Among this cohort, all cases of unsuspected UM at the time of myomectomy or hysterectomy using power morcellation were found to be endometrial carcinoma. Unsuspected UM pathology had an incidence of 1 of 502. Factors associated with increased likelihood of UM or UPM were greater uterine weight and leiomyoma as the surgical indication.

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INTRODUCTION: We implemented a multidisciplinary team approach including prophylactic internal iliac artery (IIA) catheterization to manage patients at high risk of obstetric hemorrhage due to morbidly adherent placentation (MAP). METHODS: We performed an IRB approved, retrospective cohort study of patients (2000-2018) who underwent cesarean hysterectomy for suspected MAP. We compared outcomes before and after the implementation of a multidisciplinary treatment team approach with data from the electronic medical record. RESULTS: There were 12 cases of MAP prior to implementation of the multidisciplinary approach and 24 cases after. IIA catheters were placed preoperatively in 54% of the patients in the multidisciplinary team cohort. There were no differences between groups in mean maternal age (35.2 vs 31.7, P=.14), gravidity (4.4 vs 3.8, P=.51), parity (2.6 vs 1.9, P=.12), or number of prior cesareans (2.5 vs 1.8, P=.09). There were no differences in postoperative length of stay (9.7 vs 4.8 days, P=.09), 30-day readmission (8.3% vs 12.5%, P=.071), 5 minute Apgar <7 (P=.16) or birth weight (P=.88). We observed a significant difference in estimated blood loss (4,558 mL vs 2,215 mL, P=.02) and mean number of units of packed red blood cells transfused (12.75 vs 4.5, P=.03). CONCLUSION: The multidisciplinary approach, specifically the addition of IIA catheterization, results in reduced total blood loss and units of blood transfused. This intervention may be high yield at other centers.

INTRODUCTION: Preterm delivery is associated with a prolonged third stage of labor. Our objective was to evaluate the risk of maternal morbidity associated with duration of the third stage after midtrimester delivery. METHODS: We performed a retrospective cohort study examining vaginal deliveries between 14-24 weeks gestation. Univariate logistic regression was used for statistical analysis. A receiving operating characteristics (ROC) curve was generated to estimate sensitivity and specificity of the composite outcome (PPH, maternal infection, D&C) at 60 minutes. The proportion of undelivered placentas and risk of PPH or infection were plotted over length of third stage of labor. RESULTS: Of 131 participants, 38.2% had a third stage duration greater than or equal to 60 minutes. The risk of PPH was significantly higher among women with a third stage of labor greater than 60 minutes (OR=4.85, 95% CI: 2.11-11.11). This group was also more likely to undergo a post-delivery D&C (OR=18.6, 95% CI: 5.15-67.04). There was no difference in infection risk (OR=0.76, 95% CI: 0.17-3.30). The AUROC was 0.70 (sensitivity 67.0%, specificity 71.0%) for the composite outcome at 60 minutes. The proportion of undelivered placentas demonstrated exponential decay over time, while the risk of PPH and/or infection increased after 90 minutes. CONCLUSION: Maternal risk of PPH and need for post-delivery D&C at the time of midtrimester delivery increases with a third stage of labor greater than 60 minutes. Our data suggest that if the placenta is undelivered after 90 minutes, manual extraction or D&C is indicated to mitigate the increasing risk of maternal morbidity.

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