Addressing Peer-to-Peer Resident Mistreatment Through the Use of Forum Theatre: A Pilot Intervention.

PROBLEM: Residents may experience mistreatment by faculty, peers, nurses, or patients. While faculty are reportedly the primary contributors to mistreatment, residents can also be offenders, which merits study. Forum theatre (FT) is an experiential learning modality requiring a peer group to develop problem-solving strategies. FT was piloted to address mistreatment among residents. The objective was to determine whether FT was feasible, acceptable to resident learners, and could lead to self-reported changes in perceptions or behaviors, providing program directors a focused option to address professionalism as a competency. APPROACH: This initiative was conducted from September 2019 through February 2021 in obstetrics-gynecology and urology residencies at UT Health San Antonio and consisted of 3 phases: a focus group to identify mistreatment experienced by residents, resident volunteers to create and act out the FT scenario, and enactment of the FT scenario during didactic time. Residents completed anonymous retrospective pre- and postsurveys, as well as at 6-8 months after, to assess knowledge, attitudes, and self-reported and observed behaviors. Wilcoxon rank-sum tests and 2-sample t tests for proportions were used to compare variables between groups. OUTCOMES: The FT was completed successfully in both departments during didactic time. Twenty-six residents participated, 24 (92%) responded. Most respondents (23, 96%) would recommend FT to colleagues for teaching professionalism. Behavior changes were reported by 15 (63%) participants after the program. After 6-8 months, self-reported mistreatment behaviors had decreased, including "making fun of others" (15 (63%) to 10 (38%), P = .04) and sending "disparaging texts" (13 (54%) to 7 (27%), P =.02). NEXT STEPS: The use of FT during regularly scheduled didactic times was feasible and well received among residents. The evaluation demonstrated sustained self-reported behavior changes. Plans are ongoing to expand this approach to other medical specialties and professions institutionally.

Correlation of clinical outcomes with the application of the 2020 consensus panel on histological classification for Placenta Accreta Spectrum (PAS).

OBJECTIVE: Placenta Accreta Spectrum (PAS) is a range of disorders characterized by placenta adherence to uterine myometrium. The pathologic nomenclature of PAS has varied. In 2020, a consensus panel proposed a system which would parallel the antenatal grading. Our goal was to assess if greater PAS associated morbidity correlated with increasing histopathological grades in this novel system for confirmed cases of PAS. METHODS: A retrospective cohort analysis was performed of 125 singleton, non-anomalous pregnancies complicated by PAS at the University of Texas Health San Antonio Placenta Accreta program from 2005 to 2020. PAS cases confirmed after cesarean hysterectomy were classified by the new system and outcomes were analyzed including Kaplan-Meier analysis of gestational age at delivery by new pathology categorization. RESULTS: Antepartum admission, length of stay and episodes of vaginal bleeding correlated with increasing grades of PAS. In addition, increased PAS grades were associated with deliveries at earlier gestational age and surgical outcomes including operative time, blood loss, ICU admission and post-operative length of stay. CONCLUSIONS: The grading system proposed by the 2020 consensus panel correlates with antepartum, intra-operative and postoperative outcomes in cases of PAS cesarean hysterectomy and should be implemented for uniformity of reporting.

Neuraxial to general anesthesia conversion has equitable intraoperative and improved post-operative outcomes compared to general anesthesia in cesarean hysterectomy for placenta accreta spectrum (PAS).

OBJECTIVE: Placenta Accreta Spectrum (PAS) represents a series of placental disorders with an estimated incidence of 1:1000. Delivery and subsequent cesarean hysterectomy for PAS is associated with significant maternal morbidity and mortality. Neuraxial anesthesia may be utilized initially with subsequent conversion to general anesthesia after delivery of the fetus as an alternative to initiating with general anesthesia. METHODS: We performed a case-control study and analyzed 85 cases of pathology-confirmed PAS patients who underwent a cesarean hysterectomy in singleton, non-anomalous, viable pregnancies. All patients were delivered at our institution's established Placenta Accreta Program from 2005 to 2020. RESULTS: Fifty-two (61%) patients underwent general anesthesia and 33 (39%) patients underwent neuraxial anesthesia (collectively spinal, epidural, and combined spinal-epidural) converted to general anesthesia after cesarean delivery. Baseline demographics between groups were similar. Pre-operative ASA airway assessment of III/IV was equivalent between groups (94 and 82%, p = .08). Intraoperatively, neuraxial conversion and general anesthesia were equal with respect to operative time (241 vs. 261 min, p = .47), estimated blood loss (6039 vs. 8134 mL, p = .51), and composite maternal morbidity (84.6 vs. 75.8%, p = .40). Post-operatively, ICU admission (47 vs. 46%, p = 1.0) and intensive care length of stay was equivalent (p = .07), yet the total post-operative length of stay was significantly reduced in patients who underwent neuraxial anesthesia (3.76 vs. 6.35 days, p = .02). In addition, while general anesthesia was associated with a greater sonographic suspicion for placenta percreta (40 vs. 12%, p = .007), final pathology was equivalent (52 vs. 60%, p = .5). CONCLUSIONS: Taken together, our data show neuraxial conversion to general anesthesia has equivalent intra-operative parameters with improved post-operative outcomes when compared to general anesthesia alone in the case of cesarean hysterectomy for Placenta Accreta Spectrum disorders.

The Deleterious Effects of COVID-19 in the Peripartum Period: A Case Report.

While the Coronavirus Disease 2019 (COVID-19) pandemic continues to wreak havoc across the nation and the globe as one of the most significant global health crises of our time, recent attention has been turned to the effects of COVID-19 on pregnancy and the puerperium. Although most cases have been asymptomatic, for some patients, the disease may be accompanied by serious complications such as pneumonia, acute respiratory distress, multi organ failure, and death. Several case studies have noted that patients with co-morbidities are at a significant risk of these complications. In a recent systematic review and meta-analysis, authors conclude that cardiovascular disease was associated with increased composite poor outcome in patients with COVID-19. The following case report highlights the multi-system complications and severity of symptoms that can take place after childbirth in a patient with co-morbid obstetric and prenatal conditions and an initially asymptomatic COVID-19 infection.