shown to have elevated cerebral perfusion pressure and impaired cerebral autoregulation compared to normal pregnant women. Transcranial Doppler is a non-invasive technique used to estimate cerebral perfusion pressure. The effects of different antihypertensives on cerebral perfusion pressure in preeclampsia is unknown. Objectives To compare the change in cerebral perfusion pressure before and after intravenous labetalol versus oral nifedipine in the setting of acute, severe hypertension in pregnancy. Study Design This is a prospective cohort study of pregnant women between 24 and 42 weeks of gestation with severe hypertension (systolic blood pressure ≥160 and/or diastolic blood pressure ≥110). Women who consented to the study and received either intravenous labetalol or oral nifedipine were included. Exclusion criteria included active labor or receipt of any antihypertensive medication within 2 hours of initial cerebral perfusion pressure measurement. Peripheral blood pressure and transcranial Doppler studies for middle cerebral artery hemodynamics were performed prior to the administration of antihypertensives and repeated 30 minutes after medication administration. Results Sixteen women with acute, severe hypertension were enrolled; 8 received intravenous labetalol and 8 received oral nifedipine. There were no significant differences between the labetalol and nifedipine groups for baseline characteristics including maternal age, race and ethnicity, payment, hospital site, body mass index, nulliparity, gestational age, pre-existing diabetes mellitus or chronic hypertension, fetal growth restriction, magnesium sulfate, or symptomatology (P>.05). When examined 30 minutes after the administration of either intravenous labetalol or oral nifedipine, there was a significantly greater decrease in systolic blood pressure (-9.8 mmHg versus -39 mmHg, P=.003), mean arterial pressure (-7.1 mmHg versus -22.3 mmHg, P=.02), and cerebral perfusion pressure (-2.5 mmHg versus -27.7 mmHg, P=.01) in the nifedipine group. There was no statistically significant decrease in diastolic pressure (-12.9 mmHg versus -5.4 mmHg, P=.15). The change in middle cerebral artery velocity by transcranial Doppler was compared between the groups and was not different (.07 cm/s vs .16 cm/s, P=.64). Conclusion Oral nifedipine resulted in a significant decrease in in cerebral perfusion pressure, while labetalol did not, following administration for acute, severe hypertension among women with preeclampsia. This decrease appears to be driven by a decrease in peripheral arterial blood pressure rather than a direct change in cerebral blood flow.

Background Incidence, risk factors, and perinatal morbidity and mortality rates related to amniotic fluid embolism remain a challenge to evaluate, given the presence of differing international diagnostic criteria, the lack of a gold standard diagnostic test, and a significant overlap with other causes of obstetric morbidity and mortality. Objective The aims of this study were (1) to analyze the clinical features and outcomes of women using the largest United States-based contemporary international amniotic fluid embolism registry, and (2) to investigate differences in demographic and obstetric variables, clinical presentation, and outcomes between women with typical versus atypical amniotic fluid embolism, using previously published and validated criteria for the research reporting of amniotic fluid embolism. Materials and Methods The AFE Registry is an international database established at Baylor College of Medicine (Houston, TX) in partnership with the Amniotic Fluid Embolism Foundation (Vista, CA) and the Perinatology Research Branch of the Division of Intramural Research of the NICHD/NIH/DHHS (Detroit, MI). Charts submitted to the registry between August 2013 and September 2017 were reviewed, and cases were categorized into typical, atypical, non−amniotic fluid embolism, and indeterminate, using the previously published and validated criteria for the research reporting of AFE. Demographic and clinical variables, as well as outcomes for patients with typical and atypical AFE, were recorded and compared. Student t tests, χ2 tests, and analysis of variance tables were used to compare the groups, as appropriate, using SAS/STAT software, version 9.4. Results A total of 129 charts were available for review. Of these, 46% (59/129) represented typical amniotic fluid embolism and 12% (15/129) atypical amniotic fluid embolism, 21% (27/129) were non−amniotic fluid embolism cases with a clear alternative diagnosis, and 22% (28/129) had an uncertain diagnosis. Of the 27 women misclassified as an amniotic fluid embolism with an alternative diagnosis, the most common actual diagnosis was hypovolemic shock secondary to postpartum hemorrhage. Ten percent (6/59) of the women with typical amniotic fluid embolism had a pregnancy complicated by placenta previa, and 8% (5/61) had undergone in vitro fertilization to achieve pregnancy. In all, 66% (49/74) of the women with amniotic fluid embolism reported a history of atopy or latex, medication, or food allergy, compared to 34% of the obstetric population delivered at our hospital over the study period (P Conclusion Our data represent a series of women with amniotic fluid embolism whose diagnosis has been validated by detailed chart review, using recently published and validated criteria for research reporting of amniotic fluid embolism. Although no definitive risk factors were identified, a high rate of placenta previa, reported allergy, and conceptions achieved through in vitro fertilization was observed.