Regional multidisciplinary team approach to the management of placenta accreta spectrum disorder.

OBJECTIVE: Patients with suspected placenta accreta spectrum (PAS) disorder are often referred to specialized medical centers for antepartum management and definitive treatment via cesarean hysterectomy. In 2019, our institution formed the only multidisciplinary team for the management of PAS within two of the largest counties in California. The purpose of this study was to evaluate the effects of the multidisciplinary team on patient volume and surgical outcomes for patients with PAS. METHODS: This was a single center retrospective cohort study, based in the only tertiary referral center within two of the largest counties in California. Patients who underwent cesarean hysterectomy for suspected PAS from January 2014 to April 2021 were included and divided into two groups, based on management by the multidisciplinary team from January 2019 and onward or routine care prior to that time. The outcomes of interest were quantitative blood loss, total units of packed red blood cell transfusion, referral volume, and diagnostic accuracy as well as ICU admission, bladder injury, and postoperative length of stay. Furthermore, we wanted to determine if patient's distance to the hospital impacted outcomes. Normally distributed variables were compared between groups using the t-test. Categorical variables were compared between the two groups using the chi square test. RESULTS: A total of 114 patients were included in the cohort, 59 patients were from January 2014 to December 2018 and 55 patients were from January 2019 to April 2021. Since the establishment of the multidisciplinary center, there was a 2.5-fold increase in the total patient volume (0.8 case/month to 2 cases/month) and a 2.8-fold increase in the referred patient volume. Patients undergoing cesarean hysterectomy since the establishment of the multidisciplinary team had less quantitative blood loss (1500 mL vs 2000 mL, p = .005) and required less units of packed red blood cell transfusion (2 vs 4 units, p < .001). In addition, blood loss of ≥2000 mL decreased from 57.6% to 38.2% (p = .04) and diagnostic accuracy improved from 35.6% to 83.6% (p < .001). Furthermore, we found that patient distance to the hospital did not significantly impact surgical outcomes. CONCLUSIONS: Since the establishment of the multidisciplinary team, our center experienced an increase in PAS volume and was able to demonstrate a statistically significant improvement in patient outcomes.

Initial clinical characteristics of gravid severe acute respiratory syndrome coronavirus 2-positive patients and the risk of progression to severe coronavirus disease 2019.

BACKGROUND: Available data suggest that the obstetric population is particularly vulnerable to severe respiratory syndrome coronavirus 2 infection, with a variable clinical course leading to severe respiratory failure. However, established early warning scores designed to identify patients at risk of clinical deterioration were never validated in the obstetric population. OBJECTIVE: This retrospective cohort study sought to evaluate the initial clinical characteristics of pregnant patients diagnosed with severe acute respiratory syndrome coronavirus 2 infection and to develop a pregnancy-specific early warning score to identify patients at risk for clinical deterioration and requiring advanced respiratory support. STUDY DESIGN: This was a single center, retrospective cohort study of pregnant patients diagnosed with severe acute respiratory syndrome coronavirus 2 infection between April 2020 and December 2020. A total of 50 patients with severe acute respiratory syndrome coronavirus 2 infection between April 2020 and November 2020 were used to create the prediction model. Initial clinical characteristics identified at the time of diagnosis were compared between patients who required advanced respiratory support and those who were asymptomatic or had mild symptoms for those diagnosed during the period of April 2020 to November 2020. Risk factors associated with a requirement for advanced respiratory support were used to create the Obstetric Warning Score system. The Obstetric Warning Score system was then validated using 30 patients diagnosed with severe acute respiratory syndrome coronavirus 2 infection in December 2020. A receiver operating characteristic curve was generated to evaluate the test characteristics of the Obstetric Warning Score system compared with other scoring systems including the Early Warning Score, the National Early Warning Score 2, and the Maternal Early Warning Criteria. RESULTS: Women who required advanced respiratory support were more likely to present with dyspnea (100% vs 33.3%; P<.001), have a higher heart rate (113.4 beats per minute vs 93 beats per minute; P<.001), respiratory rate (23.5 breaths per minute vs 17.7 breaths per minute; P<.001), temperature (99.1°F vs 98.3°F; P=.004), and C-reactive protein level (7.4 mg/dL vs 2.4 mg/dL; P<.001). Furthermore, 88.2% of patients requiring advanced respiratory support showed chest x-ray findings consistent with pneumonia, compared with 20.0% of the patients not requiring advanced respiratory support (P<.001). All patients requiring advanced respiratory support presented with at least 1 coronavirus disease 2019 symptom, whereas only 51.5% of patients not requiring advanced respiratory support were symptomatic (P<.001). The Obstetrical Warning Score model allocated 1 point each for a hazard ratio of >100 beats per minute, temperature of >99.0°F, C-reactive protein level of >2.0 mg/dL, respiratory rate between 20 and 24 breaths per minute, complaints of dyspnea, and a positive chest x-ray. A respiratory rate of >24 breaths per minute was assigned 2 points. The area under the curve for the Obstetric Warning Score system was 0.97 compared with 0.72 for the Early Warning Score system, 0.92 for the National Early Warning Score 2 system, and 0.85 for the Maternal Early Warning Criteria system. An Obstetric Warning Score of ≥3 was predictive of a requirement for advanced respiratory support with a sensitivity of 100%, specificity 64%, and a positive predictive value of 36%. CONCLUSION: The Obstetric Warning Score system presents a validated method for providers to identify pregnant patients who are at risk for respiratory failure and a requirement for advanced respiratory support.

Semiautonomous Treatment Algorithm for the Management of Severe Hypertension in Pregnancy.

OBJECTIVE: To evaluate whether implementation of a semiautonomous treatment algorithm was associated with improved compliance with American College of Obstetricians and Gynecologists guidelines for rapid administration of antihypertensive therapy in the setting of sustained severe hypertension. METHODS: This was a single-center retrospective cohort study of admitted pregnant and postpartum patients treated for severe hypertension between January 2017 and March 2020. The semiautonomous treatment algorithm, which included vital sign monitoring, blood pressure thresholds for diagnosis of severe hypertension, and automated order sets for recommended first-line antihypertensive therapy were implemented between May 2018 and March 2019. The primary outcomes were the administration of antihypertensive therapy within 15, 30 and 60 minutes of diagnosis of severe hypertension. Comparisons were made between the preimplementation, during implementation, and postimplementation groups using χ2. Analysis was limited to the first episode of severe hypertension treated. Statistical significance was defined as P<.05. RESULTS: In total, there were 959 obstetric patients treated for severe hypertension, with 373 (38.9%) treated preimplementation, 334 (34.8%) during implementation, and 252 (26.2%) after implementation. Treatment of severe hypertension within 15 minutes was 36.5% preimplementation, 45.8% during implementation, and 55.6% postimplementation (P=.001). Treatment within 30 minutes was 65.9% in the preimplementation group, 77.8% during implementation, and 79.0% in the postimplementation group (P=.004). There was no difference in percentage of patients treated within 60 minutes (86.3% before, 87.7% during and 92.9% after implementation, P=.12). CONCLUSION: Implementation of a semiautonomous treatment algorithm for severe hypertension was associated with a higher percentage of pregnant and postpartum patients receiving the first dose of antihypertensive therapy within 15 and 30 minutes. Implementation of similar algorithms for this and other obstetric indications may decrease time to appropriate therapy and help improve care equity.