Magnetic resonance imaging and previous cesarean section in placenta accrete spectrum disorder: Predictor model.

OBJECTIVE: To evaluate objective criteria of Magnetic Resonance Imaging (MRI) of Placenta Accreta Spectrum disorder (PAS) analyzing interobserver agreement and to derive a model including imaging and clinical variables to predict PAS. METHODS: A retrospective review including patients submitted to MRI with suspicious findings of PAS on ultrasound. Exclusion criteria were lack of pathology or surgical information and missing or poor-quality MRI. Two radiologists analyzed six MRI features, and significant clinical data were also recorded. PAS confirmed on pathology or during intraoperative findings were considered positive for the primary outcome. Variables were tested through logistic regression models. RESULTS: Final study included 96 patients with a mean age of 33 years and 73.0% of previous C-sections. All MRI features were significantly associated with PAS for both readers. After logistic regression fit, including MRI signs with a moderate or higher interobserver agreement, intraplacental T2 dark band was the most significant radiologic criteria, and ROC analysis resulted in an AUC = 0.782. After including the most relevant clinical data (previous C-section) to the model, the ROC analysis improved to an AUC = 0.893. CONCLUSION: Simplified objective criteria on MRI, including intraplacental T2 dark band associated with clinical information of previous C-sections, had the highest accuracy and was used for a predictive model of PAS.

Risk factors for severe and critical Covid-19 in pregnant women in a single center in Brazil.

BACKGROUND: Risk factors for severe SARS-CoV2 infection in pregnancy have not been extensively studied. This information can help guide the management of pregnant women with COVID-19. OBJECTIVE: Examine risk factors for severe COVID-19 in pregnant women. METHODS: We reviewed the records of all pregnant women with positive SARS-CoV2 tests (qRT-PCR) managed at a single tertiary private maternity in Sao Paulo, Brazil. We categorized women as having non-severe (mild or moderate) or severe (severe or critical) COVID-19. We conducted multivariable analyses to identify differences in sociodemographic and clinical characteristics of the two groups as risk factors for severe COVID-19. RESULTS: Between March 13 and June 7 2020, 114 women tested positive for SARS-CoV-2; 80.7% (n = 92) had non-severe disease (69 mild, 23 moderate), 15.7% (n = 18) had severe, and 3.5% (n = 4) had critical COVID-19. Women with severe/critical COVID-19 (n = 22) were significantly older (35.0 ± 5.9 × 31.8 ± 5.1 years, p = 0.011), more likely to have at least one medical comorbidity (81.8% × 52.2%, p = .011) or a history of asthma (18.2% × 3.3%, p = .025), and tended to have a higher median body mass index (30.1 kg/m2, IQR 28.1-33.9 × 28.6, IQR 26.2-32.0, p = .056) than women with non-severe disease. Multivariate logistic regression analysis identified four factors as independent predictors of severe/critical COVID-19: asthma (OR 34.469, 95% CI 1.151-78.030, p = .026), non-white ethnicity (OR 7.932, 95% CI 1.311-47.973, p = .024), maternal age with a best cutoff of ≥ 34 years (OR 1.195, 95% CI 1.001-1.427, p = .048) and gestational age at diagnosis with a best cut-off of ≥ 35 weeks (OR 0.876, 95% CI 0.780-0.983, p = .025). The predictive value of the model including all variables was 0.823 (p < .001). CONCLUSION: A history of asthma, non-white ethnicity, and older maternal age were risk factors for, while higher gestational age was protective against severe/critical COVID-19 in pregnant Brazilian women.

Magnetic resonance imaging and previous cesarean section in placenta accrete spectrum disorder: Predictor model

Abstract Objective To evaluate objective criteria of Magnetic Resonance Imaging (MRI) of Placenta Accreta Spectrum disorder (PAS) analyzing interobserver agreement and to derive a model including imaging and clinical variables to predict PAS. Methods A retrospective review including patients submitted to MRI with suspicious findings of PAS on ultrasound. Exclusion criteria were lack of pathology or surgical information and missing or poor-quality MRI. Two radiologists analyzed six MRI features, and significant clinical data were also recorded. PAS confirmed on pathology or during intraoperative findings were considered positive for the primary outcome. Variables were tested through logistic regression models. Results Final study included 96 patients with a mean age of 33 years and 73.0% of previous C-sections. All MRI features were significantly associated with PAS for both readers. After logistic regression fit, including MRI signs with a moderate or higher interobserver agreement, intraplacental T2 dark band was the most significant radiologic criteria, and ROC analysis resulted in an AUC = 0.782. After including the most relevant clinical data (previous C-section) to the model, the ROC analysis improved to an AUC = 0.893. Conclusion Simplified objective criteria on MRI, including intraplacental T2 dark band associated with clinical information of previous C-sections, had the highest accuracy and was used for a predictive model of PAS.

Obstetric emergency simulation training course: experience of a private-public partnership in Brazil.

BACKGROUND: Lack of skills on how to diagnose and manage obstetric emergencies contribute to substandard institutional care and preventable maternal deaths in Brazil. Simulation-based obstetric emergency team training can reduce adverse maternal outcomes. However, this type of training is expensive and not widely available, especially in low resource settings. We present the experience of a private-public partnership that offered a two-day obstetric emergency simulation-training course to hundreds of Brazilian professionals working in the public sector. We also present participants´ short-term learning outcomes (Kirkpatrick's level 2) and satisfaction (Kirkpatrick's level 1). METHODS: This was a non-experimental before-and-after study. The free 16-h course was held over a 14 months period in a large private hospital's simulation center using multidisciplinary scenario and model-based training. The training sessions consisted of four (4-h) modules on pre-eclampsia/eclampsia, hemorrhage, sepsis and resuscitation. An anonymous questionnaire collected participants´ satisfaction at the end of each module. Learning outcomes were assessed by comparing differences in participants´ pre- versus immediate post-course test scores. Wilcoxon, Kruskal-Wallis and Friedman tests were used for statistical analyses. P < 0.05 was considered significant. RESULTS: 340 professionals (117 doctors, 179 registered nurses-RN and 44 licensed practical nurses-LPN) working in 33 public Brazilian hospitals were trained. There was a significant increase in post-course test scores in all four modules. On average, scores increased 55% in the hypertension and 65-69% in the hemorrhage, sepsis and resuscitation modules (p = 0.019). Knowledge acquisition of RN and LPN was similar in the hypertension, hemorrhage and sepsis modules and significantly higher than doctors´ (p < 0.05). On a 0 to 10 scale, mean overall satisfaction ranged from 9.6 (for the hypertension module) to 9.8 (for the resuscitation module). CONCLUSIONS: This successful experience of a private-public partnership to offer obstetric emergency simulation training required strategic organization and a strong commitment from both sides. This promising private-public partnership model could be replicated in similar settings. The training course obtained high satisfaction scores and significantly improved the knowledge of public-sector health professionals on how to manage the main causes of maternal mortality.

Perioperative temporary occlusion of the internal iliac arteries as prophylaxis in cesarean section at risk of hemorrhage in placenta accreta.

PURPOSE: The purpose of this study was to describe the preliminary results of prophylactic temporary balloon occlusion of the internal iliac arteries for bleeding control in patients with placenta accreta during cesarean hysterectomy. METHODS: From May 2006 to March 2010, 21 patients diagnosed with placenta accreta using ultrasound and/or magnetic resonance imaging were submitted to prophylactic balloon occlusion before hysterectomy. Fluoroscopy, balloon occlusion time, surgical duration, intraoperative blood loss, transfusion volume, and procedure complications were analyzed. RESULTS: The mean age was 30.5 years with a mean of 3.6 previous gestations. Imaging studies revealed that all patients had placenta accreta and all were submitted to cesarean hysterectomy. One hysterectomy was due to previous diagnosis of fetal death and another due to cesarean with uterine curettage. Mean fluoroscopy time was 7.5 min, balloon occlusion time was 164 min, and surgery duration was 260 min. Estimated blood loss was 1,671.5 ml with mean reposition fluids of 3,538 ml of crystalloids, 309.5 ml of colloids, and 1.24 ml of packed red blood cells. Two patients were submitted to thromboembolectomy due to prolonged surgical time. There was no maternal or fetal mortality related to the procedure. CONCLUSIONS: The results demonstrated that prophylactic balloon occlusion of internal iliac artery is a safe method and appears to reduce blood loss and transfusion requirements in patients diagnosed with placenta accreta who undergo cesarean hysterectomy. Antenatal imaging diagnosis of placenta accreta enables preoperative planning.

Analise da maturidade fetal no liquido amniotico e sua correlacao com as complicacoes perinatais nas formas graves das sindromes hipertensivas na gravidez / Correlation of fetal maturity analysis in the amniotic fluid and perinatal complications of severe hypertension in pregnancy

O objetivo deste estudo foi analise da maturidade fetal, atraves do estudo do liquido amniotico obtido pela amniocentese, e sua correlacao com as complicacoes neonatais nas formas graves das sindromes hipertensivas na gravidez. Foram estudadas, de forma retrospectiva, 91 amostras de liquido amniotico avaliando-se a maturidade fetal atraves do teste de Clements e contagem de celulas orangiofilas. Considerou-se maduro, quando teste de Clements foi positivo ate o terceiro tubo e/ou celulas orangiofilas maior ou igual a 10 por cento; intermediario, quando teste de Clements foi positivo ate o segundo tubo e contagem de celulas orangiofilas de 6 por cento a 9 por cento e imaturo quando teste de Clements foi positivo ate o primeiro tubo ou negativo e/ou positivo de celulas orangiofilas menor ou igual a 5 por cento...

Transfusao intravascular por cordocentese na terapeutica da doenca hemolitica perinatal / Intravascular intrauterine transfusion by cordocentesis in Rh alloimmunization

Os autores relatam a experiencia com 65 transfusoes intravasculares no tratamento da Doenca Hemolitica Perinatal realizada em 25 gestacoes complicadas por aloimunizacao Rh no periodo de janeiro a dezembro de 1991. As transfusoes comecaram entre 20-34 semanas e foram repetidas ate 6 vezes, com intervalos de 3-28 dias...