Faculty Bibliography

Trafficking and persistence of fetal microchimeric cells (fMCs) and circulating extracellular vesicles (EVs) have been observed in animals and humans, but their consequences in the maternal body and their mechanistic contributions to maternal physiology and pathophysiology are not yet fully defined. Fetal cells and EVs may help remodel maternal organs after pregnancy-associated changes, but the cell types and EV cargos reaching the mother in preterm pregnancies after exposure to various risk factors can be distinct from term pregnancies. As preterm delivery-associated maternal complications are rising, revisiting this topic and formulating scientific questions for future research to reduce the risk of maternal morbidities are timely. Epidemiological studies report maternal cardiovascular risk as one of the major complications after preterm delivery. This paper suggests a potential link between fMCs and circulating EVs and adverse maternal cardiovascular outcomes post-pregnancies, the underlying mechanisms, consequences, and methods for and how this link might be assessed.

This international multidisciplinary expert consensus statement is intended to provide comprehensive guidance that can be referenced at the point of care to cardiac electrophysiologists, cardiologists, and other health care professionals, on the management of cardiac arrhythmias in pregnant patients and in fetuses. This document covers general concepts related to arrhythmias, including both brady- and tachyarrhythmias, in both the patient and the fetus during pregnancy. Recommendations are provided for optimal approaches to diagnosis and evaluation of arrhythmias; selection of invasive and noninvasive options for treatment of arrhythmias; and disease- and patient-specific considerations when risk stratifying, diagnosing, and treating arrhythmias in pregnant patients and fetuses. Gaps in knowledge and new directions for future research are also identified.

Antenatal diagnosis of placenta accreta spectrum (PAS) improves maternal and neonatal outcomes by allowing for multidisciplinary planning and preparedness. Ultrasound is the primary imaging tool. Simplification and standardization of placental evaluation and reporting terminology allows improved communication and understanding between teams. Prior to 10 weeks of gestation, gestational sac position and least myometrial thickness surrounding the gestational sac help PAS diagnosis very early in pregnancy. Late first-, second-, and third-trimester evaluation includes comprehensive evaluation of the placenta, transabdominal and transvaginal with partially full maternal urinary bladder, and by color Doppler. Subsequently, the sonologist should indicate whether the evaluation was optimal or suboptimal; the level of suspicion as low, moderate, or high; and the extent as focal, global, or extending beyond the uterus. Other complementary imaging modalities such as 3D-power Doppler ultrasound, magnetic resonance imaging (MRI), and vascular topography mapping strive to improve antenatal placental evaluation but remain investigational at present. KEY POINTS: · Antenatal imaging, primarily using ultrasound with partially full maternal urinary bladder, is an essential means of evaluation of those at risk for PAS.. · Simplification and standardization of placental evaluation and reporting will allow improved communication between the multidisciplinary teams.. · Gestational sac location prior to 10 weeks of gestation and four markers after that (placental lacunae and echostructure, myometrial thinning, hypoechoic zone with or without bulging between placenta and myometrium, and increased flow on color Doppler)..

Ultrasound is the hallmark imaging modality traditionally used by obstetricians for fetal diagnosis and surveillance. The COVID-19 pandemic highlighted the role of point of care ultrasound (POCUS) for expeditious assessment of maternal cardiopulmonary status. The familiarity of obstetricians with ultrasound coupled with the availability of ultrasound equipment without the need to transport the patient make POCUS particularly valuable on labor and delivery. The rising contribution of cardiopulmonary disorders to maternal morbidity and mortality carves out many potential applications for POCUS on labor and delivery. Obstetricians have access to the technology and skills to obtain the basic views required to assess for the presence of pulmonary edema, ventricular dysfunction, or intraabdominal free fluid. POCUS can routinely be used for the evaluation of pulmonary complaints or in the assessment of hypotension and may play an essential role in the diagnosis and management of life-threatening emergencies such as shock, amniotic fluid embolism, or cardiac arrest. We review the currently established POCUS protocols for the evaluation of cardiopulmonary complaints through the lens of the obstetrician. We call upon educators and academic leaders to incorporate maternal POCUS into existing curricula. POCUS is of enormous value for providers with limited access to diagnostic imaging or subspecialty providers. With the growing complexity of the obstetric population, acquiring clinical skills to meet these evolving needs is a requisite step in the ongoing efforts to reduce maternal morbidity and mortality.

This document aims to provide guidance to healthcare workers for the provision of basic and advanced life support to children and neonates with suspected or confirmed COVID-19. It aligns with the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care while providing strategies for reducing risk of transmission of SARS-CoV-2 to healthcare providers. Patients with suspected or confirmed COVID-19 and cardiac arrest should receive chest compressions and defibrillation, when indicated, as soon as possible. Due to the importance of ventilation during pediatric and neonatal resuscitation, oxygenation and ventilation should be prioritized. All CPR events should therefore be considered aerosol-generating procedures (AGPs). Thus, personal protective equipment (PPE) appropriate for AGPs (including N95 respirators or an equivalent) should be donned prior to resuscitation and high-efficiency particulate air (HEPA) filters should be utilized. Any personnel without appropriate PPE should be immediately excused by providers wearing appropriate PPE. Neonatal resuscitation guidance is unchanged from standard algorithms except for specific attention to infection prevention and control. In summary, healthcare personnel should continue to reduce the risk of SARS-CoV-2 transmission through vaccination and use of appropriate PPE during pediatric resuscitations. Healthcare organizations should ensure the availability and appropriate use of PPE. As delays or withheld CPR increases the risk to patients for poor clinical outcomes, children and neonates with suspected or confirmed COVID-19 should receive prompt, high-quality CPR in accordance with evidence-based guidelines.

INTRODUCTION/BACKGROUND:century. Factors influencing outcome of maternal cardiac arrest (MCA) remain largely unexplored. OBJECTIVE:We sought to further elucidate the factors affecting maternal death from in-hospital (IH) MCA. METHODS:Our query of the American Heart Association's GWTG®-Resuscitation voluntary registry from 2000-2017 revealed 561 index cases of IH MCA with complete outcome data. Logistic regression was performed using hospital death as the primary outcome and included variables with a p value = 0.1 or less based upon univariate analysis. Age, race, year of arrest, pre-existing conditions, first documented pulseless rhythm and location of arrest were used in the model. Sensitivity analyses and assessment of variable interaction were also performed to test model stability. Institutional review deemed this research exempt from ethical approval. RESULTS:Among 561 cases of MCA, 57.2% (321/561) did not survive to hospital discharge. IH death was not associated with maternal age, race and year of event. In the final model, IH death was significantly associated with pre-arrest hypotension/hypoperfusion (OR = 1.80 (95% CI, 1.16-2.79); p = 0.009). The occurrence of MCA outside of the delivery suite (referent group) or operating room was associated with a significantly higher risk of death: ICU/Post-Anesthesia Care Unit (PACU) (OR = 3.32 (95% CI, 2.00- 5.52); p < 0.001) and ER/other (OR = 1.89 (95% CI, 1.15-3.11); p = 0.012). While MCA cases with a shockable vs. non-shockable first documented pulseless rhythm had similar outcomes, those with an indeterminate rhythm were less likely to die, (OR = 0.41(95% CI, 0.20-0.84); p = 0.014). In a sensitivity analysis, removal of the indeterminate group did not alter outcomes regarding first documented pulseless rhythm or arrest location. Area under the curve for the final model was 0.715 (95% CI 0.673- 0.757). CONCLUSIONS:Our study identified several novel factors associated with IH death of our MCA cohort. More research is required to further understand the pathophysiologic dynamics affecting outcomes of IH MCA in this unique population.

The Appropriateness Criteria for the imaging screening of second and third trimester fetuses for anomalies are presented for fetuses that are low risk, high risk, have had soft markers detected on ultrasound, and have had major anomalies detected on ultrasound. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.