Recent Updates in Obstetrics and Gynecology
Adnexal Mass Management During Pregnancy
Laparoscopic surgery during pregnancy is safe and effective for managing adnexal masses, with specific technical modifications required to accommodate the gravid uterus. 1
Key Technical Recommendations:
- Port placement must account for fundal height, determined by palpation or ultrasound, with primary port location (umbilical, supra-umbilical, or Palmer's point) chosen according to uterine size 1
- CO2 insufflation pressure of 10-15 mm Hg is appropriate, with initial insufflation of 20-25 mm Hg for port placement, then reduced to 12 mm Hg for operating 1
- Left lateral decubitus or partial left lateral decubitus positioning is mandatory after the first trimester to prevent aortocaval compression 1
- Intraoperative CO2 monitoring by capnography should be used, avoiding both maternal hypo- and hypercapnia 1
- Modern anesthetic agents have not been shown to be teratogenic when used in standard doses, with no evidence of fetal brain developmental effects 1
Perioperative Management:
- Fetal heart rate monitoring by Doppler is sufficient for previable fetuses preoperatively and postoperatively, while simultaneous fetal heart rate tracing and contraction monitoring should be performed before and after surgery for viable fetuses 1
- Routine prophylactic tocolytics are not recommended 1
- Corticosteroid administration should be considered for patients with fetuses at viable premature gestational ages 1
- Prophylactic anti-D immunoglobulin administration is not required 1
Placenta Accreta Spectrum
The American College of Obstetricians and Gynecologists published comprehensive consensus guidelines in 2018 for placenta accreta spectrum, emphasizing the need for specialized multidisciplinary care at centers of excellence. 1
This represents a critical update as placenta accreta spectrum disorders have increased in incidence with rising cesarean delivery rates. The guidelines adopt the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework for clinical recommendations, ensuring evidence-based practice standards. 1
Obstetric Anesthesia Updates
Neuraxial opioids are preferred over intermittent parenteral opioids for postoperative analgesia after cesarean delivery. 1
Labor Analgesia:
- Early administration of neuraxial analgesia (cervical dilation <4-5 cm) is safe and does not adversely affect labor outcomes 1
- Patient-controlled epidural analgesia (PCEA) provides effective pain control during labor 1
- Continuous infusion epidural of local anesthetics with or without opioids is superior to intramuscular or IV opioids for labor analgesia 1
Aspiration Prevention:
- Oral intake of clear liquids is permitted for laboring patients 1
- A fasting period for solids of 6-8 hours is required before elective cesarean delivery 1
- Nonparticulate antacids, H2-receptor antagonists, and metoclopramide should be considered before operative procedures 1
Cardiopulmonary Resuscitation in Pregnancy:
- If maternal circulation is not restored within 4 minutes of cardiac arrest, cesarean delivery should be performed 1
- Uterine displacement (usually left displacement) must be maintained during resuscitation 1
- Basic and advanced life-support equipment must be immediately available in the operative area of labor and delivery units 1
COVID-19 Vaccination in Pregnancy
Pregnant women with COVID-19 have a 3-fold increased risk of ICU admission and 2.9-fold increased risk of invasive ventilation compared to non-pregnant women of reproductive age. 1
Risk Stratification:
- Hispanic or Latina pregnant women have a 2.8-fold increased risk of ICU admission compared to non-pregnant counterparts 1
- Asian, non-Hispanic pregnant women have a 6.6-fold increased risk of ICU admission 1
- Pregnant women aged 35-44 years have a 3.2-fold increased risk of ICU admission and 3.6-fold increased risk of invasive ventilation 1
- Pregnant women with diabetes have a 1.5-fold increased risk of ICU admission 1
These data underscore the importance of COVID-19 vaccination counseling for pregnant women, particularly those with additional risk factors. 1
Levels of Maternal Care
The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine established a four-level maternal care classification system in 2015 to reduce maternal morbidity and mortality. 1
Classification System:
- Level I (Basic Care): Standard prenatal records with regular assessment of maternal and fetal well-being 2
- Level II (Specialty Care): Detailed documentation of maternal-fetal assessments and specialized testing 2
- Level III (Subspecialty Care): Comprehensive documentation of complex maternal medical conditions and management plans 2
- Level IV (Regional Perinatal Health Care Centers): Most comprehensive documentation for the most complex maternal conditions 2
This system addresses the concerning trend that the United States is ranked 60th in the world for maternal mortality, with maternal mortality rates worsening over the past 14 years. 1 The leading causes include chronic conditions affecting women of reproductive age and common obstetric complications such as hemorrhage. 1
Prenatal Care Optimization
ACOG recommends comprehensive prenatal care with visit schedules tailored based on individual risk factors, with approximately 13 visits recommended for low-risk pregnancies in the U.S. 3, 2
Baseline Laboratory Testing:
- Complete blood count, blood type, antibody screen, and urinalysis for all pregnant women 3
- HIV testing and screening for sexually transmitted infections 3
- Papanicolaou (Pap) smear if none documented during the preceding year 3
High-Risk Pregnancy Management:
- For mild to moderate gestational hypertension, blood pressure targets are 110-135/85 mmHg 3
- Safe antihypertensive medications include methyldopa, labetalol, and long-acting nifedipine 3
- ACE inhibitors, angiotensin receptor blockers, direct renin inhibitors, and spironolactone are contraindicated during pregnancy 3
- Serial fetal growth evaluations every 4 weeks for patients with diabetes to monitor for macrosomia 3
Fetal Macrosomia Risks:
- When birth weight exceeds 4,500g, shoulder dystocia risk increases to 9.2-24% in non-diabetic pregnancies and 19.9-50% in diabetic pregnancies 3
Postpartum Care Updates
Patients with gestational hypertension, preeclampsia, or superimposed preeclampsia require blood pressure monitoring for 72 hours in the hospital and for 7-10 days postpartum. 3
Venous Thromboembolism Prevention:
- All women undergoing cesarean delivery must receive sequential compression devices starting before surgery and continuing until fully ambulatory 3
Long-Term Cardiovascular Risk:
- Home blood pressure monitoring is recommended for postpartum patients with hypertensive disorders of pregnancy 3
- Women with hypertensive disorders of pregnancy have increased lifetime cardiovascular risk requiring long-term follow-up 3
- A structured postpartum management timeline includes early and late postpartum visits focusing on blood pressure management, lifestyle counseling, and cardiovascular risk assessment 3
Obstetrical Risks in Cancer Survivors
Female childhood, adolescent, and young adult (CAYA) cancer survivors have increased likelihood of elective or primary cesarean delivery but no increased risk of congenital anomalies in their offspring. 1
Key Findings:
- Increased likelihood of any cesarean delivery in CAYA cancer survivors versus controls, particularly after radiotherapy or chemotherapy 1
- No increased risk of congenital anomalies despite exposure to ovarian-abdominal radiotherapy or alkylating agents (high-quality evidence) 1
- No increased risk of emergency/secondary/urgent cesarean delivery 1
- Increased risk of neonatal resuscitation and admission to special care units 1
These findings provide reassurance regarding offspring outcomes while highlighting the need for appropriate obstetric planning in this population. 1