Clarissa Bonanno

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.

Predictors of massive blood loss in women with placenta accreta

OBJECTIVE We examined predictors of massive blood loss for women with placenta accreta who had undergone hysterectomy. STUDY DESIGN A retrospective review of women who underwent peripartum hysterectomy for pathologically confirmed placenta accreta was performed. Characteristics that are associated with massive blood loss (≥ 5000 mL) and large-volume transfusion (≥ 10 units packed red cells) were examined. RESULTS A total of 77 patients were identified. The median blood loss was 3000 mL, with a median of 5 units of red cells transfused. There was no association among maternal age, gravidity, number of previous deliveries, number of previous cesarean deliveries, degree of placental invasion, or antenatal bleeding and massive blood loss or large-volume transfusion (P > .05). Among women with a known diagnosis of placenta accreta, 41.7% had an estimated blood loss of ≥ 5000 mL, compared with 12.0% of those who did not receive the diagnosis antenatally with ultrasound scanning (P = .01). CONCLUSION There are few reliable predictors of massive blood loss in women with placenta accreta.

Antenatal Corticosteroids in the Management of Preterm Birth: Are We Back Where We Started?

Though the preterm birth rate in the United States has finally begun to decline, preterm birth remains a critical public health problem. The administration of antenatal corticosteroids to improve outcomes after preterm birth is one of the most important interventions in obstetrics. This article summarizes the evidence for antenatal corticosteroid efficacy and safety that has accumulated since Graham Liggins and Ross Howie first introduced this therapy. Although antenatal corticosteroids have proven effective for singleton pregnancies at risk for preterm birth between 26 and 34 weeks’ gestation, questions remain about the utility in specific patient populations such as multiple gestations, very early preterm gestations, and pregnancies complicated by IUGR. In addition, there is still uncertainty about the length of corticosteroid effectiveness and the need for repeat or rescue courses. Though a significant amount of data has accumulated on antenatal corticosteroids over the past 40 years, more information is still needed to refine the use of this therapy and improve outcomes for these at-risk patients.

Single versus repeat courses of antenatal steroids to improve neonatal outcomes : Risks and benefits

Recent additions to the literature provide evidence supporting the use of repeat courses of antenatal steroids. Both human and animal studies offer evidence that repeat courses of corticosteroids improve neonatal pulmonary outcomes, especially for the infants delivered at earlier gestational ages. Although there is also evidence to suggest altered neuronal maturation and intrauterine growth restriction in animals treated with repeat steroids, randomized controlled studies in humans have shown that birth weight reduction was only seen in those infants treated with 4 or more courses of corticosteroids. In addition, the reduction in neonatal birth weight and head circumference seen after multiple courses of antenatal corticosteroids normalizes by the time of hospital discharge. Studies are ongoing to investigate the 24-month postdelivery physical and neurodevelopmental outcomes in infants exposed to repeat courses of antenatal corticosteroids. Although there is evidence demonstrating the safety of a single repeat, or “rescue”, dose of antenatal corticosteroids, this must be tempered against the adverse effects seen after multiple courses of weekly repeat steroids. Randomized controlled trials are needed to determine the optimal number of courses of antenatal steroids to reduce the frequency of neonatal respiratory distress syndrome (RDS) without adversely affecting other neonatal outcomes. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that although there are studies that support repeated courses of antenatal steroids, 24-month postdelivery and neurodevelopmental studies in infants exposed to repeated antenatal steroids are ongoing and also state that a “rescue”, single repeat dose, seven days after the first dose, appears prudent in only those mothers who are imminent of delivery prior to 32 weeks’ gestation.

Practice patterns and knowledge of obstetricians and gynecologists regarding placenta accreta

Abstract Objective: We surveyed obstetricians to determine their knowledge, patterns of care and treatment preferences for women with placenta accreta. Methods: A 27-item survey was mailed to fellows of the American College of Obstetricians and Gynecologists. The survey included demographics, questions regarding knowledge and items to examine practice patterns. Results: Among 994 surveyed practitioners 508 responded including 338 who practiced obstetrics. Among generalists, 23.8% of respondents referred patients with placenta accreta to a sub-specialist. Overall, 20.4% referred women to the nearest tertiary center, and 7.1% referred to a regional center. Delivery was recommended at 34–36 weeks by 41.2%. Adjuvant interventions including ureteral stents (26.3%), iliac artery embolization catheters (28.1%), and balloon occlusion catheters (20.1%) were used infrequently. Six or more units of blood were crossed for delivery by only 29.0% of practitioners. Conclusion: There is widespread variation in the care of women with or at risk for placenta accreta.

VBAC: a medicolegal perspective.

History has always been a series of pendulum swings, and there is perhaps no better example in obstetrics than that of vaginal birth after cesarean. Vaginal birth after cesarean (VBAC) rates rose steadily in the early 1990s. However, VBAC rates have declined dramatically over recent years, while the cesarean delivery rate has continued to rise unabated. Many physicians and hospitals are no longer offering trial of labor after cesarean, largely because of medicolegal concerns. This article explores the medical and legal risks of trial of labor after cesarean.

Practice patterns and preferences of obstetricians and gynecologists regarding thromboprophylaxis at the time of Cesarean section.

Abstract Objective: Our survey aimed to identify knowledge and application of guidelines in the United States by assessing practicing obstetricians and gynecologists (OBGYN) use of thromboprophylaxis, preferred methods and whether their type of practice influenced their choices. Study design: A cross-sectional survey of fellows of the American College of Obstetricians and Gynecologists (ACOG) was performed. A 21-item paper and electronic questionnaire was sent to each participant. A total of three mailings were carried out. Results: In total, 400 OBGYN were invited to participate. Questionnaires were returned by 209 (52.3%), 157 (75.1%) of whom provided prenatal care within the last year. All respondents used at least one method of thromboprophylaxis routinely. About 92.4% used pneumatic compression devices. An equal proportion used unfractionated heparin and low molecular weight heparin routinely (17.8%). About 19.1% routinely used combination prophylaxis. In total, 77.1% (n = 121) used the ACOG guidelines. Local hospital guidelines were referenced by 38.2% (n = 60). Other guidelines referenced were the ACCP guideline (n = 34, 21.7%) and several international guidelines (n = 5, 3.3%). Conclusion: Awareness of the risk of thromboembolism around delivery by cesarean section is high among OBGYN practitioners. Broadening guidelines to encompass all deliveries, not only cesareans, with a focus on identifying the patient at risk, would likely be successful.