Obstetric Considerations Research Articles

Familial Mediterranean Fever in Pregnancy.

Though the incidence of familial Mediterranean fever (FMF) in pregnancy is rare, understanding the etiology and symptomatology of FMF is essential for obstetric treatment of patients with FMF. Familial Mediterranean fever is a hereditary periodic fever syndrome that has unique obstetric considerations. Familial Mediterranean fever is typically characterized by recurrent episodes of high-grade fevers, pleuritis/pericarditis, and arthritis lasting 1-3 days with complete recovery seen in between episodes. Familial Mediterranean fever is seen worldwide, but particularly in patients of Mediterranean descent. Its incidence varies across ethnicities. This article provides a comprehensive review of existing literature. It is well established that colchicine is safe and effective to use during pregnancy in patients with FMF to control and prevent flares. Although most pregnancies progress without negative outcomes, FMF has been shown in the literature to be associated with preterm birth and premature rupture of membranes. Its impact on increasing the rate of fetal growth restriction and hypertensive disorders is less understood. Additionally, FMF flares may be suppressed in pregnancy, whereas other sources report that flares are similar to those outside of pregnancy in terms of frequency, type of symptoms, and severity. Breastfeeding is safe in patients with FMF who are taking colchicine. Genetic counseling can be offered to patients with FMF, but in utero diagnostic testing is generally not pursued solely for the indication of FMF diagnosis in the fetus. Further investigation of the impact of FMF on pregnancy is needed for advancing our understanding of the condition and optimizing care for pregnant individuals with FMF.

Extracorporeal membrane oxygenation (ECMO) in pregnancy and peripartum: a focused review

As the medical complexity of pregnant patients increases, the rate of maternal morbidity has risen. Maternal cardiovascular disease is a leading cause of maternal morbidity and mortality followed closely by sepsis and infection, both of which may be associated with respiratory failure. There has been an expansion in the application of extracorporeal life support in pregnant and peripartum patients which requires obstetric anesthesiologists to understand the indications, obstetric and medical considerations, relative advantages and potential complications of this invasive technology in this population. Obstetricians and anesthesiologists who care for women on the labor floor must strive to recognize at-risk and deteriorating patients, facilitate escalation of care when appropriate, and engage consultant teams to consider the need for extracorporeal support in high-risk circumstances. This article reviews the epidemiology, indications, specific considerations, potential complications, and outcomes of extracorporeal life support in pregnant and peripartum patients.

Obstetric anesthesia considerations in pregnancy-associated myocardial infarction: a focused review

Pregnancy-associated myocardial infarction (PAMI) is a rare but serious complication that can occur either during pregnancy or postpartum. The etiologies of PAMI are atherosclerosis, spontaneous coronary artery dissection, coronary thrombosis, coronary embolism, and coronary vasospasm. Therapy of acute PAMI depends largely on the ECG presentation, hemodynamic stability, and suspected etiology of myocardial infarction. Anesthetic management during delivery in patients with PAMI should consist of early and carefully titrated neuraxial analgesia and anesthesia, maintenance of normal sinus rhythm, preservation of afterload, and monitoring for and avoiding myocardial ischemia. To improve the care of women with PAMI, a multidisciplinary team of cardiologists, maternal fetal medicine specialists, obstetric providers, neonatologists, and anesthesiologists must work collectively to manage these complex patients.

Care considerations for caesarean births in a non-obstetric hospital

Background Births in non-maternity hospitals pose significant challenges to ensure delivery of safe and effective care. Methods We conducted a retrospective chart review examining the maternal and neonatal demographics and care needs of women delivering in a non-obstetric general hospital over a 10-year period. Results Cardiac conditions and placenta accreta spectrum disorder were the most common reasons for birth in this location. All 37 births occurred on a weekday, with 29 during core working hours (8 a.m.–4 p.m.). All cases required obstetric, midwifery, anaesthesiology, neonatology and inter-hospital transfer services. Level 3 support was required for 15 women following birth. Neuraxial anaesthesia was utilised in the majority of cases (24/37, 64.8%). One in six infants were breastfed on discharge, with a mean gestational age at birth of 34 weeks. Conclusion We demonstrate the significant input of the multi-disciplinary and highlight the importance of addressing both obstetric and neonatal considerations outside of their native care setting.

Navigating the Complexity: A Comprehensive Review of Managing Pregnancy in Complete Heart Block Cases.

This review explores the comprehensive management of pregnancy in cases of complete heart block, a cardiac condition characterized by the dissociation between atrial and ventricular conduction. The review begins with a thorough examination of preconception counseling, emphasizing the assessment of maternal health, the evaluation of cardiac function, and the identification of potential risks. Subsequently, the medical management section delves into using beta-blockers, pacemakers, and antiarrhythmic drugs to monitor cardiac function during pregnancy and adjust medication regimens. Obstetric considerations highlight the importance of antenatal care, fetal monitoring, and thoughtful delivery planning, including the choice between vaginal delivery and cesarean section. The section on complications underscores the risks of arrhythmias, heart failure, premature birth, and neonatal cardiac issues. Looking ahead, the future directions and research section explores ongoing studies in genetics, pharmacology, and technological innovations, envisioning potential advancements in pacing technology and personalized medicine approaches. The conclusion synthesizes key findings, offering recommendations for clinical practice and reflecting on the challenges and opportunities inherent in managing pregnancy in complete heart block cases. The multidisciplinary approach emerges as paramount, with collaborative efforts paving the way for improved patient outcomes and advancements in the field.

Obstetric considerations for aortopathy in pregnancy

Obstetric considerations for aortopathy in pregnancy

Obstetric considerations for aortopathy in pregnancy

Obstetric considerations for aortopathy in pregnancy

Pregnancy, parturition and postpartum considerations among patients with vulvar lichen sclerosus: A retrospective cross-sectional online survey.

Characterise VLS and obstetric considerations among women during pregnancy, parturition and postpartum. Retrospective cross-sectional online survey, 2022. International, English-speakers. Self-identified individuals aged 18-50 diagnosed with VLS with symptom onset prior to pregnancy. Participants recruited from social media support groups and accounts, completed a 47-question survey including yes/no, multiple answer, and free-text responses. Data were analysed with frequency, means and the Chi-square test. VLS symptom severity, mode of delivery, perineal laceration, source and sufficiency of information provided about VLS and obstetrics, anxiety about delivery, and postpartum depression. Of 204 responses, 134 met inclusion criteria, encompassing 206 pregnancies. Mean respondent age was 35 years (SD 6) and mean age of VLS symptom onset, diagnosis and birth, was 22 (SD 8), 29 (SD 7) and 31 (SD 4) years, respectively. Symptoms decreased in 44% (n = 91) of pregnancies and increased during the postpartum period in 60% (n = 123). In all, 67% (n = 137) of pregnancies resulted in vaginal birth and 33% (n = 69) in caesarean birth. Anxiety for delivery due to VLS symptoms was reported by 50% (n = 103); 31% (n = 63) experienced postpartum depression. Of respondents previously diagnosed with VLS, 60% (n = 69) used topical steroids prior to pregnancy, 40% (n = 45) were treated during pregnancy and 65% (n = 75) postpartum. In all, 94% (n = 116) reported receiving an insufficient amount of information on the topic. In this online survey, we found reported symptom severity remained unchanged or decreased during pregnancy, but increased postpartum. Use of topical corticosteroids decreased during pregnancy compared with before and after pregnancy. Half of the respondents reported anxiety regarding VLS and delivery.

The Risks and Benefits of Monoclonal Antibody Therapy During Pregnancy and Postpartum: Maternal, Obstetric, and Neonatal Considerations.

Autoimmune and rheumatologic conditions can lead to multiple adverse maternal, obstetric, and neonatal outcomes, especially if they flare during pregnancy. Although many medications to control these conditions exist, concerns regarding their safety often unnecessarily limit their use. We aim to review the current evidence available describing the use of monoclonal antibody (mAb) therapeutics in pregnancy and postpartum and understand the impact of their use on the developing fetus and neonate. Original research articles, review articles, case series and case reports, and pregnancy guidelines were reviewed. Multiple retrospective (including 1924 patients) and prospective studies (including 899 patients) of anti-tumor necrosis factor (TNF) agent use in pregnancy found no significant increase in rates of miscarriage, preterm birth, or congenital anomalies compared with controls. Most societies, including American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine, recommend initiation or continuation of TNF-α inhibitors during pregnancy for patients with autoimmune diseases. An increased risk of mild infections in newborns has been reported, although infections requiring hospitalizations are rare. Data suggest that breastfeeding while taking anti-TNF agents is safe for neonates. Less data exist for the use of other mAbs including anticytokine, anti-integrin, and anti-B-cell agents during pregnancy and postpartum. Current evidence suggests that the use of mAbs, particularly anti-TNF agents, is safe in pregnancy and postpartum, without significant adverse effects on the pregnant patient or infant. The benefits of ongoing disease control in pregnant patients result in favorable maternal and neonatal outcomes.

Obstetric Concern, Management and Considerations in the Context of COVID-19 Pandemic

Coronavirus disease (COVID-19) has emerged as a global threat. The disease largely attacks adults with higher mortality among the aged and compromised people. Although previous coronavirus havocs caused significant number of maternal and neonatal demise, most pregnant cases with COVID-19 infection are either asymptomatic or with mild symptoms only. This pandemic brought significant disruption of essential antenatal and intranatal care worldwide. The health resources became diverted to focus on general population needs rather than the specified needs of pregnant women. Limited information is known about the effect of COVID-19 disease on pregnancy. Recent evidence indicates that pregnant women are not vulnerable group for severe COVID-19 illness. However, immunological and physiological alterations during pregnancy expose women more vulnerable to SARS-CoV- 2 infection in comparison to general population.Covid-19 pandemic has created a global crisis causing great challenges for pregnant women and their obstetricians. Although the due course of pregnancy is not strained by the disease itself but complications can happen in absence of proper care and caution. Both the pregnant mother and care-giver should be vigilant and the obstetric management should be implemented following evidence based standard protocol.
 Bangladesh J Obstet Gynaecol, 2021; Vol. 36(1): 49-56

Obstetric Considerations in Pregnant Women with Crohn's Disease.

Crohn's disease affects many women of childbearing age. Fecundity rates are often lower than in the general population due to reduced fertility during active inflammation, effects of pelvic surgery or voluntary childlessness. Many women have concerns regarding the effects of pregnancy on their Crohn's, any potential effect of medication on the fetus, and passing on Crohn's disease to the offspring. International guidelines on reproduction for women with Crohn's disease provide evidence-based advice to patients and health care professionals. There is an increasing literature on the safety of advanced medication for Crohn's disease during pregnancy. This review article therefore focuses on obstetric considerations beyond medication safety. We provide information on fertility, factors affecting pregnancy and fetal outcomes, obstetric complications, factors influencing mode of delivery, management of intestinal stomas during pregnancy and general considerations around breast feeding.

Anesthetic and Obstetric Considerations of Moyamoya Disease in Pregnancy after Intracranial Bypass Grafting: A Case Report and Literature Review

Anesthetic and Obstetric Considerations of Moyamoya Disease in Pregnancy after Intracranial Bypass Grafting: A Case Report and Literature Review

Implementing an Undergraduate Nursing Elective Advanced Perinatal Course and Its Effect on Perceived Perinatal Nursing Knowledge and Self-Efficacy Levels of Students Who Aim to Enter a Perinatal Specialty as New Graduate Nurses

Nursing schools face challenges within maternal/newborn practicum courses for undergraduate nursing students, such as a lack of consistent clinical sites or experiences that capture the high acuity needs of perinatal environments. Additionally, perinatal units face challenges in orienting and retaining new graduate nurses, while new graduate nurses entering perinatal units may be likely to experience feelings of insecurity or self-doubt due to perceived inadequate preparation for such specialties (Lesher et al., 2021). There are multiple negative impacts that may stem from a lack of confident and competent novice perinatal nurses. The rise in maternal morbidity and mortality rates in the United States are of particular concern, and knowledge gaps on behalf of novice perinatal nurses may result in the lack of skills and confidence in recognizing complications and intervening appropriately, potentially jeopardizing patient safety. The literature suggests that perinatal units face challenges in effectively orientating new graduate nurses, leading to burnout and financial burdens (Dickerson et al., 2022). Recognizing the potential benefits of improving preparation for students interested in entering a perinatal specialty as new graduates, such as improved patient outcomes and increased staff retention, this study aims to analyze the impact of an elective advanced perinatal course on student perception of knowledge and self-efficacy levels for those who aim to enter a perinatal specialty as a new graduate nurse. Content will be focused on advancing knowledge of normal physiologic birth, high-risk obstetrical and newborn considerations, obstetric emergencies, perinatal mood and anxiety disorders, bereavement care, diversity/equity/inclusion care, and resiliency tips.

Fetal Disseminated Malignant Rhabdoid Tumor.

Fetal Disseminated Malignant Rhabdoid Tumor.

Maternal and perinatal outcomes in pregnant women with confirmed COVID-19 infection, Santa Teresa Hospital, Comayagua, Honduras. Case series

RESUMENObjetivos: Describir el resultado materno y perinatal de las gestantes con infección confirmada por COVID-19 en una institución hospitalaria en Comayagua, Honduras.Materiales y métodos: Estudio descriptivo tipo serie de casos. Se incluyeron gestantes sintomáticas que consultaron o fueron remitidas desde el 1 de marzo de 2020 hasta el 31 de marzo del 2021 a una institución pública de referencia, con diagnóstico confirmado por PCR de infección por COVID-19. Se midieron variables sociodemográficas, obstétricas, severidad de la infección, estancia hospitalaria, complicaciones maternas y perinatales. Se estimó la frecuencia de infección por COVID-19 y los resultados maternos y perinatales de estas gestaciones; se realizó análisis descriptivo.Resultados: En el periodo descrito consultaron 2.258 gestantes, de estas se incluyeron 23, quienes cumplieron con los criterios de selección, para una frecuencia de infección por COVID-19 del 1,01 %. La población de estudio se caracterizó por estar constituida por mujeres jóvenes y en unión libre. Trece pacientes recibieron manejo ambulatorio por cuadro clínico leve, diez requirieron hospitalización. Las embarazadas manejadas ambulatoriamente finalizaron la gestación vía cesárea (76,9 %) por estado fetal insaisfactorio, con edad gestacional mayor o igual a 37 semanas, y tres casos fueron pretérmino (36 semanas). De las gestantes hospitalizadas, una desarrolló aborto espontáneo, y nueve finalizaron la gestación por una indicación obstétrica. Se presentó un parto prematuro y se documentó una muerte materna (4 %) y neonatal.Conclusiones: El 1 % de las gestantes adquirieron la infección por COVID-19 en el Hospital Santa Teresa de Comayagua en el perido de estudio. Se requieren más estudios que analicen el impacto materno perinatal de la infección por COVID-19 en la región centroamericana.

Obstetric venous thromboembolism prophylaxis, risk factors and outcomes.

Risk factors for obstetric venous thromboembolism (VTE), a leading cause of maternal mortality in the United States, are increasing on a population basis. This review provides the obstetrician with an update of current issues related to obstetric VTE risk, prophylaxis, outcomes, anaesthesia considerations and future research opportunities. Obstetric VTE affects approximately 1 per 1000 pregnancies and accounts consistently for 9-10% of maternal deaths in the United States. In industrialized countries, risk factors for VTE, including overweight/obesity, caesarean delivery and obstetrical complications such postpartum haemorrhage and infection continue to increase. VTE prophylaxis is central to reducing maternal mortality. However, recommendations for prophylaxis from leadership societies vary widely. In the UK, maternal mortality risk from VTE has decreased significantly in the setting of broader heparin prophylaxis. In the United States where mechanical VTE prophylaxis is used more commonly, mortality risk has remained constant. Obstetric VTE is a leading cause of maternal mortality in the United States. The incidence of risk factors for obstetric VTE continues to increase. Currently, recommendations for obstetric VTE prophylaxis vary substantially. Opportunities for research in this area exist to optimize prophylaxis and improve maternal outcomes.

Characteristics and short-term obstetric outcomes in a case series of 67 women test-positive for SARS-CoV-2 in Stockholm, Sweden.

IntroductionThe Stockholm region was the first area in Sweden to be hit by the pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). The national guidelines on the care of women with a positive test for SARS‐CoV‐2 (detection with polymerase chain reaction [PCR]) recommend individualized antenatal care, mode of delivery based on obstetric considerations, and no routine separation of the mother and the newborn. Breastfeeding is encouraged, and although there is no specific recommendation regarding wearing a face mask to prevent viral transmission to the newborn while nursing, instructions are given to keep high hygiene standards. All studies based on cases tested on hospital admission will capture more women with pregnancy complications than in the general population. Our aim was to describe the clinical characteristics of SARS‐CoV‐2‐positive women and their neonates, and to report short‐term maternal and neonatal outcomes.Material and methodsA retrospective case series with data from medical records including all test‐positive women (n = 67) who gave birth to 68 neonates from 19 March to 26 April 2020 in Stockholm, Sweden. Means, proportions and percentages were calculated for clinical characteristics and outcomes.ResultsThe mean age was 32 years, 40% were nulliparous and 61% were overweight or obese. Further, 15% had diabetes and 21% a hypertensive disease. Seventy percent of the women had a vaginal birth. Preterm delivery occurred in 19% of the women. The preterm deliveries were mostly medically indicated, including two women who were delivered preterm due to severe coronavirus disease 19 (COVID‐19), corresponding to 15% of the preterm births. Four women (6%) were admitted to the intensive care unit postpartum but there were no maternal deaths. There were two perinatal deaths (one stillbirth and one neonatal death). Three neonates were PCR‐positive for SARS‐CoV‐2 after birth.ConclusionsIn this case series of 67 women testing positive for SARS‐CoV‐2 with clinical presentations ranging from asymptomatic to manifest COVID‐19 disease, few women presented with severe COVID‐19 illness. The majority had a vaginal birth at term with a healthy neonate that was negative for SARS‐CoV‐2.

Successful pregnancy and delivery in a woman with achondroplasia

Achondroplasia is a common form of dwarfism occurring in one out of 25,000 of live births. These patients present many problems during pregnancy and at the time of the delivery. The anaesthetist may also face several difficulties for both general and regional anaesthesia. The aim of this case report is to discuss various obstetric and anaesthetic considerations in such patients and ways to manage the difficulties. A 29-year-old woman expecting her first child, with achondroplasia -height of just 3'2'' (98 centimetres) - at 31 weeks of gestation, presented to our OPD for antenatal visit on May 15, 2018. Her successful elective lower segment caesarean section was performed on June 25, 2018 at 37 weeks in view of contracted pelvis under general anaesthesia. A live male baby was delivered, with no complications, good Apgar score and birth weight of 2.7kg. This shows that a woman with a genetic disorder like achondroplasia can become pregnant and deliver a healthy child at term.

Second Trimester Dilation & Evacuation in a Patient with Uterus Didelphys

Uterus didelphysis one of the rarest of the Mullerian duct anomalies and can lead to unique obstetric and gynecologic outcomes and considerations. This case describes a patient with known uterus didelphys and intact longitudinal vaginal septum who desired termination of pregnancy at 17 weeks gestation due to fetal anomaly. She underwent dilation and evacuation (D&E) under ultrasound guidance and the pregnancy was removed from the right-sided uterus. Preoperative mifepristone and misoprostol were used for cervical ripening.This case demonstrates that second trimester D&E can be safely performed on patients with uterus didelphys and is aided by the adjunctive use of prostaglandins, mifepristone, and ultrasound guidance to avoid intraoperative complications.

COVID-19: Obstetric anesthesia care considerations

• Pre-hospital COVID-19 screening should be implemented for all pregnant patients. • Limit the number of staff in a delivery room or operating room when feasible • Encourage the use of video messaging with other members of the patient's support system • An experienced provider should perform neuraxial procedures and intubations, whenever possible.