Stillbirth: we can do better Silver, Robert M.; Reddy, Uma
American journal of obstetrics and gynecology,
05/2024
Journal Article
Recenzirano
Stillbirth is far too common, occurring in millions of pregnancies per year globally. The rate of stillbirth (defined as death of a fetus prior to birth at 20 weeks' gestation or more) in the United ...States is 5.73 per 1000. This is approximately 1 in 175 pregnancies accounting for about 21,000 stillbirths per year. Although rates are much higher in low-income countries, the stillbirth rate in the United States is much higher than most high resource countries. Moreover, there are substantial disparities in stillbirth, with rates twice as high for non-Hispanic Black and Native Hawaiian or Other Pacific Islanders compared to non-Hispanic Whites. There is considerable opportunity for reduction in stillbirths, even in high resource countries such as the United States. In this article, we review the epidemiology, risk factors, causes, evaluation, medical and emotional management, and prevention of stillbirth. We focus on novel data regarding genetic etiologies, placental assessment, risk stratification, and prevention.
The most common anomalies of implantation of the placenta and umbilical cord include placenta previa, placenta accreta spectrum, and vasa previa, and are associated with considerable perinatal and ...maternal morbidity and mortality. There is moderate quality evidence that prenatal diagnosis of these conditions improves perinatal outcomes and the performance of ultrasound imaging in diagnosing them is considered excellent. The epidemiology of placenta previa is well known, and it is standard clinical practice to assess placental location at the routine screening second-trimester detailed fetal anatomy ultrasound examination. In contrast, the prevalence of placenta accreta spectrum and vasa previa in the general population is more difficult to evaluate because detailed confirmatory histopathologic data are not available in most studies. The sensitivity and specificity of ultrasonography for the diagnosis of these anomalies is also difficult to assess. Recent epidemiologic studies show an increase in the incidence of placental and umbilical cord implantation anomalies, which may be the result of increased use of assisted reproductive technology and cesarean delivery. There is good evidence to support targeted standardized protocols for women at high risk and that screening and diagnosing placenta accreta spectrum and vasa previa should be integrated into obstetric ultrasound training programs.
Accreta placentation and in particular its invasive forms are impacting maternal health outcomes globally and the prevalence of placenta accreta spectrum (PAS) continues to increase. The Royal ...College of Obstetricians and Gynaecologists (RCOG) and the American College of Obstetricians and Gynecologists (ACOG) with the Society for Maternal-Fetal Medicine (SMFM) have updated their national guidelines, whereas the Federation International of Gynecology and Obstetrics (FIGO) and the Society of Obstetricians and Gynecologists of Canada (SOGC) have developed new guidelines on the diagnosis and management of PAS. A comparison of these guidelines highlights common strong recommendations on the need to carefully evaluate women at high risk for PAS (e.g. prior uterine surgery presenting with anterior low-lying placenta or placenta previa), using multi-modal ultrasound imaging. For women diagnosed with PAS, multidisciplinary team-based care, with full logistic support structures (immediate access to comprehensive blood products, adult and neonatal intensive care) and established expertise in complex pelvic surgery, is critical to maximise safe outcomes for mothers and newborns.
Placenta Accreta Spectrum Cahill, Alison G.; Beigi, Richard; Heine, R. Phillips ...
American journal of obstetrics and gynecology,
December 2018, 2018-12-00, 20181201, Letnik:
219, Številka:
6
Journal Article
Recenzirano
Placenta accreta spectrum, formerly known as morbidly adherent placenta, refers to the range of pathologic adherence of the placenta, including placenta increta, placenta percreta, and placenta ...accreta. The most favored hypothesis regarding the etiology of placenta accreta spectrum is that a defect of the endometrial–myometrial interface leads to a failure of normal decidualization in the area of a uterine scar, which allows abnormally deep placental anchoring villi and trophoblast infiltration. Maternal morbidity and mortality can occur because of severe and sometimes life-threatening hemorrhage, which often requires blood transfusion. Although ultrasound evaluation is important, the absence of ultrasound findings does not preclude a diagnosis of placenta accreta spectrum; thus, clinical risk factors remain equally important as predictors of placenta accreta spectrum by ultrasound findings. There are several risk factors for placenta accreta spectrum. The most common is a previous cesarean delivery, with the incidence of placenta accreta spectrum increasing with the number of prior cesarean deliveries. Antenatal diagnosis of placenta accreta spectrum is highly desirable because outcomes are optimized when delivery occurs at a level III or IV maternal care facility before the onset of labor or bleeding and with avoidance of placental disruption. The most generally accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus (attempts at placental removal are associated with significant risk of hemorrhage). Optimal management involves a standardized approach with a comprehensive multidisciplinary care team accustomed to management of placenta accreta spectrum. In addition, established infrastructure and strong nursing leadership accustomed to managing high-level postpartum hemorrhage should be in place, and access to a blood bank capable of employing massive transfusion protocols should help guide decisions about delivery location.
The rising maternal mortality rate has drawn increased focus to postpartum depression. However, other mental health conditions, such as birth-related postpartum traumatic stress disorder, have not ...garnered the same level of attention. The majority of research about postpartum posttraumatic stress disorder (PTSD) is published in journals focused on psychiatry, psychology, and nursing, where this phenomenon is well recognized. In contrast, there is a lack of awareness among most obstetricians. Consequently, few recommendations are available to guide clinical practice. This commentary will present a clinical vignette, provide background that is key to the detection of PTSD, explore available data on postpartum PTSD, and provide recommendations for recognition and prevention of this disorder.
Recently updated American College of Cardiology/ American Heart Association (ACC/AHA) guidelines redefine blood pressure categories as stage 1 hypertension (systolic, 130–139 mm Hg or diastolic, ...80–89 mm Hg), elevated (systolic, 120–129 mm Hg and diastolic, <80 mm Hg), and normal (<120/<80 mm Hg), but their relevance to an obstetric population is uncertain.
We sought to evaluate the risk of gestational hypertension or preeclampsia based on early pregnancy blood pressure category and trajectory.
We utilized data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be cohort, a prospective observational study of nulliparous women with singleton pregnancies conducted at 8 clinical sites between 2010 and 2014. Women included in this analysis had no known history of prepregnancy hypertension (blood pressure, ≥140/90 mm Hg) or diabetes. We compared the frequency of hypertensive disorders of pregnancy, including preeclampsia and gestational hypertension, among women based on ACC/AHA blood pressure category at a first-trimester study visit and blood pressure trajectory between study visits in the first and second trimesters. Blood pressure trajectories were categorized based on blood pressure difference between visits 1 and 2 as stable (<5 mm Hg difference), upward (≥5 mm Hg), or downward (≤-5 mm Hg). Associations of blood pressure category and trajectory with preeclampsia and gestational hypertension were assessed via univariate analysis and multinomial logistic regression analysis with covariates identified a priori.
A total of 8899 women were included in the analysis. Study visit 1 occurred at a mean gestational age of 11.6 ± 1.5 weeks and study visit 2 at a mean gestational age of 19.0 ± 1.6 weeks. First-trimester blood pressure category was significantly associated with both preeclampsia and gestational hypertension, with increasing blood pressure category associated with a higher risk of all hypertensive disorders of pregnancy. Elevated blood pressure was associated with an adjusted relative risk of 1.54 (95% confidence interval, 1.18–2.02) and stage 1 hypertension was associated with adjusted relative risk of 2.16 (95% confidence interval, 1.31–3.57) of any hypertensive disorder of pregnancy. Stage 1 hypertension was associated with the highest risk of preeclampsia with severe features, with an adjusted relative risk of 2.48 (95% confidence interval, 1.38–8.74). Both systolic and diastolic blood pressure trajectories were also significantly associated with the risk of hypertensive disorders of pregnancy independent of blood pressure category (P < .001). Women with a blood pressure categorized as normal and with an upward systolic trajectory had a 41% increased risk of any hypertensive disorder of pregnancy (adjusted relative risk, 1.41; 95% confidence interval, 1.20–1.65) compared to women with a downward systolic trajectory.
In nulliparous women, blood pressure category and trajectory in early pregnancy are independently associated with risk of preeclampsia and gestational hypertension. Our study demonstrates that blood pressure categories with lower thresholds than those traditionally used to identify individuals as hypertensive may identify more women at risk for preeclampsia and gestational hypertension.
Magnetic resonance imaging is reported to have good sensitivity and specificity in the diagnosis of placenta accreta spectrum disorders, and is often used as an adjunct to ultrasound. But the ...additional utility of obtaining magnetic resonance imaging to assist in the clinical management of patients with placenta accreta spectrum disorders, above and beyond the information provided by ultrasound, is unknown.
We aimed to determine whether magnetic resonance imaging provides data that may inform clinical management by changing the sonographic diagnosis of placenta accreta spectrum disorders.
In all, 78 patients with sonographic evidence or clinical suspicion of placenta accreta spectrum underwent magnetic resonance imaging of the abdomen and pelvis in orthogonal planes through the uterus utilizing T1- and T2-weighted imaging sequences at the University of Utah and the University of Colorado from 1997 through 2017. The magnetic resonance imaging was interpreted by radiologists with expertise in diagnosis of placenta accreta spectrum who had knowledge of the sonographic interpretation and clinical risk factors for placenta accreta spectrum disorders. The primary outcome was a change in diagnosis from sonographic interpretation that could alter clinical management, which was defined a priori. Diagnostic accuracy was verified by surgical and histopathologic diagnosis at the time of delivery.
A change in diagnosis that could potentially alter clinical management occurred in 28 (36%) cases. Magnetic resonance imaging correctly changed the diagnosis in 15 (19%), and correctly confirmed the diagnosis in 34 (44%), but resulted in an incorrect change in diagnosis in 13 (17%), and an incorrect confirmation of ultrasound diagnosis in 15 (21%). Magnetic resonance imaging was not more likely to change a diagnosis in the 24 cases of posterior and lateral placental location compared to anterior location (33% vs 37%, P = .84). Magnetic resonance imaging resulted in overdiagnosis in 23% and in underdiagnosis in 14% of all cases. When ultrasound suspected severe disease (percreta) in 14 cases, magnetic resonance imaging changed the diagnosis in only 2 cases. Lastly, the proportion of accurate diagnosis with magnetic resonance imaging did not improve over time (61-65%, P = .96 for trend) despite increasing volume and increasing numbers of changed diagnoses.
Magnetic resonance imaging resulted in a change in diagnosis that could alter clinical management of placenta accreta spectrum disorders in more than one third of cases, but when changed, the diagnosis was often incorrect. Given its high cost and limited clinical value, magnetic resonance imaging should not be used routinely as an adjunct to ultrasound in the diagnosis of placenta accreta spectrum until evidence for utility is clearly demonstrated by more definitive prospective studies.
Concern regarding the association between cesarean delivery and long-term maternal morbidity is growing as the rate of cesarean delivery continues to increase. Observational evidence suggests that ...the risk of morbidity increases with increasing number of cesarean deliveries. The dominant maternal risk in subsequent pregnancies is placenta accreta spectrum disorder and its associated complications. A history of multiple cesarean deliveries is the major risk factor for this condition. Pregnancies following cesarean delivery also have increased risk for other types of abnormal placentation, reduced fetal growth, preterm birth, and possibly stillbirth. Chronic maternal morbidities associated with cesarean delivery include pelvic pain and adhesions. Adverse reproductive effects may include decreased fertility and increased risk of spontaneous abortion and ectopic pregnancy. Clinicians and patients need to be aware of the long-term risks associated with cesarean delivery so that they can be considered when determining the method of delivery for first and subsequent births.
Abstract Background The significance of periconceptional nutrition for optimizing offspring and maternal health and reducing social inequalities warrants greater understanding of diet quality among ...US women. Objective Our objective was to evaluate racial or ethnic and education inequalities in periconceptional diet quality and sources of energy and micronutrients. Design Cross-sectional analysis of data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be cohort. Participants and setting Nulliparous women (N=7,511) were enrolled across eight US medical centers from 2010 to 2013. Main outcome measures A semiquantitative food frequency questionnaire assessing usual dietary intake during the 3 months around conception was self-administered during the first trimester. Diet quality, measured using the Healthy Eating Index-2010 (HEI-2010), and sources of energy and micronutrients were the outcomes. Statistical analyses Differences in diet quality were tested across maternal racial or ethnic and education groups using F tests associated with analysis of variance and χ2 tests. Results HEI-2010 score increased with higher education, but the increase among non-Hispanic black women was smaller than among non-Hispanic whites and Hispanics (interaction P value <0.0001). For all groups, average scores for HEI-2010 components were below recommendations. Top sources of energy were sugar-sweetened beverages, pasta dishes, and grain desserts, but sources varied by race or ethnicity and education. Approximately 34% of energy consumed was from empty calories (the sum of energy from added sugars, solid fats, and alcohol beyond moderate levels). The primary sources of iron, folate, and vitamin C were juices and enriched breads. Conclusions Diet quality is suboptimal around conception, particularly among women who are non-Hispanic black, Hispanic, or who had less than a college degree. Diet quality could be improved by substituting intakes of refined grains and foods empty in calories with vegetables, peas and beans (legumes), seafood, and whole grains.
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