Pulmonary Hypertension and Pregnancy.

Pulmonary hypertension is a term used to describe a complex multifactorial group of conditions diagnosed by an elevated mean pulmonary artery pressure of 20 mm Hg or higher on right heart catheterization. The diagnosis of pulmonary hypertension in pregnancy is important, as it is associated with high rates of maternal morbidity and mortality, even with modern management. Diagnostic testing is important for establishing the diagnosis, type, and severity of pulmonary hypertension, which in turn, dictates treatment options. Echocardiographic assessment is the first step in diagnosis and the gold standard for monitoring right heart function in patients with pulmonary hypertension. Supportive therapy for pulmonary hypertension includes monitored exercise, vaccination, and avoidance of certain activities. Therapies for pulmonary hypertension are considered conventional or targeted. Conventional therapy includes preventative care, anticoagulation, and calcium channel blockers for appropriate patients. Targeted therapy is usually reserved for patients with World Health Organization group 1 pulmonary arterial hypertension (including idiopathic, heritable, drug-induced or associated with congenital heart disease) and involves different types of direct pulmonary vasodilators. Right heart failure is the end result of pulmonary hypertension and the options for management include medical optimization, support with extracorporeal membrane oxygenation, and combined heart-lung transplantation. With pregnancy, management must be individualized, and patients should be cared for as part of an experienced multidisciplinary team. There are few studies addressing, timing and mode of delivery, including anesthetic considerations. In this review, the natural history of pulmonary hypertension in pregnancy and outcomes are summarized and current evidence-based management is discussed.

Trauma and Considerations Unique to Pregnancy.

Trauma complicates 6% to 7% of all pregnancies and requires multidisciplinary education and training for both trauma and obstetric teams to achieve the best outcome. It is important to understand the mechanisms of certain adverse maternal and fetal/neonatal outcomes incurred as a result of trauma, as well as caveats to pregnancy physiology that make some injuries more likely and detection of maternal compromise more difficult. This article focuses on these caveats and how to incorporate these into ongoing trauma protocols and offers suggestions for the formation of obstetric trauma response team.

Iron deficiency anemia in women: a practical guide to detection, diagnosis, and treatment.

INTRODUCTION: Iron deficiency anemia (IDA) remains a widely underdiagnosed and unappreciated women's health issue, affecting women of all ages. Despite the fact that IDA is easily diagnosed and treated, it continues to be a major public health issue. The World Health Organization estimates that 30% of nonpregnant and more than 42% of pregnant women have anemia. METHODS: A multidisciplinary Group for the Research and Education on Anemia Therapy in Women (GREAT Women II) was formed, sponsored by the Society for the Advancement of Blood Management. The goal was to focus attention on the impact of IDA on women at various stages of life and evaluate and use published literature to provide a simple, evidence-based approach to diagnose and treat IDA. RESULTS: The group developed specific recommendations for evaluating and treating IDA in women. Initial diagnosis is defined as hemoglobin less than 12 g/dL in nonpregnant women. A trial of iron therapy (4 weeks) can be considered a first-line diagnostic tool. Alternatively, a low or normal mean corpuscular volume (<100 fL), low serum ferritin (<30 µg/L), and/or low transferrin saturation (transferrin saturation <20%) is sufficient to confirm IDA. If the patient does not fit the diagnosis of IDA or fails to respond to a trial of oral iron, or mean corpuscular volume is elevated, further diagnostic evaluation is needed, including iron studies, B12, folate levels, and renal function tests. If results are not definitive, and IDA persists, a hematology referral is recommended. CONCLUSION: Clinicians should routinely identify and treat IDA, thereby decreasing its negative impact on health and quality of life of women.

Cardiac disease in pregnancy.

Physiologic changes in pregnancy can place extra demands on cardiac function. Preconception counseling is key to improving pregnancy outcomes. The most commonly encountered cardiac events are pulmonary edema and dysrhythmias. A team approach to antepartum care is recommended and should include maternal-fetal medicine, cardiology, and anesthesia as indicated, particularly for patients with congenital cardiac disease.

Maternal morbidity in patients with morbidly adherent placenta treated with and without a standardized multidisciplinary approach.

OBJECTIVE: The purpose of this study was to test the hypothesis that a standardized multidisciplinary treatment approach in patients with morbidly adherent placenta, which includes accreta, increta, and percreta, is associated with less maternal morbidity than when such an approach is not used (nonmultidisciplinary approach). STUDY DESIGN: A retrospective cohort study was conducted with patients from 3 tertiary care hospitals from July 2000 to September 2013. Patients with histologically confirmed placenta accreta, increta, and percreta were included in this study. A formal program that used a standardized multidisciplinary management approach was introduced in 2011. Before 2011, patients were treated on a case-by-case basis by individual physicians without a specific protocol (nonmultidisciplinary group). Estimated blood loss, transfusion of packed red blood cells, intraoperative complications (eg, vascular, bladder, ureteral, and bowel injury), neonatal outcome, and maternal postoperative length of hospital stay were compared between the 2 groups. RESULTS: Of 90 patients with placenta accreta, 57 women (63%) were in the multidisciplinary group, and 33 women (37%) were in the nonmultidisciplinary group. The multidisciplinary group had more cases with percreta (P = .008) but experienced less estimated blood loss (P = .025), with a trend to fewer blood transfusions (P = .06), and were less likely to be delivered emergently (P = .001) compared with the nonmultidisciplinary group. Despite an approach of indicated preterm delivery at 34-35 weeks of gestation, neonatal outcomes were similar between the 2 groups. CONCLUSION: The institution of a standardized approach for patients with morbidly adherent placentation by a specific multidisciplinary team was associated with improved maternal outcomes, particularly in cases with more aggressive placental invasion (increta or percreta), compared with a historic nonmultidisciplinary approach. Our standardized approach was associated with fewer emergency deliveries.

Putting the "M" back in maternal-fetal medicine.

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.