Obstetric Perspective Research Articles

Safety and Efficacy of Inferior Vena Cava Filters in the Peri-Partum Period: Experiences at a Tertiary Care Facility

Background: Guidelines recommend placement of inferior vena cava (IVC) filters in patients with acute thrombotic episodes and a concurrent contraindication to anticoagulation, however filter placement during or immediately postpartum presents significant technical challenges. The use and complications of IVC filters in the peripartum period is poorly documented in current literature. Objective(s): To evaluate the use of and outcomes related to IVC filters in an obstetric population at a large tertiary care center. Study Design: Retrospective review of all patients at a tertiary academic medical center from 2001-2016 who either conceived with an IVC filter in place or underwent IVC filter placement during the antepartum or postpartum interval. Manual abstraction of each chart was performed, with data stored in a RedCap database. Results: A total of 24 patients were included in the final analysis: 5 with IVC filter placement prior to pregnancy, 7 with antepartum placement, and 12 with postpartum placement. One patient had multiple pregnancies during our study timeframe and was therefore included twice. The cohort of postpartum placement were the youngest mean age (23.7 years), had a higher number of IVC filters placed for polytrauma (n=4), and had the shortest time to removal (135.9 days). The vast majority (91.3%) of IVC filters placed during pregnancy were retrievable filters in the suprarenal position, while most deployed in an infrarenal position (83.3%) when placed prior to conception. Complications encountered included multiple attempts to remove IVC filter, severe angulation, embedded struts, fracture, and one case of cardiac tamponade during filter placement requiring emergent sternotomy and evacuation. Of the filters requiring multiple attempts for removal, in 1 patient (4%) it was unable to be removed despite multiple attempts and the filter was ultimately left in situ. Complications were more common when placement was performed prior to pregnancy or antepartum (40% and 57.1% respectively) versus postpartum (16.7%). From an obstetrical perspective, 1 patient (4%) required early preterm delivery due to preeclampsia; 1 maternal death occurred in a postpartum patient who experienced a massive pulmonary embolism and subsequently died despite emergent thrombectomy and IVC filter placement, and 1 neonatal death occurred due to congenital heart disease following periviable preterm delivery. Conclusion(s): In our study across 16 years at a large academic medical center we identified 23 patients who had an IVC filter placed prior to pregnancy or placed during the antepartum or postpartum periods. Data from our experience suggested a higher incidence of complications with preconceptual and antepartum placement, although the majority of these did not impact clinical outcomes. While not frequently needed, IVC filters remain an option for clinicians treating pregnant and postpartum patients but should be considered a last resource as they can lead to various complications.

P.144 Awake craniotomy in pregnancy: a systematic review

Background: Awake Craniotomy during pregnancy is a rare but urgent procedure. Since pregnancy can both accelerate the progression of a tumor and mask other diagnoses, cases may lead to premature termination of pregnancy. From a neurosurgical, anesthetic, and obstetrical perspective, these operations may be challenging. Methods: In accordance with the PRISMA guidelines, MEDLINE, Scopus, and Web of Science databases were searched from inception to January 3rd, 2023. Studies were included if they included pregnant patients who underwent awake craniotomy. Results: Nine papers fit the criteria for the final analysis. All investigations were case studies. A total of nine patients were included. Mean age at surgery was 26.9 years, and mean gestational age at craniotomy was 20.9 weeks. Eight (88.9%) patients underwent craniotomy for tumor resection and the other had a pseudoaneurysm repair. Glioma was the most common tumor pathology (n=5), followed by meningioma (n=1), and glioblastoma (n=1). None of the patients experienced significant intraoperative or immediate postoperative complications. There were no obstetrical complications or significant changes in fetal status during or after surgery, and all reported deliveries were successful with healthy infants. Conclusions: Awake craniotomy during pregnancy can be a safe procedure with appropriate pre-operative patient selection and extensive multidisciplinary planning.

MO1044: Understanding Perception of Pregnancy Risk in Women with Chronic Kidney Disease

BACKGROUND AND AIMSWomen with chronic kidney disease (CKD) are at increased risk of adverse pregnancy and renal outcomes, including preterm birth and progression of kidney disease. Women's risk perceptions of pregnancy impact behaviours and decisions including engagement with prenatal care, mode of delivery choices and adherence to medical advice, therefore, it is important that women perceive and understand their risk accurately. Pre-pregnancy counselling is recommended for all women with CKD, but it is unknown how women with CKD understand their pregnancy risk and if pre-pregnancy counselling affects women's perceptions. The aim of this study was to understand how a large cohort of diverse women with CKD perceive their pregnancy risk and compare differences in risk perceptions between those who have and have not received pre-pregnancy counselling.METHODThe ‘Perception of Pregnancy Risk Questionnaire’ (PPRQ;1) and ‘Desire to Avoid Pregnancy Questionnaire’ (2) were used to measure risk perception and pregnancy intention respectively. The PPRQ was adapted to assess risk perceptions in women with CKD including the severity of kidney disease. Content validity of the adapted PPRQ was confirmed by a panel of 21 experts including nephrologists, midwives, psychologists and obstetricians. Women aged between 18 and 50 years with CKD stages 1–5 were recruited from nine renal units in the United Kingdom and asked to complete an online survey (October 2020–December 2021). Clinical data were extracted from local databases. Data were analysed descriptively.RESULTSA total of 322 women completed the survey, mean age of 34.9 (SD 7.1) years. Women's obstetric history and pregnancy perspectives are described in the Table. Half of the respondents already had children (172/322; 54.1%) and three-quarters perceived pregnancy to be important or very important to themselves (241/322; 75.8%) and two-thirds (218/322; 66.7%) perceived pregnancy to be important or very important to their family. Only 109/321 (34%) of women with CKD had previously attended pre-pregnancy counselling, but those who had attended had a higher perception of pregnancy risk [51.4 (SD 21.4) versus 41.9 (SD 23.8); P < 0.0001] (0: not very severe to 100: extremely severe) and severity of kidney disease [51.3 (SD 24.9) versus 43.7 (SD 28.6); P = 0.014] compared to women who had not attended pre-pregnancy counselling.CONCLUSIONThis large multi-centre questionnaire study identified that risk perceptions of pregnancy for women with CKD appear to be higher than those of women with an uncomplicated pregnancy [PPRQ scores of 24.0 (SD 14.5)] [1]. However, women who had received pre-pregnancy counselling had a significantly higher perception of pregnancy risk and perceived severity of kidney disease. Limitations include a lack of measurement before and after attending a pre-pregnancy counselling clinic. Further assessment of the relationship between severity of kidney disease and perceived pregnancy risk and pregnancy intentions is needed.Table 1.Comparison by awareness of influenza vaccinationNot aware of influenza vaccine N = 21Aware of influenza vaccine N = 65 P-valueClinic respondents, n (%)Telephone respondents, n (%)7 (33.3)14 (66.7)38 (58.5)27 (41.5)0.045Age at screening, years53.2 (40.1, 59.0)39.2 (30.6, 52.6)0.02Male, n (%)8 (38.1)25 (38.5)0.98English spoken at home, n (%)7 (33.3)43 (66.2)0.008English spoken at healthcare, n (%)16 (76.2)62 (95.3)0.03Secondary school education or below, n (%)11 (52.4)14 (21.5)0.007Professional or executive, n (%)6 (28.6)37 (56.9)0.02Income above $2000/month, n (%)10 (55.6)48 (84.2)0.02Disease duration, months33 (15, 53)40 (19, 59)0.43Aware of COVID-19 vaccine, n (%)21 (100)65 (100)-Received COVID-19 vaccine, n (%)20 (95.2)52 (80.0)0.17Health literacy index32.6 (30.1, 38.5)33.3 (30.5, 38.6)0.72Categorical variables were presented as number (percentage) and compared using the Pearson chi-squared or Fisher's exact test as appropriate. Continuous variables were presented as medians with interquartile ranges [IQR (25th percentile, 75th percentile)] and compared using the Mann–Whitney U test. P-values < 0.05 were considered statistically significant.Table 2.Factors associated with influenza vaccine awareness after adjusting for survey typeAdjusted Odds Ratio95% Confidence Interval P-valueAge at screening, per 1 year increase0.950.92–0.990.02Male compared to female1.030.36–2.910.96English spoken at home, yes3.191.07–9.470.04English spoken at healthcare, yes8.871.70–46.370.01Secondary school education or below, yes0.230.08–0.680.008Professional or executive, yes3.361.20–10.930.02Income above $2000/month, yes4.031.19–16.630.03Disease duration, per 1 month increase1.010.98–1.030.63Received COVID-19 vaccine, yes3.340.38–29.470.28Health literacy index, per unit increase0.950.86–1.060.35

Cerebral Palsy and Criteria Implicating Intrapartum Hypoxia in Neonatal Encephalopathy - An Obstetric Perspective for the South African Setting.

The science surrounding cerebral palsy indicates that it is a complex medical condition with multiple contributing variables and factors, and causal pathways are often extremely difficult to delineate. The pathophysiological processes are often juxtaposed on antenatal factors, genetics, toxins, fetal priming, failure of neuroscientific autoregulatory mechanisms, abnormal biochemistry and abnormal metabolic pathways. Placing this primed compromised compensated brain through the stresses of an intrapartum process could be the final straw in the pathway to brain injury and later CP. It is thus simplistic to base causation of cerebral palsy on only an intrapartum perspective with radiological 'confirmation', as is often the practice in medicolegal cases in South African courts. The present modalities (MRI and CTG when available) that retrospectively attempt to determine causation in courts are inadequate when used in isolation. Unless a holistic scientific review of the case including all contributing clinical factors (antepartum, intrapartum and neonatal), fetal heart rate monitoring, neonatal MRI if possible (and preferred) or late MRI, and histology (placental histology if performed) are taken into account, success for plaintiff or defendant currently in a court of law will depend on eloquent legal argument rather than true scientific causality. The 10 criteria set out in this document to implicate acute intrapartum hypoxia in hypoxic ischaemic encephalopathy/neonatal encephalopathy serve as a guideline in the medicolegal setting.

Cerebral Palsy and Criteria Implicating Acute Intrapartum Hypoxia in Neonatal Encephalopathy - An Obstetric Perspective for the South African Setting.

The science surrounding cerebral palsy indicates that it is a complex medical condition with multiple contributing variables and factors, and causal pathways are often extremely difficult to delineate. The pathophysiological processes are often juxtaposed on antenatal factors, genetics, toxins, fetal priming, failure of neuroscientific autoregulatory mechanisms, abnormal biochemistry and abnormal metabolic pathways. Placing this primed compromised compensated brain through the stresses of an intrapartum process could be the final straw in the pathway to brain injury and later CP. It is thus simplistic to base causation of cerebral palsy on only an intrapartum perspective with radiological 'confirmation', as is often the practice in medicolegal cases in South African courts. The present modalities (MRI and CTG when available) that retrospectively attempt to determine causation in courts are inadequate when used in isolation. Unless a holistic scientific review of the case including all contributing clinical factors (antepartum, intrapartum and neonatal), fetal heart rate monitoring, neonatal MRI if possible (and preferred) or late MRI, and histology (placental histology if performed) are taken into account, success for plaintiff or defendant currently in a court of law will depend on eloquent legal argument rather than true scientific causality. The 10 criteria set out in this document to implicate acute intrapartum hypoxia in hypoxic ischaemic encephalopathy/neonatal encephalopathy serve as a guideline in the medicolegal setting.

Reducing the Burden of Prematurity – The Obstetric Perspective

Introduction: ‘Preterm or Premature Birth’ is defined as birth occurring before completion of 37 weeks or 259 days since the first day of the last menstrual period of the mother. Every year, an estimated 15 million babies (more than one in ten births) are born preterm worldwide, and this number is rising. In Sri Lanka, approximately 24,500 babies are born prematurely each year. Efforts by obstetricians and neonatologists have led to significant advances in reducing preterm birth and improving outcomes.

Hepatitis B - chronic carrier status and pregnancy outcomes: An obstetric perspective.

Antenatal screening for hepatitis B surface antigen (HBsAg) only identifies women with hepatitis B virus (HBV) infection for neonatal immunoprophylaxis. It does not reflect the phase of chronic infection, viral genotype and activity, hepatic inflammation, or other co-existing liver disorders. Coinfection with other viruses and micro-organisms may also be present. These factors in various combinations can impact pregnancy outcomes, and they are probably responsible for the conflicting literature on this issue. Pregnancy complications may interact with maternal HBV infection and hepatitis flares, leading to serious and lethal complications. Hepatitis flares are common especially postpartum, and they are unpredictable and unpreventable with antiviral treatment. Evidence on the association between HBsAg seropositivity with gestational diabetes mellitus, preterm birth, increased foetal growth, and reduced pregnancy hypertensive disorders is stronger than other adverse pregnancy outcomes. Baseline assessment of liver function, and viral markers and activity, can delineate the truly high-risk pregnancies for close monitoring.

Aortic dissection during pregnancy - obstetric perspective.

The risk of vascular events during pregnancy is substantially increased. Beyond comparatively frequent vascular diseases, pregnancy may lead also to the development of exceptionally rare vascular events such as the aortic dissection and aortic rupture which are conceivably endangering life conditions. Women with the connective tissue disorders and with a family history of the aorta diseases are especially prone to the aortic complications which may also develop in the absence of these risk factors due to the pregnancy-induced structural changes of the aortic wall. The preconception counselling is vital for patients with aortopathies to assess the risk of the aortic dissection and to establish the most appropriate care plan including the surgical intervention. This review presents the management guidelines in patients with the aortic dissection risk during pregnancy.

Perfil sociodemográfico e obstétrico de mulheres em idade materna avançada

Objetivo: descrever o perfil sociodemográfico e obstétrico de mulheres em idade materna avançada atendidas em 2014 em um hospital universitário do sul do Brasil. Método: pesquisa descritiva, retrospectiva, de abordagem quantitativa, constituída de 223 prontuários de mulheres. Os dados foram coletados por meio de um questionário estruturado no período de setembro de 2015 a janeiro de 2016. Resultados: das mulheres, 68,6% tinham entre 35 e 39 anos, 82,5% brancas, 75,7% casadas, 35,4% tinham ensino médio completo e 51,1% exerciam trabalho remunerado. Quanto ao perfil obstétrico, 91,9% realizaram o pré-natal, 53,4% tiveram parto cesáreo, 75,3% tiveram bebê a termo. Das 75,8% que apresentaram complicações, 14,2% tiveram pré-eclâmpsia e 28,4% diabetes mellitus gestacional. Considerações finais: os dados evidenciam um perfil sociodemográfico de mulheres brancas, com baixo nível de escolaridade e baixa renda. Na perspectiva obstétrica, houve alta porcentagem de complicações associadas à própria idade e às doenças pré-gestacionais.

Obstetric Trauma and Surgical Emergencies in the Military Operational Environment

Military medicine operates globally to deliver health service support to U.S. Servicemembers while also delivering healthcare to allies, enemy combatants, local civilians, and displaced persons. Military medical assets provide support during combat operations and in operations other than war. Obstetric trauma can and does occur in all of these populations and mission sets. This review focuses on obstetric trauma experience and perspectives in the context of military operational medicine. Comprehensive review and analysis of military operational medicine during the periods of war in Iraq and Afghanistan have informed general trauma management principles but have not contributed to significant evidence or management guidance pertinent to management of trauma in the obstetric population. Austere, foreign, focused, or low-resourced environments are challenging places to manage obstetric trauma. Fundamental trauma management principles still apply.

Predictors of poor suckling among neonates delivered at 37 weeks and beyond from obstetric perspective: a five-year observational study.

Objective: To assess prospectively the predictors of poor suckling among term neonates delivered at 37 weeks and beyond from obstetric perspective. Methods: This five-year observational study was conducted on 326 term neonates who experienced poor suckling compared to a cohort of 9482 term neonates with normal suckling. Predictors of poor suckling were explored by univariate and multivariate analyses. Data was collected and tabulated. Results: Mothers of neonates with poor suckling have significantly higher rates of medical disorders (p<0.001). Maternal hypertensive disorders (OR 2.52 with 95% CI of 0.96-3.38), elective CS before 39 weeks (OR 1.68 with 95% CI of 0.78-3.44), delivery by CS under general anesthesia (OR 1.86 with 95% CI of 0.76-2.32), PROM >18 hours (OR 2.04 with 95% CI of 0.96-4.28), meconium or blood stained amniotic fluid (OR 1.98 with 95% CI of 0.78-2.39), Induction and/or augmentation of labor (OR 2.42 with 95% CI of 0.98-4.66), gestational age <39 weeks (OR 1.54 with 95% CI of 0.66-1.98) and Prolonged labor >24 hours (OR 1.44 with 95% CI of 0.72-1.96) are predictors of poor suckling among term neonates. Conclusion: Term neonates are not immune against poor suckling which could be attributed to maternal medical disorders, intrapartum complications and mode of delivery. Obstetricians and Pediatricians should be aware of these issues.

An obstetrical perspective: the benefits of a frozen embryo transfer cycle

An obstetrical perspective: the benefits of a frozen embryo transfer cycle

Incorporation of “One Health” Into Obstetrics and Gynecology [21I

INTRODUCTION: It has been well established that there is high conservation between humans and animal organisms in their biology, genetics, and diseases. The “One Health” movement, which is an effort to have multiple health disciplines collaborate to improve the health of people, animals and the environment, is particularly suited to obstetrics and gynecology. Veterinarians are involved not only in the various obstetrical dystocias, pelvic floor prolapse and contraceptive issues of many mammals, including primates, but also in species conservation and breeding programs. An opportunity exists for OB/GYN programs to become more involved with zoos and wildlife parks in their locale. METHODS: The Rutgers OB/GYN department established a partnership with Turtle Back Zoo (a national AZA accredited site) such that physicians, fellows, residents and medical students interface with the professionals working there. RESULTS: This partnership has not only resulted in the exchange of education from a reproductive endocrinology, contraceptive, and obstetrical perspective, but also in providing needed equipment to the Zoo. It was noted that many of the items discarded after a surgical procedure (sutures, drapes, disposable instruments, etc) at our academic teaching hospital that cannot be used again for humans is suitable for veterinary use. CONCLUSION: Medical institutions and veterinary colleges have traditionally worked in isolated silos. There are few collaborations and comparative studies across the two disciplines. However, with diseases manifesting similarly in humans and animals, there is a wealth of information to be tapped into and we propose greater collaboration through the “One Health” initiative.

Predictors of poor suckling among neonates delivered at 37 weeks and beyond from obstetric perspective: a five-year observational study.

Predictors of poor suckling among neonates delivered at 37 weeks and beyond from obstetric perspective: a five-year observational study.

Predictors of poor suckling among neonates delivered at 37 weeks and beyond from obstetric perspective: a five-year observational study.

Predictors of poor suckling among neonates delivered at 37 weeks and beyond from obstetric perspective: a five-year observational study.

An Obstetric Perspective on Functional Bowel Obstruction After Cesarean Section: A Case Series

Ogilvie’s syndrome (OS) and paralytic ileus are two types of functional bowel obstructions well known in obstetrics. Cesarean section and spinal anesthetic have been reported as etiological factors. OS is rare; however, associated morbidity and mortality rates are high. We report on three patients whose post-cesarean section course was complicated by a functional bowel obstruction. Two of the patients exhibited signs of imminent perforation from cecal dilation and required major surgical intervention. The pathophysiology of OS and paralytic ileus and their respective management are discussed based on a review of the literature. A new approach to the management of functional bowel obstructions after cesarean section is offered from an obstetric perspective. Identification of cecal dilation is the key. We suggest prompt measurement of the cecum with an abdominal X-ray followed by surgical review and intervention in symptomatic patients with a cecal diameter equal to or greater than 10 cm. J Clin Gynecol Obstet. 2016;5(1):53-57 doi: http://dx.doi.org/10.14740/jcgo390w

An Obstetric Perspective on Functional Bowel Obstruction After Cesarean Section: A Case Series

An Obstetric Perspective on Functional Bowel Obstruction After Cesarean Section: A Case Series

Why such differing stances? A review of position statements on home birth from professional colleges.

Despite low rates of home birth throughout most Western countries, the topic generates considerable debate. This is reflected by the differing positions on home birth adopted by professional colleges representing obstetricians and midwives. We reviewed position statements of midwifery and obstetric colleges in the UK, USA, Australia, New Zealand, and Canada to explore how the same body of research evidence leads to different positions. Aside from a joint statement from the UK we found widely differing stances, reflecting traditional midwifery perspectives of birth as a physiological process versus obstetric perspectives of potential pathology. We feel the differences in position statements are largely the end product of significant confirmatory bias. Review of organisational position on home birth suggests bias in literature interpretation.

Analysis of pregnancy, labor and neonatal course in babies with prenatally-diagnosed complete atrioventricular heart block

Complete heart block (third-degree atrioventricular block) is a defect of the conduction system of the heart, in which the impulse generated in the sinoatrial node does not propagate to the ventricles, and thus the latter contract independently of the atria. A third-degree atrioventricular block can be either congenital or acquired. In 60-70% of the cases, the congenital heart block results from destruction of the conduction system of the fetal heart by anti-Ro/SSA and anti-La/SSB antibodies present in maternal serum. The antibodies are synthesized in the course of autoimmune maternal conditions, most often systemic lupus erythematosus or rarer rheumatoid arthritis, dermatomyositis or Sjögren's syndrome. The complete block can occur as an isolated defect or be associated with structural anomalies of the fetal heart. A total of five patients whose fetuses were diagnosed with the third-degree atrioventricular block have been hospitalized at the Department of Obstetrics, Medical University of Gdansk between 2012 and 2014. We present the data of the five patients, hospitalized at the Department of Obstetrics, Medical University of Gdansk, whose fetuses were diagnosed prenatally with the complete heart block. The cases differ in terms of etiology clinical outcome, and postnatal treatment. All data are presented in Table I. We emphasize the role of appropriate pregnancy management and careful monitoring of the fetal condition. From obstetrical perspective, it is important to monitor the condition of fetuses with the third-degree atrioventricular block ultrasonographically and echocardiographically; in turn, cardiotocography is less useful in this setting. Therefore, a non-reactive cardiotocographic tracing should not constitute an indication for a preterm delivery. An affected fetus should be delivered in a tertiary center for perinatal care that cooperates with a pediatric cardiology center. An efficient program for cardologic prenatal care and close cooperation between obstetricians, neonatologists, pediatric cardiologists, and cardiac surgeons constitute the key to a successful outcome.

Fetal growth: a review of terms, concepts and issues relevant to obstetrics

The perinatal literature includes several potentially confusing and controversial terms and concepts related to fetal size and growth. This article discusses fetal growth from an obstetric perspective and addresses various issues including the physiologic mechanisms that determine fetal growth trajectories, known risk factors for abnormal fetal growth, diagnostic and prognostic issues related to restricted and excessive growth and temporal trends in fetal growth. Also addressed are distinctions between fetal growth 'standards' and fetal growth 'references', and between fetal growth charts based on estimated fetal weight vs those based on birth weight. Other concepts discussed include the incidence of fetal growth restriction in pregnancy (does the frequency of fetal growth restriction increase or decrease with increasing gestation?), the obstetric implications of studies showing associations between fetal growth and adult chronic illnesses (such as coronary heart disease) and the need for customizing fetal growth standards.