Seminars in perinatology
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Morbidly adherent placenta, which describes placenta accreta, increta, and percreta, implies an abnormal implantation of the placenta into the uterine wall. The incidence of placenta accreta has increased significantly over the past several decades, with the main risk factors include prior cesarean section and placental previa. ⋯ The optimum time for planned delivery for a patient with placenta accreta is around 34-35 weeks following a course of corticosteroid injection. The successful management of placenta accreta includes a multidisciplinary care team approach with the successful management relying heavily on the prenatal diagnosis of this entity and preparing for the surgical management in a multidisciplinary approach by assuring the most skilled team is available for those patients.
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Seminars in perinatology · Oct 2013
ReviewObstetric ultrasound utilization in the United States: data from various health plans.
There is currently a lack of published data on ultrasound utilization in obstetrics in the United States. In order to get some meaningful information on this topic, we analyzed de-identified data obtained from large insurance providers and underwriters that covered large segment of the United States population in various geographic areas of the country. ⋯ Another important aspect of the data is a higher than expected utilization of the targeted 76811 ultrasound examination, with utilization rates between 30% and 50%, beyond the original intention of the targeted code. Despite the fact that the data was not intended to shed light on indication of ultrasound or competency of ultrasound providers, in a healthcare world of shrinking reimbursement, as leaders of quality, we should ensure that ultrasound examinations that pregnant women receive are indicated and are performed by competent healthcare workers in ultrasound laboratories that meet accreditation standards.
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Seminars in perinatology · Aug 2013
ReviewHypertensive crisis during pregnancy and postpartum period.
Hypertension affects 10% of pregnancies, many with underlying chronic hypertension, and approximately 1-2% will undergo a hypertensive crisis at some point during their lives. Hypertensive crisis includes hypertensive urgency and emergency; the American College of Obstetricians and Gynecologists describes a hypertensive emergency in pregnancy as persistent (lasting 15 min or more), acute-onset, severe hypertension, defined as systolic BP greater than 160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia. Pregnancy may be complicated by hypertensive crisis, with lower blood pressure threshold for end-organ damage than non-pregnant patients. ⋯ First-line intravenous drugs include labetalol and hydralazine, but other agents may be used, including esmolol, nicardipine, nifedipine, and, as a last resort, sodium nitroprusside. Among patients with hypertensive urgency, slower blood pressure reduction can be provided with oral agents. The objective of this article is to review the current understanding, diagnosis, and management of hypertensive crisis during pregnancy and the postpartum period.
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Disseminated intravascular coagulation in obstetrics is commonly seen associated with massive hemorrhage due to different etiological factors. It may also be seen with intrauterine demise, infections, and hepatic conditions. It is associated with very high maternal and perinatal morbidity and mortality. ⋯ Cornerstone of management is to identify the underlying pathology for disseminated intravascular coagulation. This chapter looks into molecular basis of obstetric DIC and identifies important laboratory tests, along with management. It also identifies topics of future research in the field of obstetric DIC.
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Seminars in perinatology · Aug 2013
ReviewPostpartum hemorrhage: the role of the Maternal-Fetal Medicine specialist in enhancing quality and patient safety.
Postpartum hemorrhage in excess of 1000 mL affects 2.9-4.3% of deliveries in North America and the prevalence is increasing (Calvert et al., 2012(1); Callaghan et al., 2010(2)). Given the unpredictable nature of most postpartum hemorrhages, all obstetric providers must understand the initial steps in the assessment and management of this emergency. ⋯ MFMs are uniquely positioned to develop hospital protocols, advocate for investment in resources to optimize outcomes, and utilize novel educational models, such as simulation, to educate other providers on the recognition and management of this condition. MFMs can also aid in the antepartum diagnosis of abnormal placentation, which is an increasingly common risk factor for severe hemorrhage.