Postpartum Hysterectomy Research Articles

8144 Hypertension in Sheehan Syndrome: A Diagnostic Challenge

Abstract Disclosure: E. Ahsan: None. F.F. Foo: None. C. Lesniak: None. M. Akula: None. K. Hu: None. R. Ong: None. K. Chalasani: None. J. Cheng: None. S. Holland: None. Introduction: Postpartum pituitary necrosis, commonly known as Sheehan syndrome (SS), is the term used to describe the necrosis of anterior pituitary gland cells that occurs after significant postpartum bleeding, hypovolemia, and shock. This typically occurs after delivery, during which the mother suffers significant blood loss. The pituitary gland fails to produce hormones due to this blood loss. Depending on the degree of tissue damage, SS can have an acute or chronic course, and patients may present with a wide range of clinical symptoms at diagnosis. Acute SS is associated with postpartum pituitary infarction, which can result in hypotension, shock, hypoglycemia, hyponatremia, headache, vision disturbances, unconsciousness, and an inability to lactate. We present a rare case of SS where the patient experienced hypertension instead of classic hypotension due to postpartum preeclampsia. Clinical Case: A 40-year-old female with no significant medical history presented to the hospital for scheduled induction of labor for polyhydramnios and underwent vacuum-assisted vaginal delivery and postpartum hysterectomy due to severe postpartum hemorrhage secondary to DIC. The postpartum course was also complicated by preeclampsia with severe features. Patients developed features like excessive fatigue, hypoglycemia, hyponatremia, hypothyroidism, polyuria, and failure of lactation, which were consistent with panhypopituitarism secondary to Sheehan syndrome. However, the patient was hypertensive to 145/91 before steroids were given. Labs were significant for serum sodium 116 mmol/L (135-145 mmol/L), FSH <0.7 mIU/mL (Follicular Phase: 2.5-10.2, Mid-cycle Peak: 3.1-17.7, Luteal Phase: 1.5-9.1, Postmenopausal: 23.0-116.3), LH <0.2 mIU/m (Follicular Phase: 1.9-12.5, Mid-Cycle Peak: 8.7-76.3, Luteal Phase: 0.5-16.9, Postmenopausal: 10.0-54.7), Prolactin: 2.4 ng/mL (Non-pregnant: 3.0-30.0, Pregnant: 10.0-209.0, Postmenopausal: 2.0-20.0), PM Cortisol on admission: 1.10 ug/dL (3.44-16.76 ug/dL), plasma ACTH 7 pg/mL( 6 - 50 pg/mL), TSH 0.430 uIU/mL (0.550 - 4.780 uIU/mL), FT4 0.59 ng/dL - 1.76 ng/dL). MRI of the brain pituitary showed- A 1.5 cm region of hypoenhancement and an additional 2 mm focus of hypoenhancement in the sella, findings represent evolving pituitary necrosis. The patient received 24 units of blood transfusion and hormone replacement therapy, followed by outpatient endocrinology follow-up. Clinical lessons: Although considerable blood loss causes hypotension in patients with SS, additional postpartum medical issues can sometimes result in atypical presentations. In our patient, postpartum preeclampsia caused hypertension. Identifying the atypical symptoms of SS is just as vital as identifying its typical features to prevent potentially fatal consequences. Presentation: 6/2/2024

Utilization of Immediate Postpartum Contraception and Its Association with Interpregnancy Interval: 10-Year Experience at a Single Center.

Increasing availability of immediate postpartum long-acting reversible contraception (LARC) has added contraceptive alternatives to bilateral tubal ligation (BTL) in the immediate postpartum period. The resultant access to long-term contraception has provided patients with improved control over the timing of pregnancies. Our objective is to evaluate changes in the utilization of immediate postpartum contraceptive methods over a 10-year period and its association with interpregnancy interval (IPI). Retrospective cohort study of 36,445 patients delivered at a single academic hospital center from 2012 to 2020. Deliveries <23 weeks gestation and patients who underwent a cesarean hysterectomy or postpartum hysterectomy for obstetric indications were excluded. The primary outcome was the utilization of postpartum BTL, intrauterine devices, contraceptive implants, and Depo-Provera over the study time period. The secondary outcomes were IPI and interdelivery interval (IDI). Outcomes were compared using appropriate tests of trend. We adjusted for significant covariates as assessed in baseline characteristics. A total of 35,281 patients were included in our study. Groups were different in baseline characteristics including age, race/ethnicity, parity, BMI, insurance status, comorbidity risk, and attendance at postpartum exam. Over the study period, there was a significant difference in utilization of Depo-Provera, LARC, intrauterine device (IUD), and implant (p < 0.001). There was a significant increase in IPI (p < 0.001) and IDI (p < 0.001). We observed a significant increase in utilization of immediate postpartum LARC over the study period which corresponded to a significant increase in IPI and IDI. Our findings emphasize the importance of the availability of immediate postpartum contraception as well as its effectiveness in improving family planning options for reproductive-aged patients. We found significantly increased IPI and IDI associated with increased utilization of long-acting reversible contraceptives immediately postpartum. Our findings emphasize the importance of providers offering these options to patients as well as being comfortable initiating immediate postpartum contraception. · Immediate postpartum LARC access has increased over the past 10 years.. · Access to more methods of contraception allows patients more options for family planning.. · Increased utilization of LARC led to increased IPI and IDI..

Predicting intraoperative blood loss during cesarean sections based on multi-modal information: a two-center study.

To develop and validate a nomogram model that combines radiomics features, clinical factors, and coagulation function indexes (CFI) to predict intraoperative blood loss (IBL) during cesarean sections, and to explore its application in optimizing perioperative management and reducing maternal morbidity. In this retrospective consecutive series study, a total of 346 patients who underwent magnetic resonance imaging (156 for training and 68 for internal test, center 1; 122 for external test, center 2) were included. IBL+ was defined as more than 1000mL estimated blood loss during cesarean sections. The prediction models of IBL were developed based on machine-learning algorithms using CFI, radiomics features, and clinical factors. ROC analysis was performed to evaluate the performance for IBL diagnosis. The support vector machine model incorporating all three modalities achieved an AUC of 0.873 (95% CI 0.769-0.941) and a sensitivity of 1.000 (95% CI 0.846-1.000) in the internal test set, with an AUC of 0.806 (95% CI 0.725-0.872) and a sensitivity of 0.873 (95% CI 0.799-0.922) in the external test set. It was also scored significantly higher than the CFI model (P = 0.035) on the internal test set, and both the CFI (P = 0.002) and radiomics-CFI models (P = 0.007) on the external test set. Additionally, the nomogram constructed based on three modalities achieved an internal testing set AUC of 0.960 (95% CI 0.806-0.999) and an external testing set AUC of 0.869 (95% CI 0.684-0.967) in the pregnant population without a pernicious placenta previa. It is noteworthy that the AUC of the proposed model did not show a statistically significant improvement compared to the Clinical-CFI model in both internal (P = 0.115) and external test sets (P = 0.533). The proposed model demonstrated good performance in predicting intraoperative blood loss (IBL), exhibiting high sensitivity and robust generalizability, with potential applicability to other surgeries such as vaginal delivery and postpartum hysterectomy. However, the performance of the proposed model was not statistically significantly better than that of the Clinical-CFI model.

Home birth in Croatia - a medico-legal perspective today.

In Croatia, the model of obstetrics-midwifery management of childbirth in maternity hospitals is still in effect, and this is how > 99% of Croatian women give birth. However, in my view, midwives are still not sufficiently educated for completely independent work notwithstanding their university education. The Law on Midwifery defined the role of the midwife in home birth without, however, setting out other organisational-communication and professional provisions. Then it began with sporadic midwifery home births of a few per year, which grew quite rapidly, especially with the impact of the Covid-19 virus pandemic, to about 100 out of a total of about 38,000 births that are performed annually in the Republic of Croatia in maternity hospitals. Since the start of planned home births many bad perinatal outcomes have been recorded in hospital maternity wards who have admitted women after such deliveries. These include puerperal sepsis, protracted labour of several days, neglected protracted labour with perinatal asphyxia and aspiration of meconium amniotic fluid and resuscitation of the newborn (who later developed cerebral palsy), severe postpartum haemorrhage with obstetric shock and postpartum hysterectomy, episiotomy infection, and stillbirth at term pregnancy. Therefore, planned home birth in Croatia should now be regarded as an unsafe birth in extraordinary circumstances and the person who takes charge of it must be professionally prepared, educated and have numerous social skills. Most Croatian gynaecologists and obstetricians give support to midwives in their efforts to be professional and independent when at work, including the controlled and legal implementation of the planned home birth. We unreservedly support self-aware midwives to maintain their profession as highly ethical and professional as possible above the wishes of non-professionals who call for autonomy, so that we do not have to discuss such problems of malpractice of Croatian midwifery in the 21st century.

Maternal outcomes of planned mode of delivery for term breech in nulliparous women.

To estimate short- and long-term maternal complications in relation to planned mode of term breech delivery in first pregnancy. Register-based cohort study. Denmark. Nulliparous women with singleton breech delivery at term between 1991 and 2018 (n = 30,778). We used data from the Danish national health registries to identify nulliparous women with singleton breech presentation at term and their subsequent pregnancies. We performed logistic regression to compare the risks of maternal complications by planned mode of delivery. All data were proceeded and statistical analyses were performed in SAS 9.4 (SAS Institute Inc. Cary, NC, USA). Postpartum hemorrhage, operative complications, puerperal infections in first pregnancy and uterine rupture, placenta previa, post-partum hemorrhage, hysterectomy and stillbirth in the subsequent two pregnancies. We identified 19,187 with planned cesarean and 9,681 with planned vaginal breech delivery of which 2,970 (30.7%) delivered vaginally. Planned cesarean significantly reduced the risk of postoperative infections (2.4% vs 3.9% adjusted odds ratio (aOR): 0.54 95% confidence interval (CI) 0.44-0.66) and surgical organ lesions (0.06% vs 0.1%; (aOR): 0.29 95% CI 0.11-0.76) compared to planned vaginal breech delivery. Planned cesarean delivery in the first pregnancy was associated with a significantly higher risk of uterine rupture in the subsequent pregnancies but not with risk of postpartum hemorrhage, placenta previa, hysterectomy, or stillbirth. Compared to planned vaginal breech delivery at term, nulliparous women with planned cesarean breech delivery have a significantly reduced risk of postoperative complications but a higher risk of uterine rupture in their subsequent pregnancies.

Maternal And Fetal Outcome in Placenta Previa: A Multicenter Prospective Observational Study

Objective: To find out the frequency of placenta previa and maternal and fetal outcomes in cases of placenta previa in our population. Methods: All women with an age range from 18-40 years diagnosed with placenta previa based on ultrasound were recruited with the study. Data including patient age, parity, previous normal deliveries, previous caesarian sections, grade of the placenta previa and history of previous pregnancies was recorded. Maternal complications including post-partum haemorrhage, hysterectomy and death were also recorded. Fetal complications including low APGAR score at five minutes, low birth weight and death were also recorded. Results: The age group between 26-35 years seems to have the highest incidence of placenta previa (62.58%). Post-partum haemorrhage was seen in 57 (38.77%) patients. Post-partum haemorrhage was strongly associated with the grade of placenta previa. Emergency obstetric hysterectomy was done in 7 (4.76%) patients. Two (1.36%) patients died of complications. Out of 147, 38 (25.85%) had low APGAR scores, 52 (35.37%) had low birth weight and 12 (8.16%) died of various complications. Conclusion: Placenta previa has become a very common condition which may be attributable to higher rates of caesarians. It may lead to increased morbidity and mortality of the mother and the baby if not diagnosed and managed properly. These cases should be managed by experienced multidisciplinary teams in a tertiary care centre to minimize the rate of complications. Keywords: APGAR score, Intrauterine growth retardation,Neonatal, Placenta previa, Postpartum haemorrhage

Adenomyosis among patients undergoing postpartum hysterectomy for uncontrollable uterine bleeding: Amulticenter, observational, retrospective, cohort study on histologically-based prevalence and clinical characteristics.

To assess the prevalence of adenomyosis at pathologic examination, and its association with obstetric complications, peripartum maternal clinical characteristics and neonatal birth weight in patients undergoing postpartum hysterectomy due to postpartum hemorrhage (PPH). A multicenter, observational, retrospective, cohort study was carried out including all women who underwent postpartum hysterectomy due to PPH at gestational week 23+0 or later, between January 2010 and May 2023. Patients were categorized into two groups based on the presence of adenomyosis at pathologic examination, and were compared for obstetric complications, peripartum maternal clinical characteristics, and neonatal birth weight. The histologically-based prevalence of adenomyosis in patients undergoing postpartum hysterectomy due to PPH was 39.4%. Adenomyosis was associated with a longer hospitalization time (regression coefficient: 4.43 days, 95% CI: 0.34-8.52, P = 0.034) and a higher risk of hypertensive disorders (OR: 5.82, 95% CI: 1.38-24.46, P = 0.016), threatened preterm labor (OR: 3.34, 95% CI: 1.08-10.31, P = 0.036), urgent/emergency C-section (OR: 24.15, 95% CI: 2.60-223.96, P = 0.005), postpartum maternal complications (OR: 4.96, 95% CI: 1.48-16.67, P = 0.012), maternal intensive care unit admission (OR: 3.56, 95% CI: 1.05-12.05, P = 0.041), and low birth weight neonates (OR: 3.8, 95% CI: 1.32-11.02, P = 0.013). In patients undergoing postpartum hysterectomy due to PPH, adenomyosis is a highly prevalent condition among, and is associated with adverse obstetric, maternal, and neonatal outcomes.

The Role of Ultrasonography and Magnetic Resonance Imaging in the Diagnosis of the Adherent Placenta: An Observational Study.

Introduction Placenta accreta is an important factor responsible for maternal morbidity and mortality and is commonly associated with emergent postpartum hysterectomy. The precise prenatal diagnosis of affected pregnancies allows optimal obstetric management. Ultrasonography (USG) and magnetic resonance imaging (MRI) are the only diagnostic modalities available for the prenatal diagnosis of placenta accreta. Objective This study aims to evaluate the accuracy of USG and MRI in diagnosing adherent placenta. Methods Thirty females with placenta previa or a history of previous cesarean sections were evaluated with USG at 28-30 weeks, followed by MRI. The findings of USG and MRI were compared with the intra-operative findings (gold standard) as determined at surgery and by pathological examination. Results Abnormal bridging vessel (n = 24; 80%) was the most common finding seen on USG, whereas abnormal bulge (n = 22; 73.3%) and heterogenous placenta (n = 21; 70%) were the most common findings seen on MRI. The sensitivity of USG and MRI was in the range of 86.7%-92.9% and 92.9%-100%, respectively, in diagnosing three types of adherent placenta. The positive predictive values (PPV) of USG and MRI were in the range of 86.7%-86.7%and93.8%-100%, respectively, in diagnosing three types of adherent placenta. The accuracy of USG and MRI was in the range of 86.7%-96.7% and 96.7%-100%, respectively, in diagnosing three types of adherent placenta. Conclusion MRI helps to accurately classify placental invasion according to depth, as can be seen from the results of the present study, where the MRI technique was more accurate in diagnosing three types of adherent placenta.

Emergency Bilateral Internal Iliac Artery Ligation in Antepartum Haemorrhage with Complete Placenta Previa and Placenta Accreta at Previous Caesarean Scar Site: A Case Report

Implantation and placentation at the normal site are critical for a successful pregnancy. Many complications associated with pregnancy, which manifest late in pregnancy, such as preeclampsia and preterm labour, have been reported to have origins early during pregnancy with abnormalities in implantation and placental development. Placental abnormalities result from impaired embedding of the placenta in the endometrium, encompassing a wide range of placental pathologies associated with high maternal morbidity and mortality. Pregnancy-related complications such as Postpartum Haemorrhage (PPH) and hysterectomy have been closely linked to the Placenta Accreta Spectrum (PAS). PAS refers to the aberrant and invasive implantation of the placenta into the myometrium. Invasiveness in placenta accreta is marginal, followed by placenta increta (partial), placenta percreta (total), and placenta previa (covering the cervix). Here, the authors present a unique case report of an antenatal woman with antepartum haemorrhage, placenta previa, and placenta accreta at the previous Lower Segment Caesarean Section (LSCS) scar site, with massive PPH at 35 weeks, who benefited from an emergency LSCS with bilateral uterine and internal iliac artery ligation procedure, resulting in a life-saving outcome. The most common risk factors for PAS include prior caesarean section and curettage. The adhered placenta can lead to pelvic bleeding and necessitate an emergency hysterectomy. Therefore, it poses unique diagnostic and treatment issues, with the majority of cases requiring preterm termination of pregnancy.

Clinical Risk Factors for Placenta Accreta or Placenta Percreta: A Case-Control Study

ObjectivesUterine scarring is a risk factor for placenta accreta spectrum (PAS) disorder. We aimed to determine the factors related to PAS in women who had previously undergone a cesarean. MethodsWe performed a case-control study where women who underwent postpartum hysterectomy for placenta accreta/percreta (cases) were matched to all women with a previous cesarean who delivered in the week before each case (controls). Maternal characteristics along with previous cesarean characteristics were compared between cases and controls. Univariate and multivariate logistic regression analyses were performed to determine risk factors related to PAS. ResultsWe compared 64 cases of PAS that required hysterectomy to 192 controls. The factors related to PAS were a history of uterine surgery (OR 27.4; 95% CI 5.1–146.5, P < 0.001) and the number of previous cesareans (2 cesareans: OR 7.2; 95% CI 3.4–15.4, P < 0.001; more than 2 cesareans: OR 7.9; 95% CI 2.9–21.5, P < 0.001). In women with a single previous cesarean without previous uterine surgery, an interdelivery interval of fewer than 18 months (OR 6.3; 95% CI 1.8–22.4, P = 0.004) and smoking (OR 5.8; 95% CI 1.2–27.8, P = 0.03) were related to PAS. The gestational age and the cervical dilatation at previous cesarean were not associated with PAS (all with P > 0.05). The lack of data regarding the closure of the uterus at previous cesareans prevents us from drawing solid conclusions. ConclusionsPrevious uterine surgery, the number of previous cesareans, smoking, and an interdelivery interval of fewer than 18 months after cesarean are significant risk factors for PAS requiring postpartum hysterectomy.

Abnormal Uterine Involution May Lead to Atony and Postpartum Hemorrhage: A Hypothesis, With Review of the Evidence.

Uterine involution has 2 major components-(1) involution of vessels; and (2) involution of myometrium. Involution of vessels was addressed by Rutherford and Hertig in 1945; however, involution of myometrium has received little attention in the modern literature. We suggest that the pathophysiology of myometrial involution may lead to uterine atony and postpartum hemorrhage. The myometrium dramatically enlarges due to gestational hyperplasia and hypertrophy of myocytes, caused by hormonal influences of the fetal adrenal cortex and the placenta. After delivery, uterine weight drops rapidly, with physiologic involution of myometrium associated with massive destruction of myometrial tissue. The resulting histopathology, supported by scientific evidence, may be termed "postpartum metropathy," and may explain the delay of postpartum menstrual periods until the completion of involution. When uterine atony causes uncontrolled hemorrhage, postpartum hysterectomy examination may be the responsibility of the perinatal pathologist.Postpartum metropathy may be initiated when delivery of the baby terminates exposure to the hormonal influence of the fetal adrenal cortex, and may be accelerated when placental delivery terminates exposure to human chorionic gonadotrophin (HCG). This hypothesis may explain why a prolonged third stage of labor, and delays in management, are risk factors for severe hemorrhage due to uterine atony.

Maternal morbidity among patients undergoing postpartum hysterectomy: Assessing changes in outcomes after Implementation of the gynecologic oncology provider involvement rule (2184)

Maternal morbidity among patients undergoing postpartum hysterectomy: Assessing changes in outcomes after Implementation of the gynecologic oncology provider involvement rule (2184)

Emergency postpartum hysterectomy as a consequence of cervical varix during pregnancy; a case report and literature review

Vaginal bleeding might accrue during pregnancy and it has different causes due to the pregnancy trimester and the diagnosis and management would be crucial to prevent maternal-fetal life-threatening situations. In uncommon cases, varicose veins can emerge in the neck of the uterus, leading to a severe maternal hemorrhage. We presented a pregnant woman with vaginal bleeding and spotting during pregnancy with the diagnosis of cervical varix at 22 weeks of gestation. Close monitoring and proper patient education led to a term delivery at 37 weeks of gestation. Otherwise, an emergency postpartum hysterectomy after a cesarean section was performed due to uncontrolled bleeding from cervical varix. Although rare, cervical varix should be included in the differential diagnosis in a pregnant patient who appears with extensive vaginal bleeding to reduce maternal and/or neonatal morbidity or fatality. The approved diagnosis for that is not clear. This case report showed that Doppler and transvaginal sonography could be suitable diagnostic tools. The best management for cervical varix needs further research.

Risk Factors for Adverse Maternal Outcomes among Patients with Severe Preeclampsia Before 34 Weeks.

This study aimed to characterize rates of maternal morbidity associated with early (<34 wk) preeclampsia with severe features and to determine factors associated with developing these morbidities. Retrospective cohort study of patients with early preeclampsia with severe features at a single institution from 2013 to 2019. Inclusion criteria were admission between 23 and 34 weeks and diagnosis of preeclampsia with severe features. Maternal morbidity defined as death, sepsis, intensive care unit (ICU) admission, acute renal insufficiency (acute kidney injury [AKI]), postpartum (PP) dilation and curettage, PP hysterectomy, venous thromboembolism (VTE), PP hemorrhage (PPH), PP wound infection, PP endometritis, pelvic abscess, PP pneumonia, readmission, and/or need for blood transfusion. Death, ICU admission, VTE, AKI, PP hysterectomy, sepsis, and/or transfusion of >2 units were considered severe maternal morbidity (SMM). Simple statistics used to compare characteristics among patients experiencing any morbidity and those not. Poisson regression used to assess relative risks. Of 260 patients included, 77 (29.6%) experienced maternal morbidity and 16 (6.2%) experienced severe morbidity. PPH (n = 46, 17.7%) was the most common morbidity, although 15 (5.8%) patients were readmitted, 16 (6.2%) needed a blood transfusion, and 14 (5.4%) had AKI. Patients who experienced maternal morbidity were more likely to be advanced maternal age, have preexisting diabetes, have multiples, and deliver nonvaginally (all ps < 0.05). Diagnosis of preeclampsia < 28 weeks or longer latency from diagnosis to delivery were not associated with increased maternal morbidity. In regression models, the relative risk of maternal morbidity remained significant for twins (adjusted odds ration [aOR]: 2.57; 95% confidence interval [CI]: 1.67, 3.96) and preexisting diabetes (aOR: 1.64; 95% CI: 1.04, 2.58), whereas attempted vaginal delivery was protective (aOR: 0.53; 95% CI: 0.30, 0.92). In this cohort, more than 1 in 4 patients diagnosed with early preeclampsia with severe features experienced maternal morbidity, whereas 1 in 16 patients experienced SMM. Twins and pregestational diabetes were associated with higher risk of morbidity, whereas attempted vaginal delivery was protective. These data may be helpful in promoting risk reduction and counseling patients diagnosed with early preeclampsia with severe features. · One in four patients diagnosed with preeclampsia w/ severe features experienced maternal morbidity.. · One in 16 patients with preeclampsia w/ severe features experienced severe maternal morbidity.. · Factors most associated with morbidity/severe morbidity were twins and pregestational diabetes.. · Patients who attempted vaginal delivery appeared to have a lower rate of morbidity..

Placenta Accreta Spectrum Disorders: How to reduce maternal transfusion? A center experience on extraperitoneal retrograde hysterectomy

ObjectivePlacenta Accreta Spectrum disorders (PASd) refer to the range of pathologic adherence of placenta associated with high maternal morbidity and mortality due to severe and sometimes life-threatening hemorrhage at the time of delivery. The aim of this study is to describe the surgical technique of extraperitoneal retrograde hysterectomy, which has allowed a reduction of blood transfusions compared to patients who underwent classical post-partum hysterectomy. Study designWe collected data from twelve patients with antenatal diagnosis of PASd treated between 2018 and 2021 with an extra-peritoneal hysterectomy using a posterior retrograde approach and we compared them to patients who underwent classical hysterectomy for suspected PASd, treated between 2007 and 2017. ResultsThe classical hysterectomy group presented a higher frequency of blood and plasma transfusion compared to the extraperitoneal hysterectomy group. In particular, classical hysterectomy resulted in an independent risk factor for transfusion, with an increment of 6.6 times of risk. ConclusionEven if future studies are required, we think that extraperitoneal hysterectomy could be a safe option in case of PASd, considering that classical hysterectomy compared to this approach increases, in our population, the risk of blood and plasma transfusion.

Assessment of the self-confidence of obstetrics & gynecology fellows to perform a postpartum hemostasis hysterectomy.

Hemostasis Hysterectomy (HH) is a last resort surgical procedure performed in situations of uncontrolled post-partum hemorrhage in maternity wards. The chances of being confronted with this situation are scarce during residency, and the situation is not well suited for teaching. Nevertheless, every obstetrician-gynecologist can be confronted with this stressful situation, and should therefore possess the surgical competence required, regardless of his routine practice. The aim of the present study is to evaluate clinical exposure and self-awareness concerning HH amongst obstetrics and gynecology residents and fellows. We performed a survey amongst French obstetrics and gynecology fellows. An anonymous survey was sent by email between December 1, 2020 to July 1, 2021. Half of the interrogated fellows had practiced (as operator) an HH during residency with a senior and only 22,6% in post-residency. During the last year of residency 70% of them had performed less than 10 scheduled hysterectomies as primary operator. The laparoscopic approach was the most frequently practiced. Very few hysterectomies were performed as primary operator. Fellows with a surgical or mixed activity (both gynecological surgery and obstetrical activity in current practice) felt significantly more capable of performing HH compared to those with exclusive obstetrical or reproductive medicine activity; respectively 60% vs 36%, p=0.008; Odds Ratio: 2.629 (95% CI 1.2214; 5.8094). The number of scheduled hysterectomies or HH performed as primary operator is very low during residency or fellowship. It remains largely inferior to the number deemed necessary in previous publications about the learning curve for scheduled hysterectomy, which varies from 18 to 80 interventions. Nowadays, the increasing number of residents, added to the decrease of hemostasis hysterectomies through better management of post-partum hemorrhage, pushes towards the development of specific training, such as "damage control simulation".

Remote patient monitoring for management of diabetes mellitus in pregnancy is associated with improved maternal and neonatal outcomes

Diabetes is a common medical complication of pregnancy and its treatment is complex. Recent years have seen an increase in the application of mobile health tools and advanced technologies, such as remote patient monitoring (RPM), to try to improve care of diabetes in pregnancy. Previous studies of these technologies for the treatment of diabetes in pregnancy have been small and have not clearly shown clinical benefit from implementing their use. RPM allows clinicians to monitor patients' health data (such as glucose values) in near real-time, in between clinic visits, to make timely adjustments to care. Our objective was to determine if using RPM for management of diabetes in pregnancy leads to improvement in maternal and neonatal outcomes. This was a retrospective cohort study of pregnant patients with diabetes managed by the Maternal Fetal Medicine practice at one academic institution between October 2019 - April 2021. The practice transitioned from paper blood glucose logs to RPM in February 2020. RPM options included: 1) Device integration with Bluetooth glucometers that automatically upload measured glucose values to the patient's Epic MyChart application or 2) Manual entry where patients manually log glucose readings into their MyChart application. Values in the MyChart application directly transfer to the patient's Electronic Health Record for review and changes in management by clinicians. In total, 533 patients were studied. We compared 173 patients managed with paper logs to 360 patients managed with RPM (176 device integration and 184 manual entry). Our primary outcomes were composite maternal morbidity (which included third/fourth-degree laceration, chorioamnionitis, postpartum hemorrhage requiring transfusion, postpartum hysterectomy, wound infection or separation, venous thromboembolism, and maternal admission to ICU) and composite neonatal morbidity (which included umbilical cord pH <7.00, 5 min APGAR <7, respiratory morbidity, hyperbilirubinemia, meconium aspiration, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, pneumonia, seizures, hypoxic ischemic encephalopathy, shoulder dystocia, trauma, brain or body cooling, and NICU admission). Secondary outcomes were measures of glycemic control, as well as the individual components of the primary composite outcomes. We also performed a secondary analysis comparing patients utilizing the two aforementioned RPM options. Chi square, Fisher's exact, 2-sample t, and Mann-Whitney tests were used to compare the groups. A result was considered statistically significant at p<0.05. Maternal baseline characteristics were not significantly different between the RPM and paper groups, aside from a slightly higher baseline rate of chronic hypertension in the RPM group (6.1 vs 1.2%). The primary outcome of composite maternal and composite neonatal morbidity was not significantly different between the groups. However, RPM patients submitted more values, were more likely to achieve glycemic control in target range (79.2% vs 52.0%, p<0.0001), and achieved target range sooner (median 3.3 vs 4.1 weeks, p 0.025) than patients managed with paper logs. This was achieved without increasing in-person visits. RPM patients had lower rates of preeclampsia (5.8% vs 15.0%, p 0.0006) and their infants had lower rates of neonatal hypoglycemia in the first 24 hours of life (29.8% vs 51.7%, p<0.0001). Remote patient monitoring for management of diabetes in pregnancy is superior to a traditional paper-based approach in achieving glycemic control and is associated with improved maternal and neonatal outcomes.

Differences in maternal and infant hospitalization costs associated with planned postpartum hysterectomy by gestational age

Differences in maternal and infant hospitalization costs associated with planned postpartum hysterectomy by gestational age

Differences in maternal and infant hospitalization costs associated with planned postpartum hysterectomy by race/ethnicity

Differences in maternal and infant hospitalization costs associated with planned postpartum hysterectomy by race/ethnicity

Pelvic packing in the treatment of severe postpartum posthysterectomiam hemorrhage.

Pelvic packing (PP) as a simple method of ”damage control surgery” in severe abdominopelvic hemorrhage in gynecological and obstetric surgery after emergency obstetrics or gynecological hysterectomy. To present the case of successful PP as a simple and effective method in refractory pelvic bleeding after emergent peripartum hysterectomy and severe obstetric shock with consumptive coagulopathy. Acording to laboratory findings and clinical condition in a 30-year-old (G2 P2) parturient, it was most likely an obstetric embolism with uterine rupture as the cause of severe postparum hemorrhage with disseminated intravascular coagulopathy and obstetrics hemorrhagic shock development in the described case. Pelvic packing after postpartum hysterectomy was the definitive minimally invasive and simple hemostatic procedure. The use of pelvic packing and obstetrics skills should be included in the protocol as a necessary, life-saving, and uncomplicated vital indication procedure.