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Javinani A, Qaderi S, Hessami K, Shainker SA, Shamshirsaz AA, Fox KA, Mustafa HJ, Subramaniam A, Khandelwal M, Sandlin AT, Duzyj CM, Lyell DJ, Zuckerwise LC, Newton JM, Kingdom JC, Harrison RK, Shrivastava VK, Greiner AL, Loftin R, Genc MR, Atasi LK, Abdel-Razeq SS, Bennett KA, Carusi DA, Einerson BD, Gilner JB, Carver AR, Silver RM, Shamshirsaz AA. Delivery outcomes in the subsequent pregnancy following the conservative management of placenta accreta spectrum disorder: a systematic review and meta-analysis. Am J Obstet Gynecol 2024; 230:485-492.e7. [PMID: 37918506 DOI: 10.1016/j.ajog.2023.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 11/04/2023]
Abstract
OBJECTIVE Cesarean hysterectomy is generally presumed to decrease maternal morbidity and mortality secondary to placenta accreta spectrum disorder. Recently, uterine-sparing techniques have been introduced in conservative management of placenta accreta spectrum disorder to preserve fertility and potentially reduce surgical complications. However, despite patients often expressing the intention for future conception, few data are available regarding the subsequent pregnancy outcomes after conservative management of placenta accreta spectrum disorder. Thus, we aimed to perform a systematic review and meta-analysis to assess these outcomes. DATA SOURCES PubMed, Scopus, and Web of Science databases were searched from inception to September 2022. STUDY ELIGIBILITY CRITERIA We included all studies, with the exception of case studies, that reported the first subsequent pregnancy outcomes in individuals with a history of placenta accreta spectrum disorder who underwent any type of conservative management. METHODS The R programming language with the "meta" package was used. The random-effects model and inverse variance method were used to pool the proportion of pregnancy outcomes. RESULTS We identified 5 studies involving 1458 participants that were eligible for quantitative synthesis. The type of conservative management included placenta left in situ (n=1) and resection surgery (n=1), and was not reported in 3 studies. The rate of placenta accreta spectrum disorder recurrence in the subsequent pregnancy was 11.8% (95% confidence interval, 1.1-60.3; I2=86.4%), and 1.9% (95% confidence interval, 0.0-34.1; I2=82.4%) of participants underwent cesarean hysterectomy. Postpartum hemorrhage occurred in 10.3% (95% confidence interval, 0.3-81.4; I2=96.7%). A composite adverse maternal outcome was reported in 22.7% of participants (95% confidence interval, 0.0-99.4; I2=56.3%). CONCLUSION Favorable pregnancy outcome is possible following successful conservation of the uterus in a placenta accreta spectrum disorder pregnancy. Approximately 1 out of 4 subsequent pregnancies following conservative management of placenta accreta spectrum disorder had considerable adverse maternal outcomes. Given such high incidence of adverse outcomes and morbidity, patient and provider preparation is vital when managing this population.
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Affiliation(s)
- Ali Javinani
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Shohra Qaderi
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Kamran Hessami
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Scott A Shainker
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Amir A Shamshirsaz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, IN; Fetal Center at Riley Children's Health, Indiana University Health, Indianapolis, IN
| | - Akila Subramaniam
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | | | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Christina M Duzyj
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA
| | - Deirdre J Lyell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, CA
| | - Lisa C Zuckerwise
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - John C Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Rachel K Harrison
- Department of Maternal-Fetal Medicine, Advocate Aurora Health, Chicago, IL
| | - Vineet K Shrivastava
- Miller Children's and Women's Hospital Long Beach, Long Beach Memorial Medical Center, Long Beach, CA
| | - Andrea L Greiner
- Department of Obstetrics and Gynecology, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Ryan Loftin
- Department of Maternal-Fetal Medicine, Advocate Aurora Health, Chicago, IL; Allina Health System, Minneapolis, MN
| | - Mehmet R Genc
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Gainesville, FL
| | - Lamia K Atasi
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mercy Hospital, St. Louis, MO
| | - Sonya S Abdel-Razeq
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, CT
| | - Kelly A Bennett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Stanford School of Medicine, Stanford, CA; Fetal Center at Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
| | | | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Jennifer B Gilner
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University, Durham, NC
| | | | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT
| | - Alireza A Shamshirsaz
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Padilla CR, Shamshirsaz AA, Easter SR, Hess P, Smith C, El Sharawi N, Sandlin AT. Critical Care in Placenta Accreta Spectrum Disorders-A Call to Action. Am J Perinatol 2023; 40:988-995. [PMID: 37336216 DOI: 10.1055/s-0043-1761638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The rising in placenta accreta spectrum (PAS) incidence, highlights the need for critical care allotment for these patients. Due to risk for hemorrhage and possible hemorrhagic shock requiring blood product transfusion, hemodynamic instability and risk of end-organ damage, having an intensive care unit (ICU) with surgical expertise (surgical ICU or equivalent based on institutional resources) is highly recommended. Intensive care units physicians and nurses should be familiarized with intraoperative anesthetic and surgical techniques as well as obstetrics physiologic changes to provide postpartum management of PAS. Validated tools such of bedside point of care ultrasound and viscoelastic tests such as thromboelastogram/rotational thromboelastometry (TEG/ROTEM) are clinically useful in the assessment of hemodynamic status (shock diagnosis, assessment of both fluid responsiveness and tolerance) and transfusion guidance (in patients requiring massive transfusion as opposed to tranditional hemostatic resuscitation) respectively. The future of PAS management lies in the collaborative and multidisciplinary environment. We recommend that women with high suspicion or a confirmed PAS should have a preoperative plan in place and be managed in a tertiary center who is experienced in managing surgically complex cases. KEY POINTS: · The rising in placenta accreta spectrum incidence highlights the need for critical care expertise.. · Emerging tools such as point-of-care ultrasound and thromboelastography/rotational thromboelastometry represent new avenues for real time optimization of hemodynamic and hematological care of patients with PAS.. · Patients with PAS should be referred to a tertiary center having an intensive care unit (ICU) with surgical expertise (or equivalent based on institutional resources)..
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Affiliation(s)
- Cesar R Padilla
- Division of Obstetric Anesthesiology, Stanford University School of Medicine, Stanford, California
| | - Amir A Shamshirsaz
- Department of Obstetrics and Gynecology/Surgical Critical Care Texas Children's Hospital, Baylor College of Medicine, Texas
| | - Sarah R Easter
- Department of Obstetrics and Gynecology/Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Phillip Hess
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carly Smith
- Department of Anesthesiology and Pain Management, Anesthesiology Institute, Cleveland Clinic, Ohio
| | - Nadir El Sharawi
- Division of Obstetrical Anesthesia, University of Arkansas for Medical Sciences, Fayetteville, Arkansas
| | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Fayetteville, Arkansas
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Einerson BD, Sandlin AT, Afshar Y, Sharawi N, Fox KA, Newton JM, Shainker SA, Pezeshkmehr A, Carusi DA, Moroz L. General Management Considerations for Placenta Accreta Spectrum. Am J Perinatol 2023; 40:1026-1032. [PMID: 37336221 DOI: 10.1055/s-0043-1761915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The ideal management of a patient with placenta accreta spectrum (PAS) includes close antepartum management culminating in a planned and coordinated delivery by an experienced multidisciplinary PAS team. Coordinated team management has been shown to optimize outcomes for mother and infant. This section provides a consensus overview from the Pan-American Society for the Placenta Accreta Spectrum regarding general management of PAS.
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Affiliation(s)
| | - Adam T Sandlin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Nadir Sharawi
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arizona
| | - Karin A Fox
- Division of Maternal-Fetal Medicine, Department of Obstetric and Gynecology, Baylor College of Medicine (Texas Children's Hospital Pavilion for Women), Houston, Texas
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center Nashville, Tennessee
| | - Scott A Shainker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Amir Pezeshkmehr
- Department of Radiology Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Daniela A Carusi
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Khoury-Collado F, Newton JM, Brook OR, Carusi DA, Shrivastava VK, Crosland BA, Fox KA, Khandelwal M, Karam AK, Bennett KA, Sandlin AT, Shainker SA, Einerson BD, Belfort MA. Surgical Techniques for the Management of Placenta Accreta Spectrum. Am J Perinatol 2023; 40:970-979. [PMID: 37336214 DOI: 10.1055/s-0043-1761636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The surgical management of placenta accreta spectrum (PAS) is often challenging. There are a variety of techniques and management options described in the literature ranging from uterine sparing to cesarean hysterectomy. Following the inaugural meeting of the Pan-American Society for Placenta Accreta Spectrum a multidisciplinary group collaborated to describe collective recommendations for the surgical management of PAS. In this manuscript, we outline individual components of the procedure and provide suggested direction at key points of a cesarean hysterectomy in the setting of PAS. KEY POINTS: · The surgical management of PAS requires careful planning and expertise.. · Multidisciplinary team care for pregnancies complicated by PAS can decrease morbidity and mortality.. · Careful surgical techniques can minimize risk of significant hemorrhage by avoiding pitfalls..
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Affiliation(s)
- Fady Khoury-Collado
- Division of Gynecologic Oncology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York
| | - J M Newton
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Olga R Brook
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniela A Carusi
- Department of Obstetrics and Gynecology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Vineet K Shrivastava
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Memorial Care Miller Children's & Women's Hospital, University of California Irvine, Irvine, California
| | - Brian A Crosland
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon
| | - Karin A Fox
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Meena Khandelwal
- Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Amer K Karam
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Stanford University, Palo Alto, California
| | - Kelly A Bennett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Adam T Sandlin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Scott A Shainker
- Department of Obstetrics, Gynecology, and Reproductive Biology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Brett D Einerson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Michael A Belfort
- Departments of Obstetrics and Gynecology, Surgery, Anesthesiology and Neurosurgery, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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Pagan ME, Ramseyer AM, Whitcombe DD, Doiron TE, Magann EF, Sandlin AT, Hughes DS. Management of Critically Ill Pregnant Patients with COVID-19 Infection in a Rural State. Am J Perinatol 2022; 39:165-171. [PMID: 34775583 DOI: 10.1055/s-0041-1739292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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..
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Affiliation(s)
- Megan E Pagan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas
| | - Abigail M Ramseyer
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas
| | - Dayna D Whitcombe
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas
| | - Tucker E Doiron
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas
| | - Everett F Magann
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas
| | - Adam T Sandlin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas
| | - Dawn S Hughes
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas
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Whittington JR, Pagan ME, Sharawi N, Hughes DS, Sandlin AT. REBOA placement for placenta accreta spectrum: patient selection and utilization. J Matern Fetal Neonatal Med 2021; 35:6440-6441. [PMID: 33926349 DOI: 10.1080/14767058.2021.1914580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Julie R Whittington
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Naval Medical Center Portsmouth, Portsmouth, VA, USA.,The Uniformed Services of the Health Sciences, Bethesda, MD, USA.,Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Megan E Pagan
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nadir Sharawi
- Department of Anesthesia, Division of Obstetric Anesthesia, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Dawn S Hughes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adam T Sandlin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Schoeneberg LA, Zakaria D, Bolin EH, Eble BK, Miquel-Verges F, Sandlin AT, Bornemeier RA. A Fetal Presentation of a Ruptured Right Ventricular Diverticulum. Pediatr Cardiol 2021; 42:978-980. [PMID: 33725147 DOI: 10.1007/s00246-021-02572-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 02/25/2021] [Indexed: 11/26/2022]
Abstract
Ruptured diverticula and ventricular aneurysms are rare in the fetus, with a limited number of case reports published previously. Additional fetal complications secondary to these ventricular wall abnormalities can be seen. Interventional measures can be considered and attempted either in utero or postnatally to improve the chance of survival. We present a case of a ruptured diverticulum in a fetus and the clinical course.
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Affiliation(s)
- Laura A Schoeneberg
- Department of Pediatrics (Cardiology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA.
| | - Dala Zakaria
- Department of Pediatrics (Cardiology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
| | - Elijah H Bolin
- Department of Pediatrics (Cardiology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
| | - Brian K Eble
- Department of Pediatrics (Cardiology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
| | - Franscesca Miquel-Verges
- Department of Pediatrics (Neonatology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
| | - Adam T Sandlin
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
| | - Renee A Bornemeier
- Department of Pediatrics (Cardiology), University of Arkansas for Medical Sciences and Arkansas Children's Hospital, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202, USA
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Sandlin AT, Magann EF, Whittington JR, Schneider AM, Ramseyer AM, Hughes DS, Ounpraseuth ST. Management of pregnancies complicated by placenta accreta spectrum utilizing a multidisciplinary care team in a rural state. J Matern Fetal Neonatal Med 2021; 35:5964-5969. [PMID: 33769169 DOI: 10.1080/14767058.2021.1903425] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Adam T Sandlin
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Everett F Magann
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Julie R Whittington
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Allison M Schneider
- The College of Medicine, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Abigail M Ramseyer
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Dawn S Hughes
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Songthip T Ounpraseuth
- Department of Biostatistics, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
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Whittington JR, Pagan ME, Nevil BD, Kalkwarf KJ, Sharawi NE, Hughes DS, Sandlin AT. Risk of vascular complications in prophylactic compared to emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of placenta accreta spectrum. J Matern Fetal Neonatal Med 2020; 35:3049-3052. [PMID: 32781879 DOI: 10.1080/14767058.2020.1802717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Julie R Whittington
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Megan E Pagan
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Bryan D Nevil
- Department of Anesthesia, Division of Obstetric Anesthesia, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kyle J Kalkwarf
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nadir El Sharawi
- Department of Anesthesia, Division of Obstetric Anesthesia, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Dawn S Hughes
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adam T Sandlin
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Hughes DS, Magann EF, Whittington JR, Wendel MP, Sandlin AT, Ounpraseuth ST. 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. J Ultrasound Med 2020; 39:373-378. [PMID: 31423632 DOI: 10.1002/jum.15116] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Dawn S Hughes
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Everett F Magann
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Julie R Whittington
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Michael P Wendel
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Adam T Sandlin
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Songthip T Ounpraseuth
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Rabie NZ, Sandlin AT, Ounpraseuth S, Nembhard WN, Lowery C, Miguel KS, Magann EP. Teleultrasound for pre-natal diagnosis: A validation study. Australas J Ultrasound Med 2019; 22:248-252. [PMID: 34760566 DOI: 10.1002/ajum.12175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction/Purpose There are no large validation trials comparing teleultrasound to on-site ultrasound. We aim to compare the sensitivity and accuracy of teleultrasound and demonstrate that teleultrasound is not inferior to on-site ultrasound in the pre-natal diagnosis of fetal anomalies. Methods All targeted ultrasounds performed between November 2010 and December 2012 were considered. We excluded studies performed at less than 17 weeks' gestation, on multiple gestations and for reasons other than an anatomical survey. Post-natal diagnoses were obtained from a state level mandatory birth defects surveillance programme. Descriptive statistics (sensitivity, specificity, positive and negative predictive values and accuracy) were calculated for both groups. A test of non-inferiority was performed, with the non-inferiority difference set at 0.15. Results The teleultrasound and on-site ultrasound groups consisted of 2368 and 3145 studies, respectively. The sensitivity of teleultrasound and on-site ultrasound was 57.46% and 76.57%, and the accuracy was 95.9% and 90.97%, respectively. The observed sensitivity difference was -0.1911. The accuracy, specificity, positive and negative predictive values of teleultrasound are similar to on-site ultrasound. Discussion Teleultrasound is inferior to on-site ultrasound in the detection of fetal anomalies; however, it has improved accuracy, as well as higher negative and positive predictive values. A negative teleultrasound is more likely to identify a non-anomalous fetus, and a positive teleultrasound is more likely to correctly identify an anomalous fetus. Conclusion Teleultrasound has an important role in pre-natal diagnosis for those patients unable or unwilling to travel for an on-site ultrasound.
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Affiliation(s)
- Nader Z Rabie
- Department of Ob-Gyn Tripler Army Medical Center 1 Jarrett White Road Honolulu Hawaii 96859 USA
| | - Adam T Sandlin
- Department of Obstetrics and Gynecology University of Arkansas for Medical Sciences 4301 West Markham Street Little Rock Arkansas 72205 USA
| | - Song Ounpraseuth
- Department of Biostatistics University of Arkansas for Medical Sciences 4301 West Markham Street Little Rock Arkansas 72205 USA
| | - Wendy N Nembhard
- Arkansas Children's Research Institute 1 Children's Way Little Rock Arkansas 72202 USA
| | - Curtis Lowery
- Department of Obstetrics and Gynecology University of Arkansas for Medical Sciences 4301 West Markham Street Little Rock Arkansas 72205 USA
| | - Kelly San Miguel
- Department of Obstetrics and Gynecology University of Arkansas for Medical Sciences 4301 West Markham Street Little Rock Arkansas 72205 USA
| | - Everett Pat Magann
- Department of Obstetrics and Gynecology University of Arkansas for Medical Sciences 4301 West Markham Street Little Rock Arkansas 72205 USA
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Rabie NZ, Sandlin AT, Barber KA, Ounpraseuth S, Nembhard W, Magann EF, Lowery C. Teleultrasound: How Accurate Are We? J Ultrasound Med 2017; 36:2329-2335. [PMID: 28660654 DOI: 10.1002/jum.14304] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 05/04/2017] [Accepted: 06/07/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Ultrasound serves an important role in the prenatal diagnosis of fetal structural anomalies. Recently, there has been increased use of teleultrasound protocols. We aimed to evaluate the sensitivity and accuracy of teleultrasound. METHODS We conducted an Institutional Review Board-approved retrospective cohort study determining the sensitivity and accuracy of teleultrasound. In addition, we evaluated the number of ultrasound examinations required to complete an anatomic survey. Only ultrasound examinations performed for anatomic surveys were included. Studies were excluded if performed before 16 completed weeks' gestation, if they had multiple gestations, or for reasons other than anatomy (eg, Doppler studies and fluid assessment). Prenatal diagnoses were compared with postnatal diagnoses obtained from a robust mandatory birth defects surveillance program that records all birth defects in the entire state, from deliveries before 20 weeks' gestation through infants up to 2 years of age. RESULTS A total of 2499 studies were evaluated; 2368 were included. The teleultrasound cohort had a congenital anomaly prevalence of 5.66%. The sensitivity of teleultrasound was 57.46%; the specificity was 98.21%; and the accuracy was 95.9%. Anatomic surveys were completed after 1 visit in 82% of patients, whereas 63% and 61% of the remaining patients required 2 and 3 visits, respectively. CONCLUSIONS Teleultrasound for prenatal diagnosis has similar sensitivity and accuracy as the published literature for on-site ultrasound. Further studies are needed to compare the sensitivity and accuracy within the same population and further validate this potentially cost-saving modality.
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Affiliation(s)
- Nader Z Rabie
- Department of Obstetrics and Gynecology, Tripler Army Medical Center, Honolulu, Hawaii, USA
| | - Adam T Sandlin
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Kevin A Barber
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Wendy Nembhard
- Arkansas Children's Hospital Research Institute, Little Rock, Arkansas, USA
| | - Everett F Magann
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Curtis Lowery
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Ounpraseuth ST, Magann EF, Spencer HJ, Rabie NZ, Sandlin AT. Normal amniotic fluid volume across gestation: Comparison of statistical approaches in 1190 normal amniotic fluid volumes. J Obstet Gynaecol Res 2017; 43:1122-1131. [DOI: 10.1111/jog.13332] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/01/2017] [Accepted: 02/24/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Songthip T. Ounpraseuth
- Department of Biostatistics; University of Arkansas for the Medical Sciences; Little Rock Arkansas USA
| | - Everett F. Magann
- Department of Obstetrics and Gynecology; University of Arkansas for the Medical Sciences; Little Rock Arkansas USA
| | - Horace J. Spencer
- Department of Biostatistics; University of Arkansas for the Medical Sciences; Little Rock Arkansas USA
| | - Nader Z. Rabie
- Department of Obstetrics and Gynecology; University of Arkansas for the Medical Sciences; Little Rock Arkansas USA
| | - Adam T. Sandlin
- Department of Obstetrics and Gynecology; University of Arkansas for the Medical Sciences; Little Rock Arkansas USA
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Barrinqer SN, Sandlin AT, Magann EF. Non-Invasive Prenatal Testing (NIPT) in Arkansas: Prenatal Genetics Clinic Experience and Lessons Learned. J Ark Med Soc 2016; 113:38-42. [PMID: 30047631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The term NIPT (non-invasive prenata. testing). is used to d Qscribe a relativel new screening test designed to. identit .pregnancies at increased risk for certain fetal aneuploidlies. Since May of 2012, the UAMS Malernal'Tbtal Medicine, division has provided genetic 'counseling, obtiained informed consent; and I ordered NIPT 6n over 400 high-risk pregnancies. We wish to . present data collect6d from, these results,,as well as offer tips for primary obstetricians/practition'ers. Who consider ordering NIPT for some of their patients.
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Sandlin AT, Bronstein JM, Rabie NZ, Wendel PJ, Hughes DS, Magann EF. Fetal Mortality in the Delta. South Med J 2015; 108:389-92. [PMID: 26192933 DOI: 10.14423/smj.0000000000000305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
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Affiliation(s)
- Adam T Sandlin
- From the Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, and the Department of Healthcare Organization and Policy, University of Alabama-Birmingham
| | - Janet M Bronstein
- From the Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, and the Department of Healthcare Organization and Policy, University of Alabama-Birmingham
| | - Nader Z Rabie
- From the Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, and the Department of Healthcare Organization and Policy, University of Alabama-Birmingham
| | - Paul J Wendel
- From the Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, and the Department of Healthcare Organization and Policy, University of Alabama-Birmingham
| | - Dawn S Hughes
- From the Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, and the Department of Healthcare Organization and Policy, University of Alabama-Birmingham
| | - Everett F Magann
- From the Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, and the Department of Healthcare Organization and Policy, University of Alabama-Birmingham
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Hughes DS, Ussery DJ, Woodruff DL, Sandlin AT, Kinder SR, Magann EF. The continuing antenatal management program (CAMP): Outpatient monitoring of high-risk pregnancies. Keeps patients safe, costs low and care nearby. Sexual & Reproductive Healthcare 2015; 6:108-9. [DOI: 10.1016/j.srhc.2015.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 12/29/2014] [Accepted: 01/04/2015] [Indexed: 10/24/2022]
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17
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Smith BL, Sandlin AT, Bird TM, Steelman SC, Magann E. Maternal Mortality in the Delta Region of the United States. J Obstet Gynecol Neonatal Nurs 2015. [DOI: 10.1111/1552-6909.12639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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18
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Chauhan SP, Beydoun H, Chang E, Sandlin AT, Dahlke JD, Igwe E, Magann EF, Anderson KR, Abuhamad AZ, Ananth CV. Prenatal detection of fetal growth restriction in newborns classified as small for gestational age: correlates and risk of neonatal morbidity. Am J Perinatol 2014; 31:187-94. [PMID: 23592315 DOI: 10.1055/s-0033-1343771] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We examined the rate of detecting small for gestational age (SGA; birth weight < 10%) as intrauterine growth restriction (IUGR) prenatally at four centers and determined risks of composite neonatal morbidity (CNM) and mortality among detected versus undetected (no antenatal diagnosis of IUGR). A multicenter cohort study of 11,487 nonanomalous, singleton live births with sonographic exam before 22 weeks was performed. Of 11,487 births, 8% (n = 929) were SGA that met the inclusion criteria, with 25% of them being prenatally detected. The CNM among SGA births that were prenatally detected as IUGR was higher (23.3%) than undetected SGA (9.7%), but this difference was no longer significant following adjustments for confounding factors. Among preterm births (< 37 weeks), undetected SGA had significantly higher CNM (risk ratio [RR] 10.0, 95% confidence interval [CI] 6.3, 16.1) for deliveries at 24 to 33 weeks and RR 3.0, 95% CI 1.7, 5.4 for 34 to 36 weeks). In summary, only a quarter of SGA births were detected prenatally as IUGR and among preterm SGA, the CNM is significantly higher when SGA births are undetected as IUGR.
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Affiliation(s)
- Suneet P Chauhan
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Hind Beydoun
- Graduate Program in Public Health, Eastern Virginia Medical School, Norfolk, Virginia
| | - Eugene Chang
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina
| | - Adam T Sandlin
- Department of Obstetrics and Gynecology, University of Arkansas, Little Rock, Arkansas
| | - Josh D Dahlke
- Department of Obstetrics and Gynecology, Brown University, Providence, Rhode Island
| | - Elena Igwe
- Department of Obstetrics and Gynecology, Temple University, Philadelphia, Pennsylvania
| | - Everett F Magann
- Department of Obstetrics and Gynecology, University of Arkansas, Little Rock, Arkansas
| | - Kristi R Anderson
- Department of Obstetrics and Gynecology, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Alfred Z Abuhamad
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York
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Sills A, Steigman C, Ounpraseuth ST, Odibo I, Sandlin AT, Magann EF. Pathologic examination of the placenta: recommended versus observed practice in a university hospital. Int J Womens Health 2013; 5:309-12. [PMID: 23788842 PMCID: PMC3684225 DOI: 10.2147/ijwh.s45095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The purpose of this study was to determine the frequency of appropriate placental examinations in a university hospital. Methods A retrospective review of all deliveries and all placentas submitted for pathologic examination from live births. Placentas were reviewed by a perinatal pathologist to determine whether they met the College of American Pathologists (CAP)-recommended guidelines for examination. Results We used 1346 deliveries between July 1, 2010 and December 31, 2010 as the basis of this review. According to CAP guidelines, 703 placentas (52.2%) should have been sent for pathologic examination; 575/703 (81.8%; 95% confidence interval [CI] = 78.9–84.7) were actually sent for examination. Of the 643 placentas that did not need to be examined per CAP guidelines, 568 (88.3%; 95% CI = 85.9–90.8) were appropriately not sent. In comparing the three categories of indications for examination (maternal, fetal/neonatal, placental), the only significant association was that women with fetal/neonatal indications were more likely to have their placenta sent than women with maternal indications (odds ratio, 2.63; 95% CI = 1.81–3.80). Conclusion In this university hospital, more than 80% of the time, placentas were appropriately sent to pathology, and more than 85% of the time, placentas that should not have been sent for evaluation were not sent.
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Affiliation(s)
- Amber Sills
- Departments of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
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Wyatt SN, Rhoads SJ, Green AL, Ott RE, Sandlin AT, Magann EF. Maternal response to high-risk obstetric telemedicine consults when perinatal prognosis is poor. Aust N Z J Obstet Gynaecol 2013; 53:494-7. [PMID: 23635010 DOI: 10.1111/ajo.12094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Accepted: 03/24/2013] [Indexed: 12/01/2022]
Abstract
This is a qualitative descriptive study evaluating the maternal response after the woman has learned her pregnancy has a poor prognosis via telemedicine rather than in a traditional, face-to-face, consultation method. In general, telemedicine was positively viewed by the participants; however, the experience may be markedly improved by implementing several simple changes in the overall consultative process.
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Affiliation(s)
- Stephanie N Wyatt
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, Arkansas, USA
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Abstract
Polyhydramnios is an excessive amount of amniotic fluid within the amniotic cavity. The etiology of polyhydramnios may be idiopathic, the consequence of fetal structural anomalies, or the consequence of various fetal and maternal conditions. The clinical importance of polyhydramnios is found in its association with adverse pregnancy outcomes and the risk of perinatal mortality. The antenatal management of polyhydramnios can be challenging as there are no formalized guidelines on the topic. The purpose of this review is to provide a literature-based overview on the subject of polyhydramnios in singleton pregnancies, demonstrate its clinical implications, and describe a practical approach to its management.
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Affiliation(s)
- Adam T Sandlin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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Magann EF, Doherty DA, Sandlin AT, Chauhan SP, Morrison JC. The effects of an increasing gradient of maternal obesity on pregnancy outcomes. Aust N Z J Obstet Gynaecol 2013; 53:250-7. [PMID: 23432797 DOI: 10.1111/ajo.12047] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 11/27/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Maternal obesity is becoming more prevalent in obstetrics and has been linked with pregnancy complications and perinatal outcomes. The gradient of association of increasing maternal obesity and pregnancy outcome is less well studied. AIMS To determine the influence of an increasing gradient of obesity, categorised by the body mass index (BMI), on pregnancy outcomes and to determine the BMI thresholds at which pregnancy complications occur. MATERIALS AND METHODS Secondary analysis of an observational study on pregnancy and obesity. The BMI at the first prenatal visit was grouped into BMI categories (<18.5, 18.5-24.9, 25-29.9, 30-34.9, 35-39.9, 40-44.9, and ≥45) and compared with the normal category (BMI 18.5-25) for pregnancy outcomes and adjusted for known cofounders. RESULTS A total of 4,490 women were stratified into the pre-pregnancy BMI categories: <18.5 (n = 276), 18.5-24.9 (n = 1965), 25-29.9 (n = 1072), 30-34.9 (n = 551), 35-39.9 (n = 317), 40-44.9 (n = 167), and ≥45 (n = 142). The maternal demographics were significantly different between BMI groups (P < 0.001). Compared to women with a normal BMI, different BMI thresholds convey an increased risk for specific pregnancy complications: BMI≥25 for gestational diabetes (P < 0.001), induction of labour (P < 0.001), caesarean delivery (P < 0.001) and large for gestational age neonate (P < 0.001); BMI≥30 for pre-eclampsia (P < 0.001), wound infection (P = 0.001), shoulder dystocia (P < 0.001) and meconium (P = 0.006); BMI≥35 for urinary tract infection (P < 0.001) and postpartum haemorrhage (P < 0.001); BMI≥40 for endometritis (P < 0.001). CONCLUSIONS Body mass index thresholds exist at which pregnancy complications significantly increase and they vary depending on outcome ranging from BMI ≥25 to a BMI ≥40.
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Affiliation(s)
- Everett F Magann
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA.
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Magann EF, Niederhauser A, Doherty DA, Chauhan SP, Sandlin AT, Morrison JC. Reducing hemodynamic compromise with placental removal at 10 versus 15 minutes: a randomized clinical trial. Am J Perinatol 2012; 29:609-14. [PMID: 22566115 DOI: 10.1055/s-0032-1311985] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To determine if hemodynamic compromise can be reduced with manual placental removal at 10 compared with 15 minutes. STUDY DESIGN Singleton pregnancies admitted for delivery with no contraindication to a vaginal delivery were randomized to a 10-minute group (placentas manually removed if not spontaneously delivered by 10 minutes) versus a 15-minute group. The primary outcome, hemodynamic compromise, was defined as: blood loss exceeding 1000 mL and/or circulatory instability (inability to maintain blood pressure/pulse secondary to acute blood loss) and/or drop in hematocrit of ≥10 percentage points. RESULTS From July 2006 to July 2010, 156 women were randomized into the 10-minute group and 156 in the 15-minute group. Women in the 15-minute group had a greater likelihood of hemodynamic compromise univariately (19.2% versus 6.4%, p = 0.001) and after adjustments for ethnicity, induction rate, duration of second stage of labor, and nulliparity (relative risk 3.03, 95% confidence interval 1.52 to 5.47, p = 0.002). CONCLUSION Hemodynamic compromise is decreased with manual placental removal within 10 minutes of delivery compared with 15 minutes.
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Affiliation(s)
- Everett F Magann
- Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA.
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Magann EF, Sandlin AT, Ounpraseuth ST. Amniotic fluid and the clinical relevance of the sonographically estimated amniotic fluid volume: oligohydramnios. J Ultrasound Med 2011; 30:1573-1585. [PMID: 22039031 DOI: 10.7863/jum.2011.30.11.1573] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The amniotic fluid volume (AFV) is regulated by several systems, including the in-tramembranous pathway, fetal production (fetal urine and lung fluid) and uptake (fetal swallowing), and the balance of fluid movement via osmotic gradients. The normal AFV across gestation has not been clearly defined; consequently, abnormal volumes are also poorly defined. Actual AFVs can be measured by dye dilution techniques and directly measured at cesarean delivery; however, these techniques are time-consuming, are invasive, and require laboratory support, and direct measurement can only be done at cesarean delivery. As a result of these limitations, the AFV is estimated by the amniotic fluid index (AFI), the single deepest pocket, and subjective assessment of the AFV. Unfortunately, sonographic estimates of the AFV correlate poorly with dye-determined or directly measured amniotic fluid. The recent use of color Doppler sonography has not improved the diagnostic accuracy of sonographic estimates of the AFV but instead has led to overdiagnosis of oligohydramnios. The relationship between the fixed cutoffs of an AFI of 5 cm or less and a single deepest pocket of 2 cm or less for identifying adverse pregnancy outcomes is uncertain. The use of the single deepest pocket compared to the AFI to identify oligohydramnios in at-risk pregnancies seems to be a better choice because the use of the AFI leads to an increase in the diagnosis of oligohydramnios, resulting in more labor inductions and cesarean deliveries without any improvement in peripartum outcomes.
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Affiliation(s)
- Everett F Magann
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR 72205 USA.
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