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Hypertensive disorders of pregnancy (HDP) remain one of the major causes of pregnancy-related maternal and fetal morbidity and mortality worldwide. Affected women are also at increased risk for cardiovascular disease later in life, independently of traditional cardiovascular disease risks. Despite the immediate and long-term cardiovascular disease risks, recommendations for diagnosis and treatment of HDP in the United States have changed little, if at all, over past decades, unlike hypertension guidelines for the general population. The reasons for this approach include the question of benefit from normalization of blood pressure treatment for pregnant women, coupled with theoretical concerns for fetal well-being from a reduction in utero-placental perfusion and in utero exposure to antihypertensive medication. This report is based on a review of current literature and includes normal physiological changes in pregnancy that may affect clinical presentation of HDP; HDP epidemiology and the immediate and long-term sequelae of HDP; the pathophysiology of preeclampsia, an HDP commonly associated with proteinuria and increasingly recognized as a heterogeneous disease with different clinical phenotypes and likely distinct pathological mechanisms; a critical overview of current national and international HDP guidelines; emerging evidence that reducing blood pressure treatment goals in pregnancy may reduce maternal severe hypertension without increasing the risk of pregnancy loss, high-level neonatal care, or overall maternal complications; and the increasingly recognized morbidity associated with postpartum hypertension/preeclampsia. Finally, we discuss the future of research in the field and the pressing need to study socioeconomic and biological factors that may contribute to racial and ethnic maternal health care disparities.

Sepsis resulting from maternal infection is the second leading cause of pregnancy-related death. Although screening and initial care of a septic nonpregnant patient is standardized in nonpregnant adults, many challenges exist for early recognition and management of sepsis and septic shock in the obstetric population. Because most sepsis research excludes pregnant patients, there are many challenges that contribute to a lack of standardized approach to maternal sepsis. These challenges include inconsistent early warning sign criteria, lack of validated screening tools, adaptation of bundle components for maternal physiology, delivery considerations, and knowing when to transfer the patient to a higher level of care. To overcome these challenges, reduce variation in care, and improve patient outcomes, it is important for clinicians to plan, practice, and implement a maternal sepsis bundle.

Hemorrhage remains a leading cause of preventable maternal morbidity and mortality worldwide and in the United States. Postpartum hemorrhage is the number one cause of severe morbidity during hospitalization for birth, despite hospital, state, and national initiatives. In addition, studies show that more than 90% of maternal deaths related to obstetric hemorrhage are preventable. This article reviews relevant physiologic changes of pregnancy that may have an impact on hemorrhage management and describes collaborative approaches for management of hemorrhage in this unique population.

Obstetric hemorrhage is a significant cause of perinatal morbidity and mortality that requires prompt recognition and collaborative intervention to prevent poor outcomes. Medical and surgical management goals include controlling bleeding, supporting tissue oxygenation and perfusion, and monitoring for coagulopathies and complications.

Background Women face barriers to obtaining contraception and postpartum care. In a review of Tennessee birth data from 2014, 56% of pregnancies were unintended, 22.7% were short-interval pregnancies, and 57.9% of women who were not intending to get pregnant were not using contraception. Offering long-acting reversible contraceptive methods in the immediate postpartum period allows women who desire these effective methods of contraception to obtain unobstructed access and lower unintended and short-interval pregnancy rates. Objective We report the experience of Tennessee’s perinatal quality collaborative that aimed to address unintended and short-interval pregnancy by increasing access to immediate postpartum long-acting reversible contraception through woman-centered counseling and ensuring reimbursement for devices. This followed a policy change in November 2017 that allowed women who were insured under Tennessee Medicaid programs (TennCare) to achieve access to immediate postpartum long-acting reversible contraception. Study Design From March 2018 to March 2019, 6 hospital sites participated in this statewide quality improvement project that was based on the Institute of Health Improvement Breakout Collaborative model. An evidence-based toolkit was created to provide guidance to the sites. During the year of implementation, monthly huddles occurred, and each facility took a differing amount of time to implement immediate postpartum long-acting reversible contraception. Various statewide and hospital-specific barriers occurred and were overcome throughout the year. Results In total, 2012 long-acting reversible contraception devices were provided to eligible and desiring women. All but 1 institution was able to offer immediate postpartum long-acting reversible contraception by March 2019. Reimbursement was the biggest statewide barrier because rates were low initially but improved through intensive intervention by dedicated team members at each site and the state level. Even with dedicated team members, false assurances were given repeatedly by billing and claims staff. Conclusion A statewide quality improvement project can increase access to immediate postpartum long-acting reversible contraception. Implementation and reimbursement require a dedicated team and coordination with all stakeholders. Verification of reimbursement with leaders at TennCare was essential for project sustainment and facilitated improved reimbursement rates. The impact on unintended and short-interval pregnancies requires long-term future investigation.

"Morbidly adherent placenta" is a term that describes the continuum of placenta accreta, increta, and percreta. The incidence of this type of abnormal placentation has increased significantly over recent decades. The reason is probably multifactorial but, partly, because of factors such as the increasing number of cesarean births. Women at greatest risk are those who have myometrial damage caused by a previous cesarean birth, with either anterior or posterior placenta previa overlying the uterine scar. This condition poses significant risks of morbidity and/or mortality to the pregnant woman and her fetus. A multidisciplinary approach to care throughout pregnancy is essential. This article describes the classification of morbidly adherent placenta, risk factors, methods of diagnosis, potential maternal and fetal complications, and intrapartum clinical management strategies to optimize outcomes.

In 2015, The American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine issued a joint care consensus document intended to develop standards for designations of levels of maternal care that are complimentary to, but distinct from, neonatal levels of care. Level III and Level IV centers must be prepared to provide obstetric intensive care services. Developing a critical care obstetric program is a resource-intensive process that requires a carefully planned strategic effort essential for successful program implementation and sustainability. In this article, a framework utilizing key components of program development is discussed including environment, scope, model, education and training, maternal transport, and unique aspects of care for women who become critically ill during pregnancy or the postpartum period.

Hypertension predisposes the woman and fetus to adverse outcomes during the pregnancy and postpartum. The risk for maternal complications and neonatal morbidity associated with the necessity of preterm birth extends beyond the postpartum and postnatal period. A comprehensive review of the multisystem effects of hypertensive disorders and underlying pathophysiology is provided to support the role of prompt identification of and management of acute complications of hypertension.

Multiple sclerosis is the most common chronic neurologic disability in young adults in their childbearing ages of 20 to 45. The disease affects more women than men, which prompts discussion of pregnancy-related issues in a woman with multiple sclerosis. Preconceptual counseling to discuss the safety of medications in pregnancy, the antepartum period along with what the patient can expect during birth, and the postpartum period will be discussed.

Despite current trends that indicate increasing incidence, acute myocardial infarction remains an uncommon event in pregnant women, yet an important contributor to perinatal morbidity and mortality. Diagnosis and treatments represent a complex challenge during pregnancy, and timeliness and coordination of both are critical. This article reviews the comprehensive, collaborative approach necessary for management of acute myocardial infarction during pregnancy to optimize outcomes for the woman, neonate, and family.

In recent years, there has been an increase in the number of pregnancies complicated by preexisting medical conditions as well as an increase in maternal morbidity and mortality in the United States. The goal of the REACT quality and safety initiative was to reduce maternal morbidity and mortality by providing an interprofessional education program for recognizing and managing the woman who becomes compromised during pregnancy, childbirth, or the puerperium. REACT is an acronym for Recognize, Educate, Activate, Communicate, and Treat early signs and symptoms of maternal compromise. Early signs and symptoms of maternal compromise outlined in the REACT program are similar to recently published recommendations by the American College of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, the Society for Maternal-Fetal Medicine, the Health Resources and Services Administration, the Association of Women's Health, Obstetric and Neonatal Nurses, and the American College of Nurse-Midwives.

UNLABELLED The number of women experiencing myocardial infarction (MI) in pregnancy is relatively negligible. However, the incidence of MI in pregnancy may be on the rise, and maternal and neonatal morbidity and mortality is significant. While diagnosis may be difficult, perinatal nurses must be knowledgeable about the risk factors and various means of treatment for the woman and family experiencing this acute complication of pregnancy. PRECIS MI in pregnancy is rare, but can produce significant maternal and fetal morbidity and mortality. Challenges in diagnosis and treatment of MI in pregnancy are discussed.

Cardiac disease complicates approximately 1% to 3% of pregnancies and is responsible for 10% to 15% of maternal mortality. The number of women of childbearing age with congenital disease is increasing as advances in diagnosis and treatment improve survival rates and overall health, allowing successful pregnancy. Pregnant women with severe cardiac disease or women who experience a cardiac event during pregnancy will require admission and stabilization in an adult critical care unit. This group of patients can prove challenging for the obstetrical staff and the critical care staff because they require blending of the knowledge and skills of 2 highly specialized areas of healthcare. The key component to a comprehensive and organized approach to management that ensures the best possible outcome for the woman is a multidisciplinary team that devises a plan on the basis of the most current information, communicates with each other and the patient effectively, and assumes responsibility for implementation of the plan. The purpose of this article is to review management of the woman with cardiac disease throughout pregnancy.

Following an analysis of the literature, this article reviews the current practices, guidelines, and recommendations for electronic fetal monitoring of the preterm fetus. The physiologic aspects of fetal heart rate control, electronic fetal monitor parameters, and differences between the preterm and term fetus are discussed. Clearly identified is the need for clinical research regarding electronic fetal monitoring of the preterm fetus to establish evidence-based practice guidelines.

Complications during pregnancy heralds a time of increased stress and anxiety for the obstetric patient and her family. Separation from family and home is a common stressor. Incorporating key elements of family-centered care into the policies of the obstetric units that support the health care team to include the family in the plan of care are crucial to family functioning during this difficult time. Assessment of the family and interventions to support family functioning can be structured using the Calgary Family Assessment Model and the Calgary Family Intervention Model. Models that emphasize the family assist the health care team to shift from a plan focused on the medical aspects of care to one that is incorporated to include the woman's family, the base of her support.

Cardiac arrest in pregnancy is a rare event, and the speed of resuscitation response is critical to the outcome of both the mother and the fetus. The management of the unresponsive pregnant woman differs from that of the traditional adult resuscitation. In this article, causes of maternal arrest, management of proper cardiopulmonary arrest in pregnancy, and implementation of perimortem cesarean delivery are discussed.

Electronic fetal heart rate monitoring (EFM) continues to be the primary method utilized for fetal assessment in the United States. Standardization of nomenclature associated with this perinatal technology has evolved over the past 40 years such that the current nomenclature recommended by the National Institute of Child Health and Human Development (NICHD) has been adopted by professional perinatal organizations as the agreed-upon method for professional communication and documentation. Current research continues to focus on the optimal management of intrapartum fetal heart rate tracings. The clinical controversies and challenges related to electronic fetal heart rate monitoring continue to evolve.

Objective: The purpose of this study was to describe the characteristics and outcomes of obstetric patients who require mechanical ventilation. Study design: A review was conducted of obstetric patients who required mechanical ventilation and who received care at our institutions between 1990 and 1998. Data that were collected included maternal demographics, medical condition that necessitated ventilation, delivery status, duration of ventilation, onset of parturition while receiving ventilation, mode of delivery, and maternal and early neonatal morbidity or death. Results: Fifty-one women were identified; 43 women(84%) received care in the labor and delivery setting. The most common admission diagnoses were preeclampsia/eclampsia (44%), labor/preterm labor (14%), and pneumonia (12%). Forty-three women (86%) were undelivered on admission (mean gestational age, 31.6 weeks). Delivery occurred in 37 women (86%) during their admission; 24 women (65%) underwent cesarean delivery. Eleven women began labor while receiving ventilation; 6 were delivered vaginally. The maternal mortality rate was 14% (7/51 women), and the perinatal mortality rate was 11% (4/37 fetuses). Conclusion: A large number of obstetric patients who receive mechanical ventilation will require delivery because of their condition. Centers that care for such women should form a treatment strategy to coordinate obstetric and medical care for this unique population (Am J Obstet Gynecol 2003;188:·549-52.)