Faculty Bibliography

The incidence of twin pregnancies has been rising, largely attributable to increasing use of artificial reproductive techniques. Ultrasound plays a critical role in establishing the chorionicity and amnionicity of multiple gestations, a key predictor of the expected risk and complications, along with guiding future clinical and imaging follow-up examinations and intervals. People carrying multiple gestations will typically undergo more ultrasound examinations (and occasionally fetal MRI) than those carrying singletons, at minimum including a first trimester dating scan, nuchal translucency scan at 11 to 14 weeks, an anatomy scan at 18 to 22 weeks, and other scans in the second and third trimesters for growth and surveillance. This document clarifies the most appropriate imaging guidelines for multiple gestations for seven clinical scenarios/variants, which range from initial imaging, follow-up imaging, growth and surveillance for uncomplicated multiple gestations, and those complicated by a known abnormality or discordance between fetuses. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

BACKGROUND:There is an increasing prevalence of durable mechanical circulatory supported patients in both the in-and-out of hospital communities. The scientific literature regarding the approach to patients supported by durable mechanical circulatory devices who suffer acutely impaired perfusion has not been well explored. METHODS:The International Liaison Committee on Resuscitation Advanced, Basic, and Pediatric Life Support Task Forces conducted a scoping review of the literature using a population, context, and concept framework. RESULTS:A total of 32 publications that included patients who were receiving durable mechanical circulatory support and required acute resuscitation were identified. Most of the identified studies were case reports or small case series. Of these, 11 (34.4%) included patients who received chest compressions. A number of studies reported upon delays in the application of chest compressions resulting from complexity due to the expected pulselessness in some patients with continuous flow left-ventricular assist devices as well as from concern regarding potential dislodgement of the mechanical circulatory support device. Three observational studies identified worse outcomes in durable mechanical circulatory support receiving patients with cardiac arrest and acutely impaired perfusion who received chest compressions as compared to those who did not, however those studies were at high risk of bias. Of 226 patients across 11 studies and two published scientific abstracts who sustained cardiac arrest while supported by durable MCS and underwent chest compressions, there were no reported instances of device dislodgement and 71 (31.4%) patients had favorable outcomes. CONCLUSIONS:There is a scarcity of evidence to inform the resuscitation of patients with durable mechanical circulatory support (MCS) experiencing acute impairment in perfusion and cardiac arrest. Reports indicate that delays in resuscitation often stem from rescuers' uncertainty about the safety of administering chest compressions. Notably, no instances of device dislodgement have been documented following chest compressions, suggesting that the risk of harm from timely CPR in these patients is minimal.

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.

Purpose of review: We review the epidemiology, risk factors, presentation, pathophysiology, diagnosis, peripartum management, and postpartum follow-up of chronic hypertension, hyperlipidemia, acute myocardial infarction, stroke, heart failure, pulmonary embolism, and atrial fibrillation. Recent findings: We discuss pathophysiology and evidence-based management for chronic hypertension, hyperlipidemia, acute myocardial infarction, stroke, heart failure, pulmonary embolism, and atrial fibrillation. Summary: It is essential for providers and patients to understand how cardiovascular diseases cause complications in pregnancy and to identify when patients require screening before conception and throughout the pregnancy. While primary care physicians, obstetricians, and cardiologists, should all have a general understanding of cardiovascular diseases during pregnancy, for higher risk patients it is important to create a multi-disciplinary cardio-obstetrics team for preconception planning, and for risk reduction during and after pregnancy. Shared decision-making regarding risks and benefits is crucial to improve maternal morbidity and mortality in the United States.

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.