Pregnant Patients Research Articles

Septic Abortion Complicated by Disseminated Intravascular Coagulation.

This scenario was developed to educate emergency medicine residents on the diagnosis and management of two concurrent conditions: septic abortion and disseminated intravascular coagulation (DIC). Patients with an abortion (spontaneous or induced) of less than twenty weeks gestation may present with concurrent uterine infection, also known as septic abortion. One of the complications of septic abortion is DIC. Early management of both underlying etiology (septic abortion) and subsequent complications (DIC) is crucial to minimize morbidity and mortality. At the conclusion of the simulation session, learners will be able to: 1) Obtain a relevant focused history including pregnancy history, medication use, and past medical history. 2) Develop a differential for fever and vaginal bleeding in a pregnant patient. 3) Discuss management of septic abortion, including empiric broad-spectrum antibiotics and obstetric consultation for source control with dilation and curettage (D&C). 4) Discuss expected laboratory findings of disseminated intravascular coagulation (DIC). 5) Discuss management of DIC, including identification of underlying etiology and supportive resuscitation with blood products. 6) Review the components of blood products. 7) Identify appropriate disposition of the patient to the intensive care unit (ICU). This session was conducted using high-fidelity simulation followed by a debriefing session and discussion about the diagnosis, differential, and management of both septic abortion and DIC. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. In this technique, the facilitator described something they observed in the case, outlined their reasoning as a facilitator why this observation was important or why they had questions, and then asked the learners to share their frame of reference at the time. An example: "I heard the team leader state that the platelets were normal, but then another resident disagreed. No one paused to come to a consensus. I'm wondering why this wasn't explored further in real time. Tell me more." This scenario may also be run as an oral boards case or adapted for other learners such as critical care fellows. Our residents were provided a survey at the completion of the debriefing session so they could rate different aspects of the simulation, as well as provide qualitative feedback on the scenario. The local institution's simulation center's electronic feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form,1 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Thirteen learners completed a feedback form out of seventeen participants. This session received all six and seven scores (consistently effective/very good and extremely effective/outstanding, respectively) other than two isolated 4 scores. This is a cost-effective method for reviewing septic abortion and DIC. The case may be modified for appropriate audiences, such as simplifying the case to septic abortion without DIC. You can also consider not showing an initial temperature with the initial set of vitals unless it is specifically asked for by the participants. We encourage readers to utilize bleeding moulage techniques as a visual stimulus to increase psychological buy-in. Medical simulation, septic abortion, pregnancy complications, hematology emergencies, obstetric emergencies, disseminated intravascular coagulation, emergency medicine.

Imbalance of gut microbiota in gestational diabetes

AimTo investigate the differences in gut microbiota composition among nonpregnant women of reproductive age, healthy pregnant women, and gestational diabetes (GD) patients.MethodsA total of 45 outpatients were enrolled and divided into three groups: nonpregnant women of reproductive age (control group, n = 23), healthy pregnant women (normal group, n = 10), and GD patients (GD group, n = 12). Faecal samples were collected and sequenced using 16S rRNA gene sequencing to analyse the microbial composition.Results(1) Pregnant patients exhibited an increase in the abundance of Streptococcus (Pnormal = 0.01286, PGD = 0.002965) and Blautia (Pnormal = 0.0003924, PGD = 0.000246) but a decrease in the abundance of Roseburia (Pnormal = 0.0361, PGD = 0.007075), Phascolarctobacterium (Pnormal = 0.0003906, PGD = 0.02499) and Lachnoclostridium (Pnormal = 0.0003906, PGD = 0.03866). (2) Compared with healthy pregnant women, GD patients had an excessive increase in Streptococcus abundance and decrease in Roseburia abundance. The increase in Blautia abundance and the decrease in Phascolarctobacterium and Lachnoclostridium abundance in GD patients were less than those in healthy pregnant women. (3) The abundance of Faecalibacterium prausnitzii decreased significantly in GD patients (PGD = 0.02985) but not in healthy pregnant patients (Pnormal = 0.1643).ConclusionsAbnormal increases and decreases in the abundances of gut microbiota components, especially Faecalibacterium prausnitzii, were observed in GD patients.Trial registrationThe cross-sectional research was conducted in accordance with the Declaration of Helsinki, and approved by Sir Run Run Shaw Hospital Clinical Trials and Biomedical Ethics Committee. The study has been registered in the Chinese Clinical Trial Registry (ChiCTR1900026164, 24/09/2019, http://www.chictr.org.cn/showproj.aspx?proj=43,455).

Naissances vivantes après cancer du sein parmi les femmes désirant un enfant

Introduction: In France, the breast cancer is the most common cancer among women under the age of 40. From 38 to 70 % of women have not fulfilled their parental plans at the time of diagnosis. The gonadotoxicity of the treatments and the follicular physiological decline linked to age can become an obstacle to this project.Methods: 386 patients treated for breast cancer at the Centre Georges François Leclerc in Dijon between January 2011 and December 2018 were identified. 192 patients aged under 39 met the inclusion criteria. We excluded metastatic cancers, cancer in situ and pregnant patients at diagnosis. A total of 124 patients agreed to participate in the study. The included patients filled out a self-questionnaire. Data were collected from the patient’s electronic medical. The primary endpoint of this study was the live birth rate.Result: Among women who desired a child after breast cancer, the overall rate of live births was 36.2 % (21/58). Most achieved pregnancies were spontaneous (90.5 %). No factor was significantly associated with the absence of obtaining birth. Fertility was preserved by oocyte cryopreservation in 13.8 % of patients (17/124). The median time to conception in patients who received chemotherapy was 8 months [1.0-60.0] vs 2 months [1.0-7.0] in women who did not receive chemotherapy.Discussion: The non-negligible proportion of live births following spontaneous pregnancy after breast cancer allows us to be reassuring for patients. However, the emergence of new chemotherapy protocols whose consequences on long-term gonadotoxicity are still not well known requires further studies and prompts the promotion of fertility preservation as a precautionary measure.

Dermoid cyst management and outcomes: A review of over 1,000 cases at a single institution

BackgroundMature cystic teratomas represent nearly 60% of benign ovarian neoplasms across all age groups. We aim to update existing descriptive studies of ovarian teratomas including the epidemiology, rate of torsion/malignancy, and treatment modalities in a large modern cohort of patients. Study DesignThis is a retrospective cross-sectional study of all pathology-confirmed cases of ovarian teratoma who underwent surgery at one tertiary care institution from 2004–2015. Patient demographics, ovarian cyst characteristics, surgical approach and timing, rate of spillage, and surgical complications were examined. Results1,054 cases of ovarian teratoma were identified during the study period. There were 113 cases of bilateral teratoma (10.7%). Mean age at diagnosis was 38 years. Average cyst size was 6.26cm. The overall rate of torsion was 5.6%, with a higher rate of torsion with increasing cyst size. Over 70% of cases were treated with minimally invasive surgery, which was associated with decreased perioperative complications but an increased risk of cyst spillage. Among 394 patients with cyst spillage, only one developed chemical peritonitis. The malignant transformation rate of mature cystic teratoma in this cohort was 1.1%. This cohort included 100 pregnant women with mature teratoma. Pregnant patients were more likely to have minimally invasive surgery in the 1st trimester and more likely to undergo laparotomy in the 2nd or 3rd trimester. ConclusionsIn this large modern cohort, we found similar rates of bilaterality, torsion, malignant transformation, and struma ovarii in ovarian teratomas when compared to previous literature. Most cases of ovarian teratoma can be managed laparoscopically, which is associated with a lower surgical complication rate. Despite increased risk of cyst spillage with a minimally invasive approach, chemical peritonitis is a rare complication.

Outcome of pregnant women admitted to critical care unit with confirmed severe COVID-19: A center experience.

To explore the traits and risk factors of pregnant women admitted to intensive care units (ICUs) with COVID-19. Moreover, the study classifies outcomes based on differing levels of required respiratory support during their intensive care stay. This retrospective and descriptive study included all pregnant women with COVID-19 admitted to the adult critical care unit at a specialized tertiary hospital in Riyadh, Saudi Arabia. Between January 2020 and December 2022. A total of 38 pregnant women were identified and were eligible for our study. The mean age of the patients was 32.9 (19-45) years, and the average Acute Physiology and Chronic Health Evaluation IV (APACHI IV) score was 49.9 (21-106). Approximately 60.5% of the patients suffered from superimposed infections during their ICU stay. Approximately 81.6% patients were delivered by C-section, 33 of the newborns survived, and 5 died. The crude mortality rate among pregnant women in our cohort was 15.8%. Patients treated with high-flow nasal cannula (HFNC) were mostly discharged or delivered normally, while the mechanical ventilation (MV) and extracorporeal membrane oxygenation groups mostly underwent C-sections. Most of the surviving newborns were on HFNC and MV. Patients with multiple infections had the longest ICU stay and had the highest risk of death. The results of this study highlight the characteristics of pregnant women admitted to the ICU at a specialized tertiary healthcare center in Saudi Arabia. The APACHI IV scores accurately predicted patient's mortality, duration of MV, and length of ICU stay. In our study, we shared our experience of managing severe COVID-19 infections in pregnant patients.

Adverse cardiovascular, obstetric and perinatal events during pregnancy and puerperium in patients with heart disease

Background and objectivescardiovascular changes during pregnancy carry greater risk in heart disease. We analyze cardiovascular, obstetric and perinatal adverse effects associated with congenital and acquired heart disease during pregnancy and postpartum. Materials and methodsCross-sectional and retrospective study, which included the 2017–2023 registry of pregnant or postpartum patients hospitalised with diagnosis of congenital or acquired heart disease. Adverse events (heart failure, stroke, acute pulmonary edema, maternal death, obstetric haemorrhage, prematurity and perinatal death) were compared with the clinical variables and the implemented treatment. Results112 patients with a median age of 28 years (range 15−44) were included. Short circuits predominated 28 (25%). Thirty-six patients (32%) were classified in class IV of the modified WHO scale for maternal cardiovascular risk.Heart failure occurred in 39 (34.8%), acute lung edema 12 (10.7%), stroke 2 (1.8%), maternal death 5 (4.5%), obstetric haemorrhage 4 (3.6%), prematurity 50 (44.5%) and perinatal death 6 (5.4%). Shunts were associated with prematurity (adjusted odds ratio 4; 95% CI: 1.5−10, p = 0.006). Peripartum cardiomyopathy represented higher risk of pulmonary edema (adjusted OR 34; 95% CI: 6−194, p = 0.001) and heart failure (adjusted OR 16; 95% CI: 3−84, p = 0.001). An increased risk of obstetric haemorrhage was observed in patients with prosthetic valves (adjusted OR 30; 95% CI: 1.5−616, p = 0.025) and with the use of acetylsalicylic acid (adjusted OR 14; 95% CI: 1.2–16, p = 0.030). Furthermore, the latter was associated with perinatal death (adjusted OR 9; 95% CI: 1.4−68, p = 0.021). Conclusionssevere complications were found during pregnancy and postpartum in patients with heart disease, which is why preconception evaluation and close surveillance are vital.

Practical Considerations for Managing Pregnancy in Patients With Multiple Sclerosis: Dispelling the Myths.

Lack of consistent data and guidance have led to variations between clinicians in the management of pregnancy in women with multiple sclerosis (MS). Pregnant and/or lactating women are often excluded from clinical trials conducted in MS, and thus, the labeling for most disease-modifying therapies (DMTs) excludes use during pregnancy. This has led to heterogeneity in interpretation and labeling regarding the safety of DMTs during pregnancy and lactation and the required preconception washout periods. This review identifies key themes where there is conflicting information surrounding family planning and pregnancy in MS, focusing on the most common discussion points between physicians and patients during preconception planning, pregnancy, postpartum, and lactation. The goal was to inform the patient-physician conversation and provide best practice recommendations based on expert clinical expertise and experience. We outline the latest evidence-based data for DMT use during pregnancy and lactation, the effect of MS on fertility and fertility treatments, the risk of adverse pregnancy and delivery outcomes, the risk of postpartum relapse, and immunization and clinical imaging safety during pregnancy and breastfeeding. Management of family planning and pregnancy in patients with MS requires the most current information. Health care providers should discuss family planning early and frequently with patients with MS, and partners where practicable. Because management of pregnant people with MS will often require a risk/benefit analysis of their needs, shared decision-making in family planning discussions is emphasized. Additional data are needed for specific and underrepresented populations with MS (e.g., single parents or those from the LGBTQ+ community) and those at risk of racial and socioeconomic disparities in care. Pregnancy registries and the design and conduct of clinical trials focused on pregnant and lactating patients should provide additional data to guide the ongoing management of patients with MS.

IJCM_65A: Prevalence and severity of anemia and its association with age and gender in patients attending rural health clinic in Aligarh, Uttar Pradesh: A retrospective study.

Background: Anemia is major public health concern and mainly affects young children, pregnant and postpartum women, and menstruating adolescent girls and women. As reported by WHO, 40% of all children aged 6–59 months, 37% of pregnant women and 30% of women 15–49 years of age are affected by anemia globally. The situation is even worse in India with the prevalence being 67%, 52.2% and 57% respectively, as reported by NFHS-V. Objective: To estimate prevalence of anemia and its severity stratified by age and gender in patients attending Rural Health Training Centre (RHTC), Jawan, Aligarh. Methodology: A retrospective observational study using routine clinical data of 402 patients attending general OPD of RHTC from January 1, 2022 to December 31, 2022 was performed. Pregnant females and patients who had more than one determination of hemoglobin during the study period were excluded from the study. Anemia was defined according to WHO criteria. Data was analyzed using SPSS version 20.0., descriptive statistics and Chi Square test were applied. P value Results: 40.5% of patients were males while 59.5% were females. The overall prevalence of anemia was found to be 93.3%. Anemia was most prevalent in children <5 years (95.7%). Females had significantly higher prevalence of anemia (97.4%) as compared to males (86.3%). (p<0.001) Conclusion: Prevalence of anemia was found to be very high in patients attending Rural Health Clinic. Targeted interventions like screening programmes, iron and folic acid supplementation and health education should be strengthened for decreasing prevalence of anemia especially in women and young children.

A case report: recurrent anemia related to long term acyclovir use in a pregnant HIV infected Ugandan

Abstract: This case report describes a pregnant patient with recent diagnosis of Human Immuno-Deficiency Virus (HIV) infection initiated on Anti-Retroviral Therapy (ART) in the second trimester, as well as high dose acyclovir high for large infected genital warts. She had no other HIV related opportunistic infections, and no prior anti tuberculosis treatment or preventive medication. Despite little response to acyclovir, patient was continuing on acyclovir for over 4 months. She subsequently developed recurrent anemia requiring frequent transfusion (14 units in total) over a 6-week period.
 On stopping acyclovir, the anemia subsided, a few weeks later she had a normal delivery, followed by surgical removal of the warts. At a follow-up 8 months later, she was well, with a healthy baby, and reported no other episodes of blood transfusion.
 Keywords: Recurrent anemia; acyclovir; herpes genitalis; HIV; ART.

Development and validation of interprofessional health education module for the management of gestational diabetes mellitus

BACKGROUND: Gestational diabetes mellitus (GDM) is a glucose intolerance that shows its first onset during pregnancy. In India, GDM affects as many as 5 million women annually. The interprofessional collaborative educational intervention is crucial for GDM management. This study illustrates the collaborative effort in developing and validating an interprofessional health education module designed for healthcare professionals during consultation sessions with GDM patients. MATERIALS AND METHODS: The investigation involved three stages: 1) needs assessment for module contents and objectives, 2) health education module development by an interprofessional team, and 3) module validation. We received ethics approval from the institution’s ethics committee. RESULTS: The interprofessional team developed and validated the evidence-based English-printed module. The module had 27 units and covered six topics: an introduction to GDM and its management, dietary recommendations for GDM, exercise, yoga recommendations for GDM, weight control, and postpartum care. CONCLUSION: The interprofessional team developed the educational module, wherein there is an integration of the domains of exercise and yoga along with medicines and nutrition therapy. The module was developed based on local requirements and evidence-based practices. Healthcare professionals can use the interprofessional health education module when advising diabetic pregnant patients.

Interactions Between Endocannabinoid and Endogenous Opioid Systems Prospectively Influence Postoperative Opioid Use in Pregnant Patients Undergoing Cesarean Delivery

Both endocannabinoid (EC) and endogenous opioid systems are involved in nociceptive processing and may work together synergistically based on preclinical models. This study evaluated the interactive effects of preoperative beta-endorphin concentrations (a key analgesic endogenous opioid) in cerebrospinal fluid (CSF) and ECs (CSF and plasma 2-arachidonoylglycerol [2-AG] and plasma anandamide [AEA]) on postoperative opioid use and pain intensity in a prospective cohort of n = 112 pregnant patients undergoing scheduled cesarean delivery. Maternal blood and CSF samples were collected preoperatively for beta-endorphin and EC assays. Patients completed measures of outpatient opioid use (number of tablets used and days of use) and average pain intensity at 2 weeks postoperatively. Results of general linear model analyses controlling for maternal age, BMI at time of delivery, and race revealed significant multiplicative interactions between EC and beta-endorphin concentrations on number of opioid tablets used (based on pill count), days of opioid use, and total milligram morphine equivalents used in the 2 week follow-up period. Elevated preoperative plasma and CSF 2-AG predicted reduced outpatient opioid analgesic use particularly for patients low in CSF beta-endorphin. Similar analyses for pain intensity at 2-week follow-up indicated a significant interaction (p<.02) characterized by higher preoperative beta-endorphin concentrations being associated with lower subsequent pain only for individuals with low preoperative plasma AEA concentrations. Further exploration of interactions between EC and endogenous opioid inhibitory systems as they influence responses to opioid analgesics in other clinical pain populations may help guide development of precision pain management approaches. PerspectiveIn the postoperative setting of patients undergoing cesarean delivery, elevated endocannabinoids were linked to reduced outpatient opioid analgesic use in individuals who had low endogenous opioid concentrations in cerebrospinal fluid. Further exploration of interactions between these two inhibitory systems as they impact on responses to pain management interventions appears warranted.

Implementation of perinatal quality collaborative statewide initiative improves obstetrical opioid use disorder care and outcomes

BackgroundMaternal deaths resulting from opioid use disorder (OUD) have been rising across the United States​. OUD among pregnant persons is associated with adverse pregnancy outcomes including preterm birth along with racial disparities in optimal OUD care. ObjectiveWe aimed to evaluate whether the Illinois Perinatal Quality Collaborative’s (ILPQC) implementation of the Mothers and Newborns affected by Opioids – Obstetric quality improvement initiative was associated with improvement of OUD identification, provision of optimal OUD care for birthing patients, and reduction in racial gaps of optimal OUD care. Study DesignUsing a prospective cohort design, hospitals reported monthly key measures for all patients with OUD at delivery between July 2018 – December 2020. ILPQC facilitated collaborative learning opportunities, rapid-response data, and quality improvement (QI) support. Generalized linear mixed effects regression models were used to​ evaluate improvement in optimal OUD care including increases in linkages to medication assisted treatment, recovery treatment services and naloxone counseling across time​; and to determine whether optimal OUD care was associated with positive outcomes such as lower odds of preterm birth. ResultsNinety- one hospitals submitted data on 2,095 pregnant persons with OUD. For the primary outcomes, the rates of patients receiving Medication Assisted Treatment (MAT) and recovery treatment services improved across the initiative from 41 to 78% and 48 to 67% respectively. For the secondary outcomes, the receipt of recovery treatment services and both recovery treatment services / MAT provided prenatally before delivery admission was associated with lower odds of preterm birth (aOR (95% CI) 0.67 (0.50, 0.91) and 0.49 (0.31, 0.75), respectively). During the first quarter of the initiative, Black patients with OUD were less likely to be linked to MAT (23% vs. 48%); however, an increase in MAT rates across the initiative occurred for all patients, with the greatest improvement for Black patients with an associated reduction in this disparity gap with greater than 70% of both Black and White patients linked to MAT. ConclusionThe MNO-OB initiative is associated with improvements in optimal OUD care for pregnant patients across Illinois hospitals, while racial disparity in OUD care was reduced across the MNO OB initiative. The findings further implicate how optimal OUD care can improve pregnancy outcomes and close persistent racial gaps in pregnant individuals with OUD.

Proteomics analysis of plasm exosomes in early pregnancy among normal pregnant women and those with antiphospholipid syndrome

IntroductionAntiphospholipid syndrome (APS) is an autoimmune disorder associated with thrombosis and adverse obstetric outcomes. Early diagnosis and intervention can improve pregnancy outcomes to some extent, but current results are unsatisfactory. Exosomes, containing biomacromolecules relevant to reproduction, play essential roles in pregnancy. However, research progress on their involvement in APS remains limited. ObjectivesThis study aims to investigate protein profile changes in plasma exosomes and identify potential biomarkers for obstetric APS. MethodsWe employed tandem mass tag (TMT) markers to analyze exosome protein profiles from 6 healthy early pregnant women and 6 early-stage APS patients. Quantitative proteomics analysis was conducted using the Maxquant search engine. ResultsDifferential expression analysis identified 51 upregulated and 22 downregulated proteins in plasma exosomes from early pregnant women with APS, such as serpin peptidase inhibitor C1/A1/A7, apolipoprotein 1/2, orosomucoid 1/2 and apolipoprotein H. Kyoto Encyclopedia of Genes and Genomes analysis shows that differentially expressed proteins are enriched in the PPAR signaling pathway and staphylococcus aureus infection pathway. Enrichment analysis indicated associations with glycerolipid biosynthesis, vitamin transport, and negative regulation of very-low-density lipoprotein particle remodeling. ConclusionOur study highlights alterations in the protein profiles of plasma exosomes in APS pregnant patients and proposes potential biomarkers, offering insights for early diagnosis and treatment and improving reproductive outcomes.

Unveiling the truth: is COVID-19 reimbursement in Colombia a flawed design? A cost-of-illness analysis for moderate, severe and critical infections

PurposeThis study examines the financial impact of the COVID-19 pandemic on the Colombian Health System, focusing on the adequacy of reimbursement rates for inpatient stays. The study, based on a...

Lung Protective Ventilation during Pregnancy: An Observational Cohort Study.

Objectives  We sought to describe characteristics of mechanically ventilated pregnant patients, evaluate utilization of low-tidal-volume ventilation (LTVV) and high-tidal-volume ventilation (HTVV) by trimester, and describe maternal and fetal outcomes by ventilation strategy. Study Design  This is a retrospective cohort study of pregnant women with mechanical ventilation for greater than 24 hours between July 2012 and August 2020 at a tertiary care academic medical center. We defined LTVV as average daily tidal volume 8 mL/kg of less of predicted body weight, and HTVV as greater than 8 mL/kg. We examined demographic characteristics, maternal and fetal characteristics, and outcomes by ventilation strategy. Results  We identified 52 ventilated pregnant women, 43 had LTVV, and 9 had HTVV. Acute respiratory distress syndrome occurred in 73% ( N  = 38) of patients, and infection was a common indication for ventilation ( N  = 33, 63%). Patients had LTVV more often than HTVV in all trimesters. Obstetric complications occurred frequently, 21% ( N  = 11) experienced preeclampsia or eclampsia, and among 43 patients with available delivery data, 60% delivered preterm ( N  = 26) and 16% had fetal demise ( N  = 7). Conclusion  LTVV was utilized more often than HTVV among pregnant women in all trimesters. There was a high prevalence of maternal and fetal morbidity and fetal mortality among our cohort. Key Points Our center utilized low tidal more often than high-tidal-volume ventilation during all trimesters of pregnancy.Prone positioning can be performed at advanced gestations.Infection is a common cause of antepartum ventilation.

Management of peri-surgical anemia in elective surgery. Conclusions and recommendations according to Delphi-UCLA methodology

IntroductionPreoperative anemia affects approximately one third of surgical patients. It increases the risk of blood transfusion and influences short- and medium-term functional outcomes, increases comorbidities, complications and costs. The “Patient Blood Management” (PBM) programs, for integrated and multidisciplinary management of patients, are considered as paradigms of quality care and have as one of the fundamental objectives to correct perioperative anemia. PBM has been incorporated into the schemes for intensified recovery of surgical patients: the recent Enhanced Recovery After Surgery 2021 pathway (in Spanish RICA 2021) includes almost 30 indirect recommendations for PBM. ObjectiveTo make a consensus document with RAND/UCLA Delphi methodology to increase the penetration and priority of the RICA 2021 recommendations on PBM in daily clinical practice. Material and MethodsA coordinating group composed of 6 specialists from Hematology-Hemotherapy, Anesthesiology and Internal Medicine with expertise in anemia and PBM was formed. A survey was elaborated using Delphi RAND/UCLA methodology to reach a consensus on the key areas and priority professional actions to be developed at the present time to improve the management of perioperative anemia. The survey questions were extracted from the PBM recommendations contained in the RICA 2021 pathway. The development of the electronic survey (Google Platform) and the management of the responses was the responsibility of an expert in quality of care and clinical safety.Participants were selected by invitation from speakers at AWGE-GIEMSA scientific meetings and national representatives of PBM-related working groups (Seville Document, SEDAR HTF section and RICA 2021 pathway participants).In the first round of the survey, the anonymized online questionnaire had 28 questions: 20 of them were about PBM concepts included in ERAS guidelines (2 about general PBM organization, 10 on diagnosis and treatment of preoperative anemia, 3 on management of postoperative anemia, 5 on transfusion criteria) and 8 on pending aspects of research. Responses were organized according to a 10-point Likter scale (0: strongly disagree to 10: strongly agree). Any additional contributions that the participants considered appropriate were allowed. They were considered consensual because all the questions obtained an average score of more than 9 points, except one (question 14).The second round of the survey consisted of 37 questions, resulting from the reformulation of the questions of the first round and the incorporation of the participants' comments. It consisted of 2 questions about general organization of PBM programme, 15 questions on the diagnosis and treatment of preoperative anemia; 3 on the management of postoperative anemia, 6 on transfusional criteria and finally 11 questions on aspects pending od future investigations.Statistical treatment: tabulation of mean, median and interquartiles 25–75 of the value of each survey question (Tables 1, 2 and 3). ResultsExcept for one, all the recommendations were accepted. Except for three, all above 8, and most with an average score of 9 or higher. They are grouped into:1.- “It is important and necessary to detect and etiologically diagnose any preoperative anemia state in ALL patients who are candidates for surgical procedures with potential bleeding risk, including pregnant patients”.2.- “The preoperative treatment of anemia should be initiated sufficiently in advance and with all the necessary hematinic contributions to correct this condition”.3.- “There is NO justification for transfusing any unit of packed red blood cells preoperatively in stable patients with moderate anemia Hb 8−10 g/dL who are candidates for potentially bleeding surgery that cannot be delayed.”4.- “It is recommended to universalize restrictive criteria for red blood cell transfusion in surgical and obstetric patients.”5.- “Postoperative anemia should be treated to improve postoperative results and accelerate postoperative recovery in the short and medium term”. ConclusionsThere was a large consensus, with maximum acceptance,strong level of evidence and high recommendation in most of the questions asked. Our work helps to identify initiatives and performances who can be suitables for the implementation of PBM programs at each hospital and for all patients.

Outcomes of severely injured pregnant trauma patients: a multicenter analysis.

Nearly 10% of pregnant women suffer traumatic injury. Clinical outcomes for pregnant trauma patients (PTPs) with severe injuries have not been well studied. We sought to describe outcomes for PTPs presenting with severe injuries, hypothesizing that PTPs with severe injuries will have higher rates of complications and mortality compared to less injured PTPs. A post-hoc analysis of a multi-institutional retrospective study at 12 Level-I/II trauma centers was performed. Patients were stratified into severely injured (injury severity score [ISS] > 15) and not severely injured (ISS < 15) and compared with bivariate analyses. From 950 patients, 32 (3.4%) had severe injuries. Compared to non-severely injured PTPs, severely injured PTPs were of similar maternal age but had younger gestational age (21 vs 26weeks, p = 0.009). Penetrating trauma was more common in the severely injured cohort (15.6% vs 1.4%, p < 0.001). The severely injured cohort more often underwent an operation (68.8% vs 3.8%, p < 0.001), including a hysterectomy (6.3% vs 0.3%, p < 0.001). The severely injured group had higher rates of complications (34.4% vs 0.9%, p < 0.001), mortality (15.6% vs 0.1%, p < 0.001), a higher rate of fetal delivery (37.5% vs. 6.0%, p < 0.001) and resuscitative hysterotomy (9.4% vs. 0%, p < 0.001). Only approximately 3% of PTPs were severely injured. However, severely injured PTPs had a nearly 40% rate of fetal delivery as well as increased complications and mortality. This included a resuscitative hysterotomy rate of nearly 10%. Significant vigilance must remain when caring for this population.

Causes and Effects of COVID-19 Vaccine Hesitancy Among Pregnant Women and its Association with Adverse Maternal, Placental, and Perinatal Outcomes.

Populations identified to be severely affected by COVID-19, such as pregnant patients, require special consideration in vaccine counseling, access, and provider education. Maternal infection with COVID-19 poses a significant risk to the maternal-fetal dyad with known adverse placenta destruction [1-5]. Despite the widespread access and availability of vaccinations, vaccine hesitancy continues to persist and is highly prevalent in pregnant populations [6-9]. Addressing the multitude of social ecological factors surrounding vaccine hesitancy can aid in providing holistic counseling [10]. However, such factors are foremost shaped by maternal concern over possible fetal effects from vaccination. While changes in policy can help foster vaccine access and acceptance, increasing global provider education and incorporation of motivational interviewing skills are the first steps towards increasing maternal acceptance.

Where is the “counseling” in prenatal genetic counseling?

ObjectivePrenatal genetic testing is routinely offered to all pregnant patients in the United States and is variably offered to certain pregnant populations globally [1]. To achieve value-based, informed decision-making, we argue for a shift away from the predominant “teaching” model of genetic counseling practice that prioritizes information and counselor dominance, toward a “counseling” model of practice that prioritizes the patient’s narrative, values and beliefs. DiscussionSince prenatal testing began, genetic counseling has aimed to facilitate informed decision-making. Many patients are not familiar with the conditions which can be screened for prenatally or the quality of life of affected children. This lack of understanding can leave expectant parents unprepared to make informed decisions about prenatal testing. As the number of prenatal genetic tests expands, genetic counselors and all healthcare providers who discuss prenatal testing face a growing amount of information that is not feasible to explain to patients in a routine appointment. Research demonstrates that the common approach to genetic counseling, including in the prenatal setting, is the provision of biomedical information. Yet, genetic counseling outcome studies suggest that attending to the relational aspects of genetic counseling are associated with more positive patient outcomes, including enhanced knowledge, informed decision-making and greater patient satisfaction [2,3]. Through case vignettes, we illustrate the application of a counseling model of practice using Accreditation Council for Genetic Counseling (ACGC) practice-based competencies in the domain of “Interpersonal, Psychosocial and Counseling Skills” [4]. Finally, we propose changes across the genetic counseling profession to move clinical practice toward a more relational model of care. Practice implicationsA counseling model of genetic counseling practice leads to more positive patient outcomes [2,3]. Genetic counselors and other prenatal healthcare providers can leverage existing counseling and communication skills to support clients in value-based, informed decision-making in prenatal genetic counseling practice.

Should pregnant patients fast before their one-hour glucose tolerance test?

Should pregnant patients fast before their one-hour glucose tolerance test?