Longitudinal assessment of obstetrics and gynecology resident perceptions and comfort following cerclage placement simulation.

BACKGROUND: Utilization of simulation training in medical education has increased over time, particularly for less common scenarios and procedures. Simulation allows trainees to practice in a low-stress environment and eliminates patient risk. Cerclage placement has become less frequent, which limits obstetrics and gynecology (OB/GYN) exposure to cerclage placement during training. This exposes an area of training requiring simulation in OB/GYN resident education. OBJECTIVE: To evaluate resident reception to cerclage simulation, their self-reported comfort with and ability to troubleshoot difficult cerclage placement immediately and 12 months following didactic education and simulation. METHODS: In 2019, 18/20 (90%) OB/GYN residents in our university program underwent didactic teaching and simulation in cerclage placement using a pelvic model with removable cervix. Residents completed a survey immediately and 12 months following simulation. Wilcoxon signed-rank test was used to analyze resident self-report of comfort with cerclage placement and skill techniques for navigating difficult placement before and after simulation training. Descriptive statistics were analyzed as means and standard deviations. RESULTS: Eighteen of twenty (90%) residents participated in the education session in cerclage placement. All 18 (100%) completed a postsimulation survey and 17/18 (94%) completed a survey 12 months later. All reported improved comfort with cerclage placement and statistically significant improvement in knowledge on techniques for troubleshooting difficult placement after simulation. All residents reported that the simulation enhanced their learning and recommended the simulation for future educational opportunities. CONCLUSIONS: Cerclage simulation was well-received by OB/GYN residents in learning and practicing cerclage placement. Residents demonstrated improved comfort with placement following simulation.

Risk of vascular complications in prophylactic compared to emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of placenta accreta spectrum.

OBJECTIVE: To compare prophylactic and emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter placement in the management of placenta accreta spectrum (PAS). STUDY DESIGN: Retrospective chart review of all patients with PAS (January 2018 to January 2020) at a single tertiary center who underwent prophylactic or emergent REBOA for cesarean hysterectomy for PAS. RESULTS: A total of 16 pregnant patients with PAS underwent percutaneous REBOA placement by acute care surgeons in collaboration with a multi-disciplinary PAS team. The REBOA catheter was placed prophylactically in 11 cases and emergently in 5 cases. No complications occurred in the prophylactic placement group. In the emergent placement group, 3 of 4 surviving patients had vascular access site complications requiring intervention. CONCLUSION: A multidisciplinary approach for the management of PAS utilizing REBOA is feasible in the setting of both planned and emergent cesarean hysterectomy and can aid in the control of acute hemorrhage. The risk for vascular access site complications related to REBOA catheter placement is higher in the emergent setting compared to prophylactic placement.

Management of pregnancies complicated by placenta accreta spectrum utilizing a multidisciplinary care team in a rural state.

PURPOSE: To compare maternal and neonatal outcomes following the development of a multidisciplinary care team for the management of pregnancies complicated by placenta accreta spectrum (PAS) in a rural state. METHODS: This is a retrospective cohort study evaluating pregnancies managed before PAS team care management formation (2010-2015) and after (2016-2020) in a university medical center. Maternal and neonatal outcomes were analyzed. Patients were grouped by delivery date to either before or after dedicated PAS team formation. Maternal and neonatal outcomes were analyzed. Frequencies and percentages were reported for categorical measures while means and standard deviations were computed for continuous measures. Wilcoxon rank-sum test was used for continuous variables while Chi-square or Fisher's exact was used for categorical measures. FINDINGS: There were 82 patients with PAS managed at our institution (29 in Pre-PAS team group and 53 in Post-PAS team group). The number of units of packed red blood cells (PRBCS) transfused intraoperatively was significantly higher in the Pre-PAS care team group (6.52 vs. 3.26, p = .0057). The total number of units PRBCS transfused (9.93 vs. 3.51, p = .0014) and total number of cryoprecipitate transfused (0.77 vs. 0.08, p = .0225) during the entire hospital stay were increased in the Pre-PAS team group. Median neonatal 1 min and 5 min APGAR scores were lower in the Pre-PAS care team group (2 vs 6 at 1 min, p = .0035; 6 vs. 7at 5 min, p = .0301). CONCLUSIONS: Management of PAS by a dedicated, multidisciplinary team results in less blood transfusion requirements and improved maternal and neonatal outcomes.

Management of Critically Ill Pregnant Patients with COVID-19 Infection in a Rural State.

OBJECTIVE: There is limited data on the treatment of coronavirus disease 2019 (COVID-19) in pregnancy. Arkansas saw an increase in COVID-19 cases in June 2020. The first critically ill pregnant patient was admitted to our institution on May 21st, 2020. The objective of this study was to evaluate outcomes in critically ill pregnant women with COVID-19 at a single tertiary care center who received remdesivir and convalescent plasma (CCP). STUDY DESIGN: This is a retrospective observational review of critically ill pregnant women with COVID-19 who received remdesivir and CCP. This study was approved by the institutional review board (#261354). RESULTS: Seven pregnant patients with COVID-19 were admitted to the intensive care unit (ICU). All received remdesivir and CCP. Six received dexamethasone. The median ICU length of stay (LOS) was 8 days (range 3-17). Patient 1 had multi-organ failure requiring vasopressors, renal dialysis, and had an intrauterine fetal demise. Patients 4 and 6 required mechanical ventilation, were delivered for respiratory distress and were extubated at 2 and 1 days postpartum, respectively. The only common risk factor was obesity. There were no adverse events noted with remdesivir or CCP. CONCLUSION: There is little data regarding the use of remdesivir or CCP for the treatment of COVID-19 in pregnant women. In our cohort, these were well tolerated with no adverse events. Previously reported median ICU LOS in critically ill pregnant women with COVID-19 was 8 days (range 4-15).1 Our study found a similar ICU LOS (8 days; range 3-17). Patient 1 did not receive remdesivir or CCP until transport to our facility on hospital day 3. Excluding patient 1, median ICU LOS was 6.5 days (range 3-9). Our institution's treatment of pregnant women with critical illness with remdesivir, CCP and dexamethasone combined with delivery in select cases has thus far had good outcomes. KEY POINTS: · Combined therapy: remdesivir, CCP, dexamethasone.. · Remdesivir, CCP and dexamethasone was effective in treating critically ill pregnant women with COVID-19.. · No adverse events were associated with combined therapy.. · Delivery improved respiratory status..

Detection of Fetal Anomalies by Remotely Directed and Interpreted Ultrasound (Teleultrasound): A Randomized Noninferiority Trial.

OBJECTIVE: To determine the accuracy and reliability of remotely directed and interpreted ultrasound (teleultrasound) as compared with standard in-person ultrasound for the detection of fetal anomalies, and to determine participants' satisfaction with teleultrasound. STUDY DESIGN: This was a single-center, randomized (1:1) noninferiority study. Individuals referred to the maternal-fetal medicine (MFM) ultrasound clinic were randomized to standard in-person ultrasound and counseling or teleultrasound and telemedicine counseling. The primary outcome was major fetal anomaly detection rate (sensitivity). All ultrasounds were performed by registered diagnostic medical sonographers and interpretations were done by a group of five MFM physicians. After teleultrasound was completed, the teleultrasound patients filled out a satisfaction survey using a Likert scale. Newborn data were obtained from the newborn record and statewide birth defect databases. RESULTS: Of 300 individuals randomized in each group, 294 were analyzed in the remotely interpreted teleultrasound group and 291 were analyzed in the in-person ultrasound group. The sensitivity of sonographic detection of 28 anomalies was 82.14% in the control group and of 20 anomalies in the telemedicine group, it was 85.0%. The observed difference in sensitivity was 0.0286, much smaller than the proposed noninferiority limit of 0.05. Specificity, negative predictive value, positive predictive value, and accuracy were more than 94% for both groups. Patient satisfaction was more than 95% on all measures, and there were no significant differences in patient satisfaction based on maternal characteristics. CONCLUSION: Teleultrasound is not inferior to standard in-person ultrasound for the detection of fetal anomalies. Teleultrasound was uniformly well received by patients, regardless of demographics. These key findings support the continued expansion of telemedicine services. KEY POINTS: · For detection of major anomalies, teleultrasound is comparable to standard ultrasound.. · Teleultrasound was well accepted by patients.. · Teleultrasound use should be expanded..

Is a Surrogate Pregnancy a High-Risk Pregnancy?

IMPORTANCE: As assisted reproductive technology has advanced, there has been an increase in gestational carriers/surrogate pregnancies. Information is needed to determine if these pregnancies are high-risk pregnancies and should be managed by maternal fetal medicine or if they are not high risk and should be cared for by residency-trained obstetricians and gynecologists. OBJECTIVE: In this review of the literature, we explore whether surrogate pregnancies should be classified as high-risk pregnancies and managed by subspecialists. EVIDENCE ACQUISITION, RESULTS: Our literature search discovered 28 relevant studies that evaluated surrogate pregnancy and pregnancy complications/outcomes. We learned that the overall risk by using artificial reproductive technology and risks for hypertension, preterm delivery, cesarean delivery, low birth weight neonate, fetal anomalies, and stillbirth did not seem to increase maternal/perinatal risk to the level where a subspecialist was required for the inclusive management of a gestational surrogate. Given that the ideal gestational carrier is healthy, has previously had a term pregnancy, has a single embryo implanted, and has had no more than 3 prior cesarean deliveries, these pregnancies should be lower-risk pregnancies. CONCLUSIONS: We recommend that close monitoring and high index of suspicion should be maintained for complications, but care for the surrogate pregnancy can be accomplished by a residency-trained obstetrician-gynecologist. RELEVANCE: An uncomplicated surrogate pregnancy can be managed by a residency-trained obstetrician-gynecologist and does not need to be managed by high-risk obstetric subspecialists.

Accuracy of the Ultrasound Estimate of the Amniotic Fluid Volume (Amniotic Fluid Index and Single Deepest Pocket) to Identify Actual Low, Normal, and High Amniotic Fluid Volumes as Determined by Quantile Regression.

OBJECTIVES: To identify abnormal amniotic fluid volumes (AFVs), normal volumes must be determined. Multiple statistical methods are used to define normal amniotic fluid curves; however, quantile regression (QR) is gaining favor. We reanalyzed ultrasound estimates in identifying oligohydramnios, normal fluid, and polyhydramnios using normal volumes calculated by QR. METHODS: Data from 506 dye-determined or directly measured AFVs along with ultrasound estimates were analyzed. Each was classified as low, normal, or high for both the single deepest pocket (SDP) and amniotic fluid index (AFI). A weighted κ statistic was used to assess the level of agreement between the AFI and SDP compared to actual AFVs by QR. RESULTS: The overall level of agreement for the AFI was fair (κ = 0.26), and that for the SDP was slight (κ = 0.19). Although not statistically significant (P = .792), the positive predictive value to classify a low volume using the AFI was lower compared to the SDP (35% vs 43%). The positive predictive value for a high volume was higher using the AFI compared to the SDP (55% versus 31%) but not statistically significant. The missed-call rate for high-volume identification by the SDP versus AFI was statistically significant (odds ratio, 5.5; 95% confidence interval, 2.04-14.97). The missed-call rate for low-volume identification by the AFI versus SDP was not statistically significant (odds ratio, 3.3; 95% confidence interval, 0.96-11.53). CONCLUSIONS: Both the AFI and SDP identify actual normal AFVs by QR, with sensitivity higher than 90%. The SDP is superior for identification of oligohydramnios, and the AFI superior for identification of polyhydramnios.

Is There a Difference in Sonographic Estimation of Amniotic Fluid Volume When Measuring With the Probe Perpendicular to the Floor Compared With Perpendicular to the Uterine Contour?

OBJECTIVE: This study sought to determine whether there is a significant difference in amniotic fluid measurements when measuring perpendicular to the floor compared with perpendicular to the uterine contour using both amniotic fluid index and single deepest pocket. METHODS: This was a single-centre, prospective study of women with singleton gestation who were undergoing fetal ultrasound examination. A total of 240 women were enrolled, and single deepest pocket and amniotic fluid index were measured with both techniques. Correlation coefficient and intraclass correlation coefficient were used to assess the agreement between the values using the two methods of measurement (Canadian Task Force Classification II-2). RESULTS: A strong correlation was found between amniotic fluid index measurements (correlation coefficient 0.82; intraclass correlation coefficient 0.7). A strong correlation also was found between single deepest pocket measurements (correlation coefficient 0.7; intraclass correlation coefficient 0.6). CONCLUSION: The measurement of amniotic fluid index and single deepest pocket can be performed either perpendicular to the floor or perpendicular to the uterine contour. There is no significant difference between these measurements and they correlate well.

Addition of Color Doppler Sonography for Detection of Amniotic Fluid Disturbances and Its Implications on Perinatal Outcomes.

OBJECTIVES: To determine whether color Doppler sonography increases the detection of pregnancies at risk for adverse outcomes. METHODS: Participants admitted to labor and delivery with the anticipation of a vaginal delivery underwent measurements of amniotic fluid volume (AFV) using amniotic fluid index (AFI) and single deepest pocket (SDP) techniques by grayscale followed by color Doppler sonography. Oligohydramnios was defined as an AFI of less than 5 cm or an SDP of less than 2 cm. Intrapartum and perinatal outcomes were compared between participants with a diagnosis of a low AFV by grayscale and color Doppler sonography. RESULTS: Over 42 months, 428 women were enrolled in the study. Color Doppler sonography resulted in lower AFV estimates (mean ± SD by the AFI, 10.7 ± 3.7 cm by grayscale sonography and 8.6 ± 3.6cm by color Doppler sonography; P < .0001). For the SDP, the mean AFVs were 4.6 ± 2.0 cm by grayscale sonography and 3.4 ± 1.4 cm by color Doppler sonography (P < .0001). The level of agreement between grayscale and color Doppler sonography in estimating the AFV was fair, with κ = 0.32 for the AFI and 0.28 for the SDP. Outcome measures of AFVs classified as low based on color Doppler sonography (normal by grayscale sonography) and those classified as low by grayscale sonography (low by color Doppler sonography) were compared. There was no difference in composite perinatal complications, mode of delivery, or composite neonatal complications. CONCLUSIONS: The use of color Doppler sonography leads to the overdiagnosis of low AFVs and does not appear to increase the detection of pregnancies destined for adverse intrapartum or perinatal outcomes.

Antenatal fetal surveillance "Assessment of the AFV".

The evaluation of amniotic fluid volume (AFV) is an established part of the antenatal surveillance of pregnancies at risk for an adverse pregnancy outcome. The two most commonly used ultrasound techniques to estimate AFV are the amniotic fluid index (AFI) and the single deepest pocket (SDP). Four studies have defined normal AFVs, and although their normal volumes have similarities, there are also differences primarily due to the statistical methodology used in each study. Dye-determined AFV correlates with ultrasound estimates for normal fluid volumes but correlates poorly for oligohydramnios and polyhydramnios. The addition of color Doppler in estimating AFV leads to the overdiagnosis of oligohydramnios. Neither the AFI nor the SDP is superior in identifying oligohydramnios, but the SDP is a better measurement choice as the use of AFI increases the diagnosis rate of oligohydramnios and labor inductions without an improvement in pregnancy outcomes.

Fetal Mortality in the Delta.

OBJECTIVES: To compare the fetal mortality rate in the Delta counties of a state in the Mississippi Delta region of the United States with that of the non-Delta counties of the same state. METHODS: Hospital discharge data for maternal hospitalizations were linked to fetal death and birth certificates for 2004-2010. Data on maternal characteristics and comorbidities and pregnancy characteristics and outcomes were evaluated. The frequency of characteristics of pregnant women and pregnancy outcomes between Delta and non-Delta areas of the state was compared. RESULTS: There were a total of 248,255 singleton births, of which 35,605 occurred in the Delta counties. Delta patients were more likely to be younger than 20 years old, African American, multigravida, Medicaid recipients, smokers, and not married (P < 0.001) when compared with the non-Delta patients. The overall odds of fetal death within Delta counties are 1.40 times (95% confidence interval [CI] 1.22-1.61) higher than the non-Delta counties, and the odds of fetal death at ≤28 weeks are 1.56 times (95% CI 1.28-1.91) higher. After controlling for maternal age, race/ethnicity, level of prenatal care, and maternal comorbidities, the odds of fetal death remained 1.21 times higher (95% CI 1.05-1.41) and 1.28 times higher at ≤28 weeks' gestational age (95% CI 1.03-1.60). CONCLUSIONS: Fetal mortality is significantly greater in the Delta counties compared with the non-Delta counties, with a 21% increase in the odds of overall fetal death in the Delta counties compared with non-Delta counties and a 28% increase in the odds of fetal death at ≤28 weeks.

The continuing antenatal management program (CAMP): Outpatient monitoring of high-risk pregnancies. Keeps patients safe, costs low and care nearby.

A program was developed for referred, stable, high-risk obstetrical patients allowing them to receive antenatal care close to a tertiary hospital without the costs of a hospital admission. There were 426 women managed from September 2007 through December of 2012 with diagnosis of preterm labor, fetal anomalies, hypertensive disorders, placental abruption and other conditions. This management saved the hospital almost $9,000,000 USD or $20,956 USD per patient.

Late Abdominal Pregnancies (≥20 Weeks Gestation): A Review from 1965 to 2012.

BACKGROUND: Information about the diagnosis and management of late abdominal pregnancies (≥20 weeks gestation) is limited to case reports and small case series. METHODS: We performed a literature review of abdominal pregnancies ≥20 weeks gestation from 1965 to November 2012. Excluded were abdominal ectopic pregnancies that did not primarily implant in the peritoneal cavity, including tubal, ovarian, and intraligamentary pregnancies, and those prior to 20 weeks gestation. RESULTS: The 31 cases identified were at 30.4 ± 7.4 weeks at diagnosis and 33 ± 8.3 weeks at delivery. The most common sites of placental implantation were uterus or adnexa (47.8%), bowel (30%), and the potential spaces surrounding the uterus (8.7%). There were 5 cases of an intra-abdominal abscess in the 14 patients in whom the placenta had been left in situ. Maternal outcomes were documented in 26 cases with 7 deaths; 27 fetal outcomes were documented in 22 cases with 3 fetal deaths (13.6%). CONCLUSION: An abdominal ectopic pregnancy is an uncommon but serious event and should be considered in all patients until intrauterine gestation is confirmed. Management should be undertaken by an experienced surgical team in a tertiary care facility.