The American Heart Association (AHA) categorizes pulmonary embolism (PE) into three main categories based on the presence or absence of hemodynamic changes and evidence of right ventricular ...dysfunction. The AHA characterizes massive PE as occurring in the setting of persistent hypotension, profound bradycardia, or pulselessness; submassive PE as occurring with evidence of right ventricular dysfunction or myocardial necrosis in the absence of hemodynamic changes; and low-risk PE as occurring in the absence of markers of massive and submassive PE. This chapter provides an overview of how to identify and manage patients with submassive and massive pulmonary embolism. Delivery planning considerations are discussed. We also address the management of critically ill obstetric patients with respect to VTE risk.
The American Heart Association (AHA) categorizes pulmonary embolism (PE) into three main categories based on the presence or absence of hemodynamic changes and evidence of right ventricular dysfunction. The AHA characterizes massive PE as occurring in the setting of persistent hypotension, profound bradycardia, or pulselessness; submassive PE as occurring with evidence of right ventricular dysfunction or myocardial necrosis in the absence of hemodynamic changes; and low-risk PE as occurring in the absence of markers of massive and submassive PE.1 This chapter provides an overview of how to identify and manage patients with submassive and massive pulmonary embolism. Delivery planning considerations are discussed. We also address the management of critically ill obstetric patients with respect to VTE risk.
To evaluate whether cervical ripening with oral misoprostol increases cesarean delivery risk and prolongs time to vaginal delivery compared with vaginal misoprostol in a predominantly overweight ...population.
This single center, retrospective cohort study was performed at a tertiary care academic medical center and compared labor induction outcomes with vaginal misoprostol to outcomes with oral misoprostol after a complete institutional shift to oral misoprostol. Labor induction using 25 micrograms vaginal misoprostol in 2013-2014 was compared with 50 micrograms oral misoprostol in 2014-2015. The primary outcome was cesarean delivery. Secondary outcomes included time to vaginal delivery, uterine tachysystole, maternal hemorrhage, and composite adverse neonatal outcomes. Demographics and outcomes were analyzed using standard statistical tests. Multivariable regression models accounting for potential confounders were created for the primary and secondary outcomes with adjusted odds ratios (aOR) as the measures of effect.
There were 138 women in the oral and 138 women in the vaginal misoprostol groups. In the overall cohort, the median (interquartile range) body mass index was 31.7 (28.2-36.8) and most women (72%) were of either black or Hispanic race or ethnicity. The frequency of cesarean delivery was higher in the oral than the vaginal misoprostol group (32% vs 21%; P=.04). The adjusted odds of cesarean was higher with oral misoprostol (aOR 2.01; 95% CI 1.07-3.76). Among nulliparous women, the frequency of cesarean delivery was 41% in the oral and 28% in the vaginal misoprostol groups (aOR 2.79; 95% CI 1.26-6.19). Women had a longer time to vaginal delivery in the oral compared with vaginal misoprostol group (41 vs 31 hours respectively, P=.01). Tachysystole occurred more frequently with vaginal misoprostol (20% vs 11%; P=.04).
Compared with vaginal misoprostol, oral misoprostol may be associated with increased risk of cesarean delivery and longer time to vaginal delivery.
To determine whether infertility diagnoses differ between Black ethnic subgroups.
Retrospective review.
an urban safety-net hospital.
Women seeking infertility care between 2005 and 2015.
Charts of ...women with infertility and polycystic ovary syndrome (International Classification of Diseases, Ninth Revision diagnoses) were reviewed to confirm diagnoses. Data were stratified by race and subsequently by ethnicity to evaluate the differences in infertility diagnoses between Black American, Black Haitian, and Black African women. White American women were used as the comparison group.
Infertility diagnoses between Black ethnic subgroups and White women.
A total of 358 women met the inclusion criteria, including 99 Black American, 110 Black Haitian, 61 Black African, and 88 White American women. Anovulation/polycystic ovary syndrome was the most common diagnosis in each ethnic group, accounting for 40% of infertility among White American, 57% among Black American, 25% among Black Haitian, and 21% among Black African women. There were no significant differences in the individual infertility diagnoses between Black and White women. Between ethnic subgroups, multivariate analysis showed significantly higher odds of infertility because of anovulation/polycystic ovary syndrome in Black American women compared with Black African women (odds ratio OR, 4.9; 95% confidence interval CI, 1.4–17.0). Compared with Black African women, higher odds of tubal factor infertility were observed in Black American (OR, 4.7; 95% CI, 1.16–18.7) and Black Haitian women (OR, 4.0; 95% CI, 1.1–14.0).
Infertility diagnoses were not homogeneous across Black ethnic groups. Studies examining infertility should specify the ethnic subgroups within a race because this may affect results.
Despite the knowledge that bed rest does not reduce the risk of preterm birth (PTB), it continues to be recommended by many providers worldwide. This is because there are no quantitative data ...assessing the relationship between PTB and physical activity in pregnancy.1–3 We designed a prospective cohort study using a Fitbit activity tracker to quantitatively explore the association between baseline physical activity in pregnancy in steps/day and the risk of PTB (<37 weeks).
This was a prospective cohort study assessing the association between the risk of PTB and physical activity in healthy nulliparous women from 10 to 24 weeks to delivery. The physical activity (San Francisco, California) was measured from the time of entry into the study until the day before admission for delivery using the Fitbit Flex 2. The participants wore the faceless device 24/7 without modifying their activity. The primary exposure was steps/day in low- (<5000 steps/d) and high-level (≥5000 steps/d) activity groups. The primary outcome was the rate of PTB (<37 weeks). An additional unplanned secondary analysis was performed using a 3500 steps/d cutoff. The secondary outcomes included peripartum complications and median steps/day in term vs preterm groups. Adjusted analyses were performed to account for possible confounders.
A total of 134 women were enrolled, of which 25 (19%) and 109 (81%) were in the low- and high-level activity groups, respectively. Overall, 11 (8.2%) women delivered preterm. The high-level activity group was older, partnered, employed, and had a higher education level. The PTB did not differ between the groups (adjusted risk ratio, 0.99; 95% confidence interval CI, 0.99–1.00) (Table). There was no difference in the median steps/d between preterm and term deliveries (7767 interquartile range, 5188–10,387 vs 6986 5412–8528); percentile difference, −442; (95% CI, −2233 to 1507) steps. Using a 3500 steps/d cutoff, there was a 75% reduction in the PTB risk (29% vs 7%, respectively; risk ratio, 0.25; 95% CI, 0.05–2.35) (Table).
This prospective study of nulliparous women showed no difference in the risk of PTB between low- vs high-activity groups using a cutoff of 5000 steps/d. The gestational age at delivery was similar between the groups. No significant difference in the number of steps/d was observed between women who delivered preterm compared with term. The women who were prescribed activity restriction (AR) had a marked reduction in their median number of steps/d after AR was prescribed. However, their median number of steps per day (>5000) reflected that they remained active despite this instruction. An additional analysis using 3500 steps/d as a cutoff for exposure groups showed a significantly increased risk of PTB in the <3500 steps/d group than the ≥3500 steps/d group. It is therefore plausible that activity levels <3500 steps/d are associated with an increased risk of PTB.
Abstract Background Power morcellation during gynecological procedures may cause seeding of undiagnosed cancers. We used a national database to determine the prevalence of malignant and premalignant ...conditions that were present but undetected at the time of laparoscopic supracervical hysterectomy and laparoscopic myomectomy, surgeries in which morcellation is commonly used. Methods Data from 2007 to 2012 were obtained from MarketScan, an administrative database of diagnostic and treatment data for 55.7 million commercially insured women in the United States. Because power morcellation is not captured with billing codes, we limited our analysis to women undergoing procedures that typically use morcellation and that are contraindicated in the case of suspected malignancy to describe the rates at which undetected cancers occur, thus potentially putting patients at risk for seeding of malignant tissue. We defined the rate of preoperative endometrial biopsy and postoperative cancers and hyperplasia by manually reviewing inpatient and outpatient International Classification of Disease, 9th edition, and Current Procedural Terminology codes for all suspected cases. Results In all, 17,903 women underwent laparoscopic supracervical hysterectomy and 1,603 underwent laparoscopic myomectomy. The rate of uterine cancer among women undergoing hysterectomy was 2.96 per 1000 and increased with age from 0 per 1,000 at age younger than 35 to 9.07 per 1,000 at ages 55 to 64 ( p < .05 for age ≥45 compared with <45). Preoperative endometrial biopsy was documented in 47% of women subsequently diagnosed with uterine cancer. The overall rate of malignant and premalignant gynecological conditions was 5.14 per 1,000 for laparoscopic supracervical hysterectomy and 1.87 per 1,000 for laparoscopic myomectomy. Conclusion Approximately 1 in 350 women undergoing laparoscopic supracervical hysterectomy had an undiagnosed uterine cancer, with higher risks among older women. Approximately one-half of women had endometrial biopsies documented before hysterectomy. Safer alternatives, such as contained morcellation, should be evaluated to reduce the risk of complications after morcellation procedures.
Preterm birth is one of the leading causes of perinatal morbidity and mortality. Clinical data suggest that low-dose aspirin may decrease the rate of overall preterm birth, but investigators have ...speculated that this is likely due to a decrease in medically indicated preterm birth through its effect on the incidence of preeclampsia and other placental disease. We hypothesized that low-dose aspirin may also have an impact on the mechanism of spontaneous preterm labor.
Our objective was to determine whether low-dose aspirin reduces the rate of spontaneous preterm birth in nulliparous women without medical comorbidities.
This is a secondary analysis of a randomized, placebo-controlled trial of low-dose aspirin for the prevention of preeclampsia in healthy, low-risk, nulliparous women. Low-risk women were defined by the absence of hypertension, renal disease, diabetes, other endocrine disorders, seizures, heart disease, or collagen vascular disease. Our study was limited to singleton, nonanomalous gestations. Women were eligible if they had prior pregnancy terminations but not prior spontaneous pregnancy loss <20 weeks. Current pregnancies that resulted in a loss or termination <20 weeks or antepartum stillbirth or had missing follow-up data were excluded. The treatment intervention was 60 mg of aspirin, initiated at 13–25 weeks’ gestation or matching placebo. The primary outcome was spontaneous preterm birth <34 weeks’ gestation. Secondary outcomes included spontaneous preterm birth <37 weeks and overall preterm birth <37 and <34 weeks. Baseline demographics and primary and secondary outcomes were compared between treatment groups. A logistic regression model was used to adjust for confounders related to spontaneous preterm birth.
Of 2543 included women, 1262 (49.6%) received low-dose aspirin and 1281 (50.4%) placebo. Baseline characteristics were similar between groups, except for marital status. The rate of spontaneous preterm birth <34 weeks was 1.03% (n = 13) and 2.34% (n = 30) in the low-dose aspirin and placebo group, respectively (odds ratio, 0.43, 95% confidence interval, 0.26–0.84). Additionally, the rate of spontaneous preterm birth <37 weeks was 6.58% (n = 83) in the low-dose aspirin group and 7.03% (n = 90) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.71–1.33), and the rate of overall preterm birth <37 weeks was 7.84% (n = 99) in the low-dose aspirin group and 8.2% (n = 105) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.72–1.31). After adjustment for variables that were clinically relevant or statistically significant, including body mass index, race, tobacco use, marital status, and education level, there was a significant reduction in spontaneous preterm birth <34 weeks in the low-dose aspirin group (adjusted odds ratio, 0.46, 95% confidence interval, 0.23–0.89). The rates of overall preterm birth <34 and <37 weeks and spontaneous preterm birth <37 weeks were similar in women who received low-dose aspirin compared with placebo.
Low-dose aspirin is associated with a substantial decrease in spontaneous preterm birth <34 weeks in healthy nulliparous women without comorbidities. These findings suggest a new therapeutic option for preterm birth prevention that requires further study.
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