All authors have declared all potential conflicts of interest Data available on request due to privacy/ethical restrictions. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Aim: To estimate the incidence of abruption in first births and recurrence in the subsequent birth in patients of a large US-based integrated health care system. Methods: Retrospective population-based cohort study of patients with first two consecutive singleton births using data from the Kaiser-Permanente South California health care system who delivered over a period of 30 years (1991-2021), using longitudinally linked electronic health records. ICD-9/ICD-10 codes "641.20" and "O45.x" identified placental abruption. We calculated the incidence and rates of abruption in first and second pregnancies. We used logistic regression to estimate the adjusted odds ratios (aOR) for abruption in second pregnancies in patients with and without abruptions in their first pregnancies. Results: Of the 126 264 patients with first two consecutive singleton births over the period, 805 had abruptions in their first births, and 861 in their second births. Rates of abruption in first and second births were 0.63% and 0.68%, respectively. Twenty-seven patients had abruptions in both first and second births. Rates of abruption in the second birth among individuals with and without previous placental abruption were 3.35% and 0.66%, respectively, giving an approximately five-fold increased odds of abruption in a second pregnancy in individuals who had abruption in their first birth when compared with those who did not have placental abruption in their first birth (aOR: 4.95, 95% confidence interval: 3.35-7.31, p < 0.00001). Interpregnancy interval had no statistically significant association with recurrence. Conclusion: Abruption in a first birth is associated with an approximately five-fold increased odds of abruption in a second birth.

Placenta accreta spectrum (PAS) is associated with significant pregnancy and postpartum complications. We evaluated the effect of pregnancy complications during a PAS pregnancy on quality of life (QOL). This was a retrospective survey from February-May 2023 of patients with a PAS pregnancy enrolled in the National Accreta Foundation or Placenta Accreta Ireland. QOL was assessed using the validated SF-36 Short Form measuring physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy/ fatigue, emotional well-being, social functioning, pain, general health, and health change. Participants were asked to compare their current health to one year prior to their PAS pregnancy. Of the 448 respondents, the median age at delivery was 34 years (interquartile range (IQR) 31 – 37). Gestational age at delivery was 35 weeks (IQR 34-38). Participants were mostly white (89.5%), had private health insurance (69%), a history of depression (17.4%) and anxiety (23.4%). Surveys were completed at a median of 3 years (IQR 2–6) after PAS. Participants who had a hemorrhage vs. no hemorrhage reported lower QOL; specifically in social functioning, general health, and health change (all p≤0.02). Peripartum hysterectomy vs. no hysterectomy was associated with a lower; specifically in energy/fatigue, emotional well-being, social functioning, and pain (all p≤0.04). Antenatal suspicion of PAS was associated with better QOL; specifically in role functioning/physical and pain (both p≤0.02). This pattern was not seen across all subscales between those who had an unplanned vs. planned delivery; however, those with unplanned delivery reported a better QOL in role functioning/physical and general health (both p=0.04). Postpartum hemorrhage and hysterectomy resulting from a PAS pregnancy are associated with a lower QOL, even years after their delivery. Differences were also seen in those with and without an antenatal diagnosis, and those with unplanned vs. planned delivery.

We aim to describe a first trimester ultrasound marker for cesarean scar pregnancy (CSP) diagnosis and compare it to the currently used “crossover sign". This is a retrospective case-control study of first trimester transvaginal ultrasound (TVUS) images from obstetric imaging databases. All images were in the midsagittal plane of the uterus with visualization of cervix to fundus. Cases were those with suspected CSP diagnosed radiographically. Controls were the next available first trimester TVUS of a viable singleton intrauterine pregnancy with prior cesarean delivery matched for gestational age. Images were independently reviewed by two experts. The distance from point "M” (as defined by the crossover sign) to the fundus was divided into thirds, with point A closest to fundus, B in the middle, and C at the “M-line”. At each point the anterior myometrial thickness was measured and compared between cases and controls. The visual “tadpole sign” is the presence of the gestational sac (the “head”) fixed anteriorly towards the cesarean scar, with closed uterine cavity extending cephalad towards the fundus (the “tail”). Analyses included interclass correlation coefficient (ICC) and area under the curve (AUC) with 95% confidence intervals (CI). We identified 52 CSP cases and 52 controls. Distribution of the myometrial thickness measurements at each of the three points are presented in image 1. The ICC for the measurements at points A, B and C were 0.88, 0.95, 0.86, respectively. The AUC and 95% CI for each measurement was 0.96 (95% CI 0.93-0.99), 0.98 (95% CI 0.94-1.0), 0.75 (95% CI 0.65-0.85), respectively. There was 100% agreement between the crossover sign and tadpole sign in identifying CSPs. Both the tadpole sign and crossover sign identified all CSPs accurately except one case. The tadpole sign highly correlates with the crossover sign for diagnosis of CSP. Myometrial thickness correlates well to the presence of the tadpole sign. This novel sign is easily identified and carries strong interrater reliability without need for additional ultrasound image manipulation.

The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.

In vitro fertilization (IVF) has been identified as an important risk factor for placenta accreta spectrum (PAS); however, there is a lack of knowledge on how patients with PAS may differ based on the conception method.1 The mechanism of PAS in patients who conceived with IVF may differ from those with classic risk factors, specifically placenta previa and previous cesarean delivery (CD).2 This study aimed to evaluate patient and pregnancy characteristics and delivery outcomes for PAS pregnancies conceived with IVF (IVF-PAS) or PAS pregnancies conceived without IVF (N-PAS), including those with vaginal deliveries and conservative uterine management.

Also available from AJOG MFM, the newest member of the AJOG family of journals -Conservative management for placenta accreta spectrum: questions

Inflammatory bowel disease (IBD) often affects people in their childbearing years and has implications for pregnancy outcomes, particularly as related to increased risk of preterm delivery and effects of immunosuppressive medications on the fetus. Ideally, people with IBD should attempt conception at a time when their disease is in remission to optimize pregnancy outcomes and reduce risks of flares. Generally, pregnant individuals should continue immunosuppressive medications throughout gestation in an attempt to control the disease. Maternal risks of IBD in pregnancy include exacerbated anemia, disease flare, cesarean delivery, and treatment risks. Fetal and neonatal risks include preterm birth, low birthweight, and medication exposures. There are too few clinical trials that include pregnant or breastfeeding patients to analyze the risk/benefit profile of immunosuppressive medications for IBD treatment during pregnancy, limiting the amount of data available to guide medical treatment in this population. More studies are needed on IBD therapies, particularly as more biologics are developed and become the mainstay of treatment. Neonatal clinicians should be aware of in utero medication exposure to help guide decisions regarding newborn care.

Enhanced communication between maternal-fetal medicine (MFM)/obstetrics and neonatology regarding counseling at extreme prematurity remains an essential element of prenatal consultations. Together, the obstetrician and neonatologist can collaborate to provide timely and synergistic information to affected couples during a dynamic period, combining their expertise to elucidate values and formulate a plan that best supports the pregnant person and partner's goals. Such collaboration can help resolve differing perspectives between specialties, minimize redundancy and inconsistencies, and mitigate the impact of clinician bias. Best practices for joint-specialty collaboration include a precounseling clinician huddle, contemporaneous counseling by MFM specialists/obstetricians and neonatologists with the expectant parents or individualized sequential counseling if preferred by the couple, and a postcounseling clinician debrief. This approach can help establish a trusting relationship with families facing possible extremely preterm delivery and optimize the overall counseling experience. Future efforts focused on education and research, including a standardized approach to educational curricula among fellowship programs, should be emphasized.

To clarify whether the risk of recurrent placenta accreta spectrum (PAS) among patients with prior IVF conceptions is modified by mode of conception in the subsequent pregnancy. This was a retrospective, single center cohort study including patients who had an index IVF pregnancy with a clinical or pathologic diagnosis of PAS and who returned with a subsequent delivery between January 2012 and December 2018. Cases of PAS were validated using FIGO diagnostic criteria. The primary outcome was diagnosis of recurrent PAS. Additional outcomes included a composite of hemorrhagic morbidity, including EBL >1L, hysterectomy, arterial embolization, uterine rupture, transfusion or surgical procedure to manage hemorrhage. Groups were compared using Fisher Exact and Wilcoxon tests, and the associations between mode of conception and outcomes were modeled using log binomial regression and generalized estimating equations. We identified 53 eligible deliveries. Of the subsequent conceptions, 16 (30%) were non-IVF while 37 (70%) used IVF. None of the index pregnancy demographics, index pregnancy outcomes nor subsequent delivery characteristics were statistically significant between the two groups (Table 1). Those who went on to have subsequent IVF pregnancy were significantly more likely to have a PAS diagnosis than those with a non-IVF subsequent pregnancy (49% vs 12%, respectively, p=0.02). Composite hemorrhagic morbidity was similar between groups at 25% for non-IVF conceptions and 35% with IVF (Table 2). With adjustment for confounders, the association between IVF conception and recurrent PAS was significant (aOR 8.20, 95% CI 1.58-42.4), while that for subsequent hemorrhagic morbidity was not (aOR 1.12, 95% CI 0.30-4.22). In this high-risk cohort with a prior IVF conception and PAS diagnosis, IVF conception in the subsequent pregnancy had a strong association with recurrent PAS, suggesting that the procedure itself contributes to the risk. Rates of hemorrhagic morbidity were high and similar for both groups, and may be influenced more by obstetric history than mode of conception.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, the terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and was endorsed in 2005 by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). In 2008, ACOG, NICHD, and the Society for Maternal-Fetal Medicine reviewed and updated the definitions for fetal heart rate (FHR) patterns, interpretation, and research recommendations. Following is a summary of the terminology definitions and assumptions found in the 2008 NICHD workshop report. Normal arterial umbilical cord gas values and indications of acidosis are defined in the Table.Definitions are developed for visual interpretation, assuming that both the FHR and uterine activity recordings are of adequate qualityDefinitions apply to tracings generated by internal or external monitoring devices Periodic patterns are differentiated based on waveform, abrupt or gradual (eg, late decelerations have a gradual onset and variable decelerations have an abrupt onset)Long- and short-term variability are evaluated visually as a unitGestational age of the fetus is considered when evaluating patternsComponents of FHR do not occur alone and generally evolve over timeApproximate mean FHR rounded to increments of 5 beats/min in a 10-minute segment of tracing, excluding accelerations and decelerations, periods of marked variability, and segments of baseline that differ by >25 beats/minIn the 10-minute segment, the minimum baseline duration must be at least 2 minutes (not necessarily contiguous) or the baseline for that segment is indeterminateBradycardia is a baseline of <110 beats/min; tachycardia is a baseline of >160 beats/minSinusoidal baseline has a smooth sine wave-like undulating pattern, with waves having regular frequency and amplitudeFluctuations in the baseline FHR of ≥2 cycles per minute, fluctuations are irregular in amplitude and frequency, fluctuations are visually quantitated as the amplitude of the peak to trough in beats per minuteClassification of variability:Absent: Amplitude range is undetectableMinimal: Amplitude range is greater than undetectable to 5 beats/minModerate: Amplitude range is 6–25 beats/minMarked: Amplitude range is >25 beats/minAbrupt increase in FHR above the most recently determined baselineOnset to peak of acceleration is <30 seconds, acme is ≥15 beats/min above the most recently determined baseline and lasts ≥15 seconds but <2 minutesBefore 32 weeks’ gestation, accelerations are defined by an acme ≥10 beats/min above the most recently determined baseline for ≥10 secondsProlonged acceleration lasts ≥2 minutes but <10 minutesGradual decrease in FHR (onset to nadir ≥30 seconds) below the most recently determined baseline, with nadir occurring after the peak of uterine contractionsConsidered a periodic pattern because it occurs with uterine contractionsGradual decrease in FHR (onset to nadir ≥30 seconds) below the most recently determined baseline, with nadir occurring coincident with uterine contractionAlso considered a periodic patternAbrupt decrease in FHR (onset to nadir <30 seconds)Decrease is ≥15 beats/min below the most recently determined baseline lasting ≥15 seconds but <2 minutesMay be episodic (occurs without a contraction) or periodicDecrease in the FHR ≥15 beats/min below the most recently determined baseline lasting ≥2 minutes but <10 minutes from onset to return to baselineDecelerations are tentatively called recurrent if they occur with ≥50% of uterine contractions in a 20-minute periodDecelerations occurring with <50% of uterine contractions in a 20-minute segment are intermittentVisually apparent, smooth sine wave-like undulating pattern in the baseline with a cycle frequency of 3 to 5 per minute that persists for ≥20 minutesQuantified as the number of contractions in a 10-minute window, averaged over 30 minutes Normal: ≤5 contractions in 10 minutesTachysystole: >5 contractions in 10 minutesA 3-tier FHR interpretation system has been recommended as follows: Category I FHR tracings: Normal, strongly predictive of normal fetal acid-base status and require routine care. These tracings include all of the following: − Baseline rate: 110 to 160 beats/min− Baseline FHR variability: Moderate− Late or variable decelerations: Absent− Early decelerations: Present or absent− Accelerations: Present or absentCategory II FHR tracings: Indeterminate, require evaluation and continued surveillance and reevaluation. Examples of these tracings include any of the following: − Bradycardia not accompanied by absent variability− Tachycardia− Minimal or marked baseline variability− Absent variability without recurrent decelerations− Absence of induced accelerations after fetal stimulation− Recurrent variable decelerations with minimal or moderate variability− Prolonged decelerations− Recurrent late decelerations with moderate variability− Variable decelerations with other characteristics, such as slow return to baselineCategory III FHR tracings: Abnormal, predictive of abnormal fetal acid-base status and require prompt intervention. These tracings include: − Absent variability with any of the following: ▪ Recurrent late decelerations▪ Recurrent variable decelerations▪ Bradycardia− Sinusoidal patternData from Macones GA, Hankins GDV, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring. Obstet Gynecocol. 2008;112:661–666 and American College of Obstetricians and Gynecologists. Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. Washington, DC: American College of Obstetricians and Gynecologists; 2009.We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.Four days after symptom onset, a 36-year-old, unvaccinated, gravida 2, para 1-0-0-1 woman presented to her local emergency department (ED) at 35 weeks and 5 days’ gestation with shortness of breath, nausea, and vomiting. She tested positive for COVID-19 on a polymerase chain reaction (PCR) nasal swab. Her pregnancy was complicated by untreated hepatitis C (viral load at the time of admission 76 IU/mL), class II obesity, and mild persistent asthma. In the month prior to her infection, ultrasonography findings were consistent with a well-grown fetus and normal amniotic fluid. Her obstetrical history included an uncomplicated full-term vaginal delivery. Her evaluation included computed tomography angiography without pneumonia or pulmonary embolism. After her ED evaluation, she was discharged from the hospital for outpatient management. Her 11-year-old son and partner were also symptomatic with PCR test–confirmed COVID-19 infections.Five days later, now 9 days after symptom onset, she presented to her local ED again with progressive shortness of breath. Her laboratory findings were notable for an anion gap metabolic acidosis (bicarbonate level of 9 mEq/L [9 mmol/L], anion gap of 17, and no initial pH), for which she was hydrated and transferred to an obstetric/medicine care unit. On the 10th day after symptom onset, she became increasingly hypoxemic, requiring 5 L of oxygen via nasal cannula to maintain pulse oxygen saturations between 93% and 95%. Arterial blood gas measurement confirmed persistent metabolic acidosis despite hydration (pH 7.26, bicarbonate 12 mEq/L [12 mmol/L]). Chest radiography demonstrated left lower lobe consolidations with concern for superimposed bacterial pneumonia. She was started on azithromycin, remdesivir, and dexamethasone and symptomatically treated with ondansetron, metoclopramide, and acetaminophen. Tertiary care referral and transfer to our facility was initiated for intensive care unit access for maternal and neonatal care.At the time of admission to our facility, the patient was receiving 4 L of oxygen via nasal cannula, with a pulse oxygen saturation between 97% and 99%. She was tachycardic to 110 beats/min, with a pulmonary examination notable for bilateral upper lobe coarse breath sounds, bilateral lower lobe decreased breath sounds, and tachypnea with a respiratory rate of 28 breaths/min. Laboratory evaluation was remarkable for a bicarbonate level of 10 mEq/L (10 mmol/L) with an anion gap of 20. β-hydroxybutyrate was elevated at 5.2 mmol/L (93.6 mg/dL or 0.0052 mol/L), C-reactive protein was elevated at 7.99 mg/dL (79.9 mg/L), and D-dimer was significantly elevated at 6,174 μg/L (6.174×10−6 g/mL or 19,633 nmol/L).Upon arrival, an initial arterial blood gas was notable for metabolic acidosis with a pH of 7.32, partial pressure of oxygen of 108 mm Hg (14.3 kPa), partial pressure of carbon dioxide of 17 mm Hg (2.2 kPa), bicarbonate of 8 mEq/L (8 mmol/L), and base deficit of 16. Her overall clinical status was consistent with severe COVID-19 infection with starvation metabolic acidosis. She continued to receive dexamethasone, remdesivir, and antibiotics for community-acquired pneumonia and intravenous fluids with dextrose. Bedside fetal ultrasonography confirmed normal amniotic fluid and vertex fetal presentation. A representative FHR tracing at the time of transfer is included in Fig 1.Interpretation of Fig 1: Variability: ModerateBaseline rate: 150 beats/minAccelerations: YesEpisodic patterns: NonePeriodic patterns: NoneUterine contractions: Every 2 minutesInterpretation: Category IDifferential diagnosis: Possible relative fetal tachycardia, dehydration, hypoxiaAction: Ongoing assessment of maternal and fetal clinical statusThe patient required ongoing inpatient treatment for hypoxemia and persistent metabolic acidosis. The patient was within the peak window from symptom onset (10–14 days), when her risk of decompensation from inflammatory response was most likely. Her metabolic derangement was thought to be starvation ketosis, given the ketonuria noted on admission (150 ketones mg/dL on urinalysis) and minimal oral intake for approximately 1 week before hospitalization. Other etiologies, such as euglycemic diabetic ketoacidosis, alcohol use, and aspirin toxicity, were excluded. The neonatology and anesthesia teams were notified, given the potential need to move toward delivery at a greater preterm gestational age. She remained in the labor and delivery department for prolonged monitoring. A follow-up fetal assessment on the morning after admission is represented in Fig 2.Interpretation of Fig 2: Variability: MinimalBaseline rate: 155 beats/minAccelerations: AbsentEpisodic patterns: NonePeriodic patterns: NoneUterine contractions: NoneInterpretation: Category IIDifferential diagnosis: Normal fetal status (sleep cycle), fetal hypoxia, abruption.Action: Intervention included ongoing COVID-19 treatment, fluids, ensuring adequate maternal oxygenation, and maternal repositioning for intrauterine resuscitationOn the day after admission (11 days after symptom onset), her oxygen requirement decreased, her tachypnea improved, and the anion gap metabolic acidosis improved; however, she continued to require oxygen. A representative FHR tracing is seen in Fig 3.Interpretation of Fig 3: Variability: ModerateBaseline rate: 125 beats/minAccelerations: PresentEpisodic patterns: NonePeriodic patterns: NoneUterine contractions: Occasional sporadic.Interpretation: Category IDifferential diagnosis: Improved maternal/fetal statusAction: Given overall clinical improvement, continuous fetal monitoring was changed to intermittent fetal monitoring; the patient was transferred to our antepartum floorDespite initial improvement, the next evening, the patient’s respiratory status declined and her oxygen requirement increased to 8 L via cannula. Repeat chest radiography showed progression of multifocal opacities consistent with worsening COVID-19 pneumonia. Given her respiratory decompensation and late preterm gestational age at 36 weeks and 4 days’ gestation, delivery was advised. An induction of labor was initiated. During her induction course, the patient’s respiratory status worsened. The intrapartum FHR tracing is shown in Fig 4:Interpretation of Fig 4: Variability: Minimal-moderate variabilityBaseline rate: 150 beats/minAccelerations: AbsentEpisodic patterns: Late decelerations to 140 beats/minPeriodic patterns: NoneUterine contractions: Every 2 minutesInterpretation: Category IIDifferential diagnoses: Fetal acidosis secondary to worsening maternal respiratory status, uteroplacental insufficiencyAction: Stabilization of maternal oxygenation statusThe fetal tracing improved after optimization of maternal oxygenation status with an increase to 10 L nonrebreather face mask. The induction continued. She progressed to becoming fully dilated. With pushing, the patient’s oxygen level dropped to 89% on 12 L via cannula. Her oxygen supplementation was then transitioned to high-flow oxygen with improvement in oxygen saturations to 95%. A representative FHR tracing during this period of desaturation before delivery is shown in Fig 5.Interpretation of Fig 5: Variability: ModerateAccelerations: AbsentBaseline rate: 150 beats/minEpisodic patterns: Variable decelerations without recovery to baselinePeriodic patterns: NoneUterine contractions: Every 2 minutesInterpretation: Category IIDifferential diagnosis: Fetal acidosis from deteriorating maternal respiratory status, uteroplacental insufficiencyAction: Expedite delivery with operative assisted vaginal delivery if delivery is not imminentAfter a short second stage of labor, the patient had a vaginal delivery of a liveborn male infant weighing 3,550 g with Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. Neonatology staff was present in the delivery room and the newborn was transferred to the NICU for monitoring. Immediately after delivery, the patient’s respiratory status improved, with reduced oxygen requirement. She was eventually transitioned back to minimal oxygen support via nasal cannula at the time of transfer to the postpartum floor. On postpartum day 6, she was weaned to room air.The infant continued to be monitored in the NICU. As both parents were COVID-19 positive, neither was able to visit the infant in the NICU. The infant had a negative COVID-19 swab on day 2 after birth and was reunited with his parents in the postpartum room at that time.Our case describes a pregnant woman with severe COVID-19 pneumonia and hypoxemia resulting in significant maternal and fetal morbidity. FHR monitoring can help determine the oxygenation status of the fetus. (1) However, there is limited information regarding whether maternal COVID-19 infection has any effect on FHR tracing. A study of 224 pregnant women infected with COVID-19 demonstrated no statistically significant relationship between the severity of infection and any FHR pattern or Apgar scores. (2) Similar to other maternal disease states, the FHR tracing in this case improved after maternal respiratory stabilization.Available data suggest that COVID-19 infection in and of itself is not an indication for delivery; expedited delivery should be evaluated on a case-by-case basis with consideration of gestational age, current maternal status, the maternal disease course, and anticipated progression. (3)(4) Data suggest a severity peak in the second week of maternal illness. (3)(5) If respiratory compromise is significant despite maximizing treatment modalities, a preterm delivery may be considered. (4)(6)(7) Data on pregnant women with severe COVID-19 and acute respiratory distress syndrome are limited; some retrospective studies indicate that delivery may improve the maternal respiratory status of pregnant women with acute respiratory failure. (8)(9) Although the threshold for cesarean delivery may be lower in patients with COVID-19 pneumonia, COVID-19 infection is not a contraindication to vaginal delivery. (4)(10)Although COVID-19 infection is associated with maternal morbidity, the risks to the fetus or neonate are somewhat limited. Currently available data indicate that vertical transmission appears to be uncommon. (10)(11)(12) In 9,500 cases in the Perinatal COVID-19 Registry, approximately 2% of infants tested positive for COVID-19 in the first 24 to 96 hours after birth to pregnant women infected with COVID-19. (11)(13) The risk of infection to newborns is highest when a pregnant women has onset of COVID-19 near the time of delivery. (13)(14)Recommendations regarding the need for physical separation of newborns from their mother with COVID-19 have evolved during the pandemic. Data continue to suggest that neonatal COVID-19 infection is uncommon, rarely symptomatic, and the rate of infection is not increased when the neonate is born vaginally, breastfed, or remains with the mother. Currently American Academy of Pediatrics guidance recommends avoiding separation of the mother and newborn unless the maternal status prohibits care of the newborn. (15)(16) As with our patient, the neonate needed ongoing support in the NICU and the parents were unable to visit due to their positive status. Once the neonate was discharged from the NICU and sufficiently stable for the regular nursery, our patient was reunited with her newborn in her postpartum room.This case demonstrates the implications of maternal respiratory status on fetal status. Delivery timing of a pregnancy affected by severe COVID-19 pneumonia needs to be individualized. For our patient, the maternal status significantly worsened at a late preterm gestation and delivery was recommended. Fortunately, despite severe COVID-19 infection in an unvaccinated patient, the outcome was reassuring.

When compared to unplanned peripartum hysterectomy in the setting of placenta accreta spectrum (PAS), planned PAS cases have fewer complications and lower rates of blood loss and transfusion. Unplanned peripartum hysterectomy is indicated in the setting of refractory uterine bleeding. We compare maternal morbidity in people undergoing planned versus unplanned peripartum hysterectomy for all indications. We performed a retrospective cohort study of all people who underwent a peripartum hysterectomy, defined as hysterectomy within 24 hours of delivery, since 2014. The primary outcome is a maternal morbidity composite (MMC) defined as transfusion of ≥4 units of red blood cells, use of additional hemorrhage management procedures, surgical complications, dialysis/acute renal failure, venous thromboembolism, intensive care unit admission, hospital readmission, and maternal death. Data was stratified according to planned versus unplanned status. Comparisons were made using a Chi-square or Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. Eighty-six patients were included, 53 (61.6%) in the planned group and 33 (38.4%) in the unplanned group. The planned group was older (median age 37.2 years [interquartile range (IQR) 33.6-39.1] versus 34.8 years [IQR 31.8-39.0]) and were more likely to be nulliparous (21.2% versus 1.9%). All planned cases were for suspected PAS, compared to 72% in the unplanned group. (Table 1). The unplanned group had a higher MMC score compared to the planned group (p=0.004) (Table 2). The unplanned group had larger estimated blood loss (3000 [IQR 2000-4500] mL vs 2000 [IQR 1500-3500] mL, p=0.06) and were more likely to require activation of the massive transfusion protocol (42.4% vs. 5.7%, p< 0.001). There were no maternal deaths in either group. Despite all planned cases having PAS, unplanned hysterectomy carries a higher incidence of maternal morbidity. This highlights the benefit of advanced planning for complex cases with high risk of maternal morbidity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Placenta accreta spectrum (PAS) refers to the range of pathologic adherence of the placenta to the uterine myometrium, including the placenta accreta, increta, and percreta. The incidence of PAS is rising primarily because of an increase in related risk factors, such as the rate of cesarean deliveries and pregnancies resulting from assisted reproductive technology. The maternal risks associated with PAS are significant, including hemorrhage, hysterectomy, and death. Fetal and neonatal risks are primarily the result of premature delivery. Antenatal diagnosis via ultrasonography and magnetic resonance imaging remains imperfect. Management of PAS varies, however, and there is a clear improvement in maternal outcomes with an antenatal diagnosis compared with unexpected diagnosis at the time of delivery. Studies that evaluate the balance between maternal and fetal/neonatal risks of expectant management versus preterm delivery have found that planned delivery between 34 and 35 weeks’ gestation optimizes outcomes. Multidisciplinary PAS care teams have become the norm and recommended approach to management, given the complexity of caring for this obstetrical condition. Although significant advances have been made over the years, large knowledge gaps remain in understanding the pathophysiology, diagnosis, and clinical management.

Our primary objective was to analyze the impact of implementing a dedicated placenta accreta spectrum (PAS) team on maternal morbidity outcomes and utilization of critical care resources in patients with pathologically confirmed adherent placentation. This is a retrospective cohort study of patients with pathologically confirmed PAS at a single tertiary care institution. The intervention was the development of a specialized placenta accreta program in March 2015. The pre-intervention period was May 1997 to March 2015; the post-intervention period was April 2015 through June 1, 2021. The primary outcome is a maternal morbidity index (MMI); defined as intensive care unit admission (ICU), transfusion of ≥4 units of packed red blood cells, urologic injury, venous thromboembolism, and acute renal failure. Secondary outcomes include blood transfusion and number of units transfused; additional procedures for hemorrhage management; ICU admission; hospital readmission; and maternal death. Comparisons were made using a Chi-square or Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. There were 63 patients in the pre-implementation and 227 in the post-implementation group. There was a significant reduction in hemorrhagic morbidity between the two groups; including estimated blood loss, incidence of transfusions, and transfusion of ≥4 units of packed red blood cells (all p≤ 0.01). There were no maternal deaths in either group. Each individual component of the MMI was significantly reduced after implementation of the program (all p≤0.01) and there was a significant difference in the overall MMI between the two periods (p < 0.01) with the patients in the post-implementation period having lower scores. Hospital readmission and need for additional procedures did not differ between the two groups. (Table 1) Implementation of a specialized placenta accreta program had a significant reduction in maternal morbidity and critical care resource allocation in people whose pregnancies were affected by PAS.

•FATWOs are rare gynecologic neoplasms of low malignant potential derived from mesonephric (Wolffian) duct remnants.•FATWOs have diverse presentations from vague abdominal symptoms to incidental diagnosis.•In general, FATWOs require no additional management beyond initial surgical intervention.