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This chapter presents an overview on the current recommendations and guidelines that may be implemented to improve the management of planned and unplanned urgent high-risk obstetric patients and prevent fatal outcomes for both mothers and their babies. Reviewing morbidity and mortality data over the 10 years from 2000 reveals an increase in the proportion of indirect causes of maternal deaths and demonstrates that many of the case-fatalities were women who did not receive pre-pregnancy counseling or any specific medical management. The chapter discusses two examples of multidisciplinary care planning: for women who have placenta previa with acreta and have had a previous cesarean section and for women with a serious comorbidity. The goal of rapid response teams (RRTs) is to bring critical expertise and equipment to the patient without delay, in a timely manner, and to provide a solution to the problem in a standardized manner.
The International Postpartum Hemorrhage Collaborative Group has observed an increasing trend in postpartum hemorrhage (PPH) and its severity in a number of high-resource countries including the UK, Australia, Canada, and the United States. Antenatal optimization of hematinic status may avoid the need for transfusion should a hemorrhage occur. This is particularly important for women with identified risk factors or who refuse blood. Early recognition of physiological derangement is vital and modified obstetric early warning systems, tracking changes in maternal physiology, have been introduced. The physiological changes of pregnancy initially buffer the effects of hemorrhage, so early signs such as tachycardia, decreased urine output and tachypnoea should be sought. The aim is to resuscitate the patient by stopping the bleeding and restoring a circulating blood volume with oxygen-carrying potential. Placenta accreta is most commonly associated with a combination of a low-lying placenta and uterine trauma from an earlier cesarean section (CS).
With the advancement of ultrasound (US) technology with introduction of 3D technology as well, detailed examination of the uterine cervix, anatomy, and accurate measurements have become possible. Benign gynecologic conditions seen by US in non-pregnant state include nabothian cysts, cervical polyps, fibroids and Mullerian anomalies. The importance of transvaginal US in diagnosing placenta previa lies also in the ability by transvaginal US to determine exact distance of placental edge from internal os, which will consequently determine mode of delivery. US is the main diagnostic tool for cervical pregnancy. Doppler is a very important tool as well, due to its difficult diagnosis, it should be differentiated from the cervical stage of spontaneous abortion and nabothian cyst and cervical choriocarcinoma. The risks of cervical pregnancy are mainly severe hemorrhage, necessitating hysterectomy in many situations, and it usually occurs in nulliparous or low-parity women, adding to the dilemma of management.
Karen W. Green, Associate Professor Obstetrics and Gynecology, University of Massachusetts Medical Center Worcester, Massachusetts,
Matthew A. Esposito, Assistant Professor, Department of Obstetrics and Gynecology University of Massachusetts Medical Center Worcester, Massachusetts
Obstetric complications secondary to placental dysfunction can occur at any point in gestation. Improvements in perinatal diagnostic techniques such as focused ultrasound studies of fetal growth, placental blood flow, and fetal/placental anatomy now permit the identification of certain complications related to poor implantation or abnormal early development that can be linked to placental function. Confusion caused by the potential overlap in history and physical findings with the various placental abnormalities has led physicians in recent years to rely heavily on ultrasound scanning to help in identifying the cause of ante- and intrapartum hemorrhage. With the known association of placenta previa and prior cesarean delivery with placenta accreta, and an ever-increasing rate of cesarean delivery, there has been a recent focus on identifying ultrasound findings predictive of abnormal placenta adherence. Placental abnormalities can lead to maternal adverse outcomes such as hemorrhage requiring transfusion, more extensive surgery, emotional consequences, and even death.
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