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Objective This study aimed to evaluate whether enhanced recovery after cesarean (ERAC) pathways reduces inpatient and outpatient opioid use, pain scores and improves the indicators of postoperative recovery. Study Design This is a prospective, longitudinal, quality improvement study of all patients older than 18 undergoing an uncomplicated cesarean delivery (CD) at an academic medical center. We excluded complicated CD, patients with chronic pain disorders, chronic opioid use, acute postpartum depression, or mothers whose neonate demised before their discharge. Lastly, we excluded non-English- and non-Spanish-speaking patients. Our study compared patient outcomes before (pre-ERAC) and after (post-ERAC) implementation of ERAC pathways. Primary outcomes were inpatient morphine milligram equivalent (MME) use and the patient's delta pain scores. Secondary outcomes were outpatient MME prescriptions and indicators of postoperative recovery (time to feeding, ambulation, and hospital discharge). Results Of 308 patients undergoing CD from October 2019 to September 2020, 196 were enrolled in the pre-ERAC cohort and 112 in the post-ERAC cohort. Patients in the pre-ERAC cohort were more likely to require opioids in the postoperative period compared with the post-ERAC cohort (81.6 vs. 64.3%, p < 0.001). Likewise, there was a higher use of MME per stay in the pre-ERAC cohort (30 [20–49] vs. 16.8 MME [11.2–33.9], p < 0.001). There was also a higher number of patients who required prescribed opioids at the time of discharge (98 vs. 86.6%, p < 0.001) as well as in the amount of MMEs prescribed (150 [150–225] vs. 150 MME [112–150], p < 0.001; different shape of distribution). Furthermore, the patients in the pre-ERAC cohort had higher delta pain scores (3.3 [2.3–4.7] vs. 2.2 [1.3–3.7], p < 0.001). Conclusion Our study has illustrated that our ERAC pathways were associated with reduced inpatient opioid use, outpatient opioid use, patient-reported pain scores, and improved indicators of postoperative recovery. Key Points Implementation of ERAC pathways is associated with a higher percentage of no postpartum opioid use. Implementation of ERAC pathways is associated with lower delta (reported − expected) pain scores. The results of ERAC pathways implementation are increased by adopting a patient-centered approach. [ABSTRACT FROM AUTHOR]

To explore the association between COVID-19 severity and pregnancy using measures such as COVID-19 ordinal scale severity score, hospitalization, intensive care unit (ICU) admission, oxygen supplementation, invasive mechanical ventilation, and death. We conducted a retrospective, multicenter cohort study to understand the association between COVID-19 severity and pregnancy. We reviewed consecutive charts of adult females, ages 18–45, with laboratory testing for SARS-CoV-2 infection between March 1, 2020, and August 31, 2020. Cases were patients diagnosed with COVID-19 during pregnancy, whereas controls were not pregnant at the time of COVID-19 diagnosis. Primary endpoints were the COVID-19 severity score at presentation (within four hours) and the nadir of the clinical course. The secondary endpoints were the proportion of patients requiring hospitalization, ICU admission, oxygen supplementation, invasive mechanical ventilation, and death. A higher proportion of pregnant women had moderate to severe COVID-19 disease at the nadir of the clinical course than non-pregnant women (25 vs. 16.1 %, p=0.04, respectively). There was a higher rate of hospitalization (25.6 vs. 17.2 %), ICU admission (8.9 vs. 4.4 %), need for vasoactive substances (5.0 vs. 2.8 %), and invasive mechanical ventilation (5.6 vs. 2.8 %) in the pregnant cohort. These differences were not significant after applying propensity score matching.We found a high rate of pregnancy complications in our population (40.7 %). The most worrisome is the rate of hypertensive disorders of pregnancy (20.1 %). In our propensity score-matched study, COVID-19 in pregnancy is associated with an increased risk of disease severity and pregnancy complications. [ABSTRACT FROM AUTHOR]

To evaluate the timing of antenatal corticosteroids (ACS) administration in relation to the delivery timing based on indications and risk factors for preterm delivery. We conducted a retrospective cohort study to understand what factors predict the optimal timing of ACS administration (ACS administration within seven days). We reviewed consecutive charts of adult pregnant women receiving ACS from January 1, 2011, to December 31, 2019. We excluded pregnancies under 23 weeks, incomplete and duplicate records, and patients delivered outside our health system. The timing of ACS administration was categorized as optimal or suboptimal. These groups were analyzed regarding demographics, indications for ACS administration, risk factors for preterm delivery, and signs and symptoms of preterm labor. We identified 25,776 deliveries. ACS were administered to 531 pregnancies, of which 478 met the inclusion criteria. Of the 478 pregnancies included in the study, 266 (55.6 %) were delivered in the optimal timeframe. There was a higher proportion of patients receiving ACS for the indication of threatened preterm labor in the suboptimal group as compared to the optimal group (85.4 % vs. 63.5 %, p<0.001). In addition, patients who delivered in the suboptimal timeframe had a higher proportion of short cervix (33 % vs. 6.4 %, p<0.001) and positive fetal fibronectin (19.8 % vs. 1.1 %, p<0.001) compared to those who delivered in the optimal timeframe. More emphasis should be placed on the judicious use of ACS. Emphasis should be placed on clinical assessment rather than relying solely on imaging and laboratory tests. Re-appraisal of institutional practices and thoughtful ACS administration based on the risk-benefit ratio is warranted. [ABSTRACT FROM AUTHOR]

Objective This study aimed to evaluate whether there is a difference in neonatal outcomes with general anesthesia (GA) versus regional anesthesia (RA) when induction of anesthesia to delivery time (IADT) is prolonged (≥10 minutes). Study Design This is a retrospective case–control study that included cases from July 2014 until August 2020. We reviewed all singleton pregnancies delivered between 24 and 42 weeks of gestation with IADT ≥ 10 minutes. Urgent deliveries, those who received RA for labor pain management or started cesarean delivery under RA and converted to GA, as well as cases with fetal anomalies, were excluded. The propensity score (PS) matching method was performed using age, ethnicity/race, body mass index, gestational age at delivery, preexisting maternal comorbidities, and pregnancy complications. Analyses were performed with SAS software version 9.4. Results During the study period, we identified 258 cases meeting inclusion criteria. After the PS matching was applied, the study sample was reduced to 60 cases in each group. The median IADT and uterine incision to delivery time were similar between groups (41.5 [30.5, 52] vs. 46 minutes [38, 53.5], p = 0.2 and 1.5 [1, 3] vs. 2 minutes [1, 3], respectively). There was no significant difference between groups with respect to arterial or venous cord pH (7.24 [7.21, 7.26] vs. 7.23 [7.2, 7.27], p = 0.7 and 7.29 [7.26, 7.33] vs. 7.3 [7.26, 7.33], p = 0.4, respectively). Nor were there any associations between maternal characteristics and Apgar's score at 5 minutes, except for Apgar's score at 1 minute (p < 0.001). No significant difference was identified in the rate of admission to the neonatal intensive care unit (NICU; 11 [52.4%] vs. 10 [47.6%], p = 0.8) or NICU length of stay between GA and RA (4 [3, 14] vs. 4.5 [3, 11], p = 0.9). Conclusion Our data indicate that even with prolonged IADT, favorable neonatal outcomes are seen with both GA and RA, in contrast with previous studies performed decades ago. Key Points Improving cesarean delivery safety, including the safety of anesthesia, is of paramount importance. Reappraisal of historical outcomes is warranted as advances in the medical field unfold. Favorable neonatal outcomes are seen with both general and regional anesthesia. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to evaluate the temporal trend of novel coronavirus disease 2019 (COVID-19) symptoms and severity of clinical outcomes among pregnant women over a calendar year in the State of Maryland and compare clinical outcomes between different ethnic and racial groups. Study Design We conducted a retrospective, multicenter observational study of the temporal trend of COVID-19 clinical presentation during pregnancy in the State of Maryland. We reviewed consecutive charts of adult pregnant females, aged 18 to 55 years, with laboratory-confirmed severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection between March 1, 2020, and February 28, 2021, and managed within the University of Maryland Medical System and Johns Hopkins Medicine. We excluded cases with insufficient data for assessing the COVID-19 diagnosis, pregnancy status, or clinical outcomes. We evaluated the evolution of COVID-19 symptoms at the time of presentation. Also, we compared COVID-19 infection rate, hospitalization rate, oxygen use, and intensive care unit (ICU) admission rates between different ethnic and racial groups. Results We included 595 pregnant women with laboratory-confirmed COVID-19 over the study period. The prevalence of respiratory and systemic symptoms decreased over time with incidence rate ratios (IRRs) of 0.91 per month (95% confidence interval [CI]: 0.88–0.95) and 0.87 per month (95% CI: 0.83–0.95), respectively. The prevalence of hospitalization, O 2 requirement, and ICU admission decreased over time with IRRs of 0.86 per month (95% CI: 0.82–0.91), 0.91 per month (95% CI: 0.84–0.98), and 0.70 per month (95% CI: 0.57–0.85), respectively. The Hispanic and Black populations had a higher COVID-19 infection rate and hospitalization rate than the non-Hispanic White population (p = 0.004, < 0.001, and < 0.001, respectively). Conclusion Understanding the concepts of viral evolution could potentially help the fight against pandemics like COVID-19. Moreover, this might improve the knowledge of how pandemics affect disadvantaged populations and help close the gap in health care inequities. Key Points A trade-off between virulence and transmissibility is determined by the natural selection of viruses. Understanding the concepts of viral evolution can help the fight against pandemics like COVID-19. Evolution of SARS-CoV-2 over time resulted in decreased virulence and increased infectivity. [ABSTRACT FROM AUTHOR]

Introduction: Prone positioning has been widely utilized in ARDS management before and during the COVID-19 pandemic due to its demonstrated mortality benefits. In pregnancy, proning requires careful attention to often overlooked physiologic changes in pregnancy and additional technical challenges accompanying a gravid abdomen. The purpose of this manuscript is to demonstrate a proning technique that was successfully used at our institution to avoid premature delivery of the fetus while improving maternal outcomes. All technical challenges are addressed in the instructional videos using a pregnant model with twin gestation at 32 weeks. Methods: We reviewed all the patients’ charts with positive SARS-CoV-2 from March 2020 until July 2020 and identified those who developed ARDS. Subsequently, we identified four patients that were proned during the antepartum period. We described their clinical course, including the change in ventilatory parameters in relationship with proning timing. Stepwise instructions for self-proning and proning in mechanically ventilated patients are illustrated in video format. Results: During the study period, we identified 100 pregnant patients with SARS-CoV-2 infection. Mechanical ventilation was required in 8 of these patients. In four cases, proning was performed during the antepartum period. We were able to improve the P/F ratio while decreasing FiO2 and avoiding iatrogenic preterm delivery. Except for one case, where the patient self-extubated and required emergent delivery, all patients were successfully extubated, followed for prenatal care, and delivered for usual obstetric indications. Conclusion: Proning remains a well-proven intervention in ARDS and should be considered in pregnant women when indicated. We recognize that proning might not be effective in all cases. However, proning positioning is an option to improve oxygenation in patients with severe hypoxemia when the next consideration is delivery of a premature infant or maternal cannulation for extracorporeal membrane oxygenation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether the implementation of our surgical approach, referred to in the text as Linear Cutter Vessel Sealing System (LCVSS) technique, will improve perioperative outcomes in patients with placenta accreta spectrum (PAS), specifically by reducing blood loss and blood transfusion rates at the time of cesarean hysterectomy (C-HYST). The LCVSS technique integrates the following: (1) hysterotomy performed using the Linear Cutter, (2) no placental manipulation, (3) cauterization of anatomically prominent vascular anastomosis using the handheld vessel sealing system, and (4) completion of bladder dissection until the cervico-vaginal junction before ligation and division of uterine arteries. Materials and methods: This is a retrospective cohort study that analyzed perioperative outcomes in patients undergoing C-HYST for PAS at a tertiary care center from 1 July 2014 to 1 December 2019. Comparisons were performed between cases managed with the use of the LCVSS technique (designated as LCVSS cohort) and those managed without the use of the LCVSS technique (designated as no technique cohort). The primary outcomes were cumulative blood loss (CBL) and total perioperative blood transfusion of ≥4 and ≥6 units of PRBCs. The secondary outcomes were intra- and postoperative complications. Continuous and categorical variables were compared according to the sample size and distribution. Binary logistic regression analysis was performed to predict confounders for blood transfusion of ≥4 units of PRBCs. Results: A total of 69 prenatally diagnosed PAS cases underwent C-HYST at the time of delivery. Forty-four cases that were performed using the LCVSS technique comprised the LCVSS cohort. The remaining 25 were marked as no technique cohort. CBL was significantly lower in the LCVSS cohort (1124"ml [300-4100] vs 3500"ml [650-10600]; p"<".001). The rate of urinary tract injuries was similar (16%). The rate of postoperative complications and reoperation for intra-abdominal bleeding were lower but not significantly different in LCVSS cohort (9 vs 20% and 0 vs 8%, p"=".26 and p"=".12, respectively). There were no differences in neonatal outcomes. Conclusion: Implementation of this advanced surgical approach for PAS management resulted in reduced blood loss and blood transfusion rates in comparison with no technique cohort. [ABSTRACT FROM AUTHOR]

In the last two decades, the world faced three epidemics caused by novel coronaviruses, namely, SARS-CoV in 2002, MERS-CoV in 2012, and the ongoing SARS-CoV-2 that started in late 2019. Despite a growing understanding of SARS-CoV-2 virology, epidemiology, and clinical management strategies, other aspects, such as mode of delivery, vertical transmission, and maternal bonding, remain controversial. The question we faced upon the decision to separate the neonates of SARS-CoV-2 positive mother is whether we follow the principle of "do no harm"? This is a quality improvement project that analyzed all cases of SARS-CoV-2 positive pregnancies that delivered at a major health care system from March 1, 2020 to June, 1 2020. The article was prepared following Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guidelines. Data were prospectively collected and entered into the Research Electronic Data Capture (REDCap). Maternal bonding was defined by events such as rooming-in, skin to skin contact (STSC), and breastfeeding. Descriptive analysis was performed using the same software platform. We compared neonatal transmission rates between those neonates who experienced bonding versus those who were separated. A total of 1989 women were screened for SARS-CoV-2, from which 86 tested positive. Out of 31 analyzed pregnancies, five women (16%) were admitted to ICU and required mechanical ventilation. From the remaining 26 (84%), 17 (65%) opted for rooming-in, 12 (46%) for STSC, and 16 (61%) fed the infants with breastmilk (11 direct breastfeedings and five pumped the breast milk). All neonatal tests for SARS-CoV-2 returned negative. Our results have illustrated that maternal bonding appears safe in neonates born to mothers that are SARS-CoV-2 positive. [ABSTRACT FROM AUTHOR]

Upper limb trauma cases vary from simple to high energy impactful injuries, with different etiologies; situations which frequently require unique, demanding and challenging endeavors in order to obtain the most favorable outcome. Experience, good decision-making and knowledge of functional goals are mandatory in order to elaborate a therapeutic plan and execute it accordingly. Although cases differ in nature and prognosis, respecting a set of therapeutic principles whilst dealing with either simple or complex cases, will enhance patient outcome and give the surgeon the confidence to tackle any kind of upper limb trauma. After clearing out vital threat, the emergency surgery represents the first threshold in achieving and restoring normal function and biomechanics, mostly in young and labor active patients, with the mindset to salvage as much tissue as possible, with a thorough debridement and step-by-step approach to different types of tissues. Secondary surgery and reconstructive surgery can be planned timely, with prior discussion with both the therapist and the patient in order to enhance patient’s upper limb function and aesthetic and ensure social reintegration. [ABSTRACT FROM AUTHOR]

To evaluate the impact of an Enhanced Recovery After Cesarean (ERAC) protocol on the post-cesarean recovery experience using a validated ten-item questionnaire (ERAC-Q). This is a prospective cohort study of patients completing ERAC quality-of-life questionnaires (ERAC-Q) during inpatient recovery after cesarean delivery (CD) between October 2019 and September 2020, before and after the implementation of our ERAC protocol. Patients with non-Pfannenstiel incision, ICU admission, massive transfusion, bowel injury, existing chronic pain disorders, acute postpartum depression, or neonatal demise were excluded. The ERAC-Q was administered on postoperative day one and day of discharge to the pre- and post-ERAC implementation cohorts, rating aspects of their recovery experience on a scale of 0 (best) to 10 (worst). The primary outcome was ERAC-Q scores. Statistical analysis was performed with SAS software. There were 196 and 112 patients in the pre- and post-ERAC cohorts, respectively. The post-ERAC group reported significantly lower total ERAC-Q scores compared to the pre-ERAC group, reflecting fewer adverse symptoms and greater perceived recovery on postoperative day one (1.6 [0.7, 2.8] vs. 2.7 [1.6, 4.3]) and day of discharge (0.8 [0.3, 1.5] vs. 1.4 [0.7, 2.2]) (p<0.001). ERAC-Q responses did not predict the time to achieve objective postoperative milestones. However, worse ERAC-Q pain and total scores were associated with higher inpatient opiate use. ERAC implementation positively impacts patient recovery experience. The administration of ERAC-Q can provide real-time feedback on patient-perceived recovery quality and how healthcare protocol changes may impact their experience. [ABSTRACT FROM AUTHOR]

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the agent responsible for coronavirus disease 2019 (COVID-19), continues to have a devastating impact on healthcare systems worldwide, and many questions remain unanswered. The effect of COVID-19 on the pregnant population is widely debated, and the unique risks in pregnancy have not yet been elucidated. What has been established, however, is the recommendation for healthcare workers to use personal protective equipment (PPE) for both contact and airborne precautions to prevent transmission of the pathogen—adding another barrier to care for vulnerable populations. We report a case of a young woman from Haiti during her first pregnancy, who was admitted to the antepartum service at 22 weeks of gestation with preterm premature rupture of membranes (PPROM) and remained admitted in isolation, though asymptomatic, for over six weeks due to persistent positive SARS-CoV-2 testing. Our case highlights the unique barriers to care that COVID-19 poses to antepartum patients, particularly in the setting of pregnant women with persistent positive testing. [ABSTRACT FROM AUTHOR]

Introduction: Studies indicate a very low rate of SARS-CoV-2 detection in the placenta or occasionally a low rate of vertical transmission in COVID-19 pregnancy. SARS-CoV-2 Delta variant has become a dominant strain over the world and possesses higher infectivity due to mutations in its spike receptor-binding motif.Case Presentation: To determine whether SARS-CoV-2 Delta variant has increased potential for placenta infection and vertical transmission, we analyzed SARS-CoV-2 infection in the placenta, umbilical cord, and fetal membrane from a case that unvaccinated mother and her neonate were COVID-19 positive. A 35-year-old primigravida with COVID-19 underwent an emergent cesarean delivery due to placental abruption in the setting of premature rupture of membranes. The neonate tested positive for SARS-CoV-2 within the first 24 hours, and then again on days of life 2, 6, 13, and 21. The placenta exhibited intervillositis, increased fibrin deposition, and syncytiotrophoblast necrosis. Sequencing of viral RNA from fixed placental tissue revealed SAR-CoV-2 B.1.167.2 (Delta) variant. Both spike protein and viral RNA were abundantly present in syncytiotrophoblasts, cytotrophoblasts, umbilical cord vascular endothelium, and fetal membranes.Discussion/conclusion: We report with strong probability the first SARS-CoV-2 Delta variant transplacental transmission. Placental cells exhibited extensive apoptosis, senescence, and ferroptosis after SARS-CoV-2 Delta infection. [ABSTRACT FROM AUTHOR]

Tumor nerve compressions in the upper limb are relatively rare, usually involving ganglion cysts and benign tumors. We present a case series of five patients with peripheral nerve compression in the upper limb due to tumor or cystic masses- ulnar nerve compression in the Guyon’s tunnel due to a ganglion cyst, large median nerve schwannoma compressing anterior interosseous nerve and median nerve, voluminous lipoma compressing median nerve in the proximal forearm, superficial branch of radial nerve compression by a synovial cyst and elbow region lipoma compressing radial nerve. In the beginning, those benign lesions are asymptomatic but, as they continue to grow adjacent to a peripheral nerve clinical manifestations appear progressively as compressive neuropathies. After a preoperative imagistic analysis, tumor resection with careful dissection, in order to preserve the neurovascular structures, is the elective surgical procedure in order to obtain an optimal functional recovery. [ABSTRACT FROM AUTHOR]

Traditional reconstructive methods can fail in achieving a good functional and aesthetic outcome in patients with extensive defects, involving multiple layers of functional tissue, often necessitating numerous, and staged, surgical interventions with unsatisfactory results. Transplantation of vascularized composite allografts(VCA) opened a new, promising era in reconstructive surgery, offering a unique restorative opportunity for those complex situations. VCA transplantation have been performed for life enhancing indications in a selected group of patients under institutional protocols. The controversy of those procedures, having functional benefits and the goal of quality of life restoration, rather than life-saving indications, resides to the life-long required immunosuppressive therapy, with implicit side effects. In order to extend VCA indications, translational studies are needed to develop less toxic immunosuppressive regimens and possibly achieve donor-specific tolerance, the ideal situation in transplantation. Extensively burned patients, especially of the face and cervical region, having severe mutilations and also unilateral or bilateral hand amputations, like after high voltage electric injuries, present functional and aesthetic deficits, with devastating impact on their quality of life and, constituting potential candidates for receiving a vascularized composite allotransplantation, as the only reconstructive solution. With this paper, we discuss the indications and limits, from clinical and immunological perspectives, of the consideration of VCA as surgical option for burn patients with complex tissue defects, impossible to approach by conventional techniques. [ABSTRACT FROM AUTHOR]

Traditional reconstructive methods can fail in achieving a good functional and aesthetic outcome in patients with extensive defects, involving multiple layers of functional tissue, often necessitating numerous, and staged, surgical interventions with unsatisfactory results. Transplantation of vascularized composite allografts(VCA) opened a new, promising era in reconstructive surgery, offering a unique restorative opportunity for those complex situations. VCA transplantation have been performed for life enhancing indications in a selected group of patients under institutional protocols. The controversy of those procedures, having functional benefi ts and the goal of quality of life restoration, rather than life-saving indications, resides to the life-long required immunosuppressive therapy, with implicit side effects. In order to extend VCA indications, translational studies are needed to develop less toxic immunosuppressive regimens and possibly achieve donor-specifi c tolerance, the ideal situation in transplantation. Extensively burned patients, especially of the face and cervical region, having severe mutilations and also unilateral or bilateral hand amputations, like after high voltage electric injuries, present functional and aesthetic defi cits, with devastating impact on their quality of life and, constituting potential candidates for receiving a vascularized composite allotransplantation, as the only reconstructive solution. With this paper, we discuss the indications and limits, from clinical and immunological perspectives, of the consideration of VCA as surgical option for burn patients with complex tissue defects, impossible to approach by conventional techniques. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Available data on the association between COVID-19 and adverse pregnancy outcomes is limited by ascertainment bias. Our objective was to assess the impact of COVID-19 on pregnancy outcomes in a propensity score matching (PSM) study. This allows for balancing of observed baseline covariates and decreases the effect of confounding factors. METHODS: We conducted a retrospective, multicenter, case-control study to understand the association between COVID-19 and pregnancy outcomes. We reviewed all consecutive charts of adult females aged 18–45 years with SARS-CoV-2 infection between March 1, 2020, and August 31, 2020. Cases were patients diagnosed with COVID-19 during pregnancy (COVID+), whereas controls were pregnant patients who tested negative for COVID-19 (COVID–). We excluded cases with multiple gestation or incomplete data. PSM was performed using age, race/ethnicity, body mass index, and past medical history. The primary outcome was a compound score of pregnancy complications (pregnancy loss, neonatal demise, fetal growth restriction, hypertensive disorders of pregnancy, preterm premature rupture of membranes, preterm delivery, and placental abruption). Analyses were performed with SAS software. RESULTS: A total of 2,474 patients were identified, of which 2,374 were COVID– and 100 COVID+. There was a trend toward higher rate of adverse pregnancy outcomes in the COVID+ group (48 [48%] versus 917 [38.7%], P =.06). The results remained unchanged after optimal one-to-four PSM was applied (48 [48%] versus 151 [37.8%], P =.06). CONCLUSION: COVID-19 in pregnancy appears to be associated with an increased risk for adverse pregnancy outcomes. Although our study had a trend toward statistical significance, further research with a large sample size is required. [ABSTRACT FROM AUTHOR]