Sleep disturbances are common in pregnancy, and sleep disorders may worsen or present de novo in the course of gestation. Managing a pregnant patient is complicated by the risk of teratogenicity, pharmacokinetic changes, and the dynamic nature of pregnancy. Although nonpharmacologic interventions are likely safest, they are often ineffective, and a patient is left dealing with frustrations of the sleep disturbance, as well as the negative outcomes of poor sleep in pregnancy. As with any other condition in pregnancy, management requires an understanding of pregnancy physiology, knowledge of the impact of a given condition on pregnancy or fetal and neonatal outcomes, and an ability to weigh the risk of the exposure to an untreated, or poorly treated condition, against the risk of a given drug. In partnership with the pregnant patient or couple, options for therapy should be reviewed in the context of the impact of the condition on pregnancy and offspring outcomes, while understanding that data (positive or negative) on the impact of therapy on perinatal outcomes are lacking. This article reviews the epidemiology of sleep disorders in pregnancy, general principles of prescribing in pregnancy and lactation, and safety surrounding therapeutic options in pregnancy.CHEST 2020; 157(1): [184][185][186][187][188][189][190][191][192][193][194][195][196][197]

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Background Medical podcasts have the potential to educate residents and fellows in specialized or uncommon disciplines, but the acceptability and benefits of educational podcasts are unclear. Objective We compared knowledge acquisition and engagement of audio-only (podcast) versus written curricular formats and assessed podcast feasibility and uptake for teaching obstetrical neurology to residents and fellows. Methods Key concepts in obstetrical neurology were developed into parallel case-based modules: written reviews and podcasts interwove patient and expert voices with narration. In 2017, we tested this curriculum among 60 volunteer residents and fellows in obstetrics and gynecology, neurology, emergency medicine, internal medicine, and family medicine training programs at a single institution. Participants took content-based pretests, were randomized, and then completed written (n = 32) or podcast (n = 28) modules, and finally, completed posttests and feedback questionnaires. Results Among all participants, there was an increase in immediate posttest scores compared with pretest scores (46 of 60, 77% ± 17% pretest versus 56 of 60, 93% ± 10% posttest, P < .05), with participants in the podcast and written groups performing equally well. However, listeners rated the podcasts somewhat higher than written materials in the areas of maintaining interest, enjoyability, entertaining, and desire for wider use. Conclusions Written and podcast curricula improved immediate knowledge similarly, but the narrative-style podcasts were perceived as more enjoyable by residents and fellows from several specialties, suggesting narrative podcasting can be an engaging and feasible educational alternative for trainees to acquire information.

Massive perivillous fibrinoid deposition is a rare placental pathology associated with significant adverse pregnancy outcome and can recur. We provide a detailed case review of a woman through 10 of her pregnancies, including 8 consecutive pregnancy losses and 2 live births. We also conducted a retrospective chart review of all massive perivillous fibrinoid deposition placenta specimens at our institution over an eight-year period. A total of 42 cases of massive perivillous fibrinoid deposition were identified from 2007 to 2015, yielding an incidence of 0.16%. Recurrence was seen in subsequent pregnancy in eight out of nine (88.9%) cases with more than one specimen. The clinical characteristics, perinatal outcomes and α-feto protein level of the 42 cases are presented. Also, presented is a review of the literature discussing placental pathology, pathogenetic mechanisms and management of this condition.

Sepsis accounts for up to 28% of all maternal deaths. Prompt, appropriate treatment improves maternal and fetal morbidity and mortality. To date, there are no validated tools for identification of sepsis in pregnant women, and tools used in the general population tend to overestimate mortality. Once identified, management of pregnancy-associated sepsis is goal-directed, but because of the lack of studies of sepsis management in pregnancy, it must be assumed that modifications need to be made on the basis of the physiologic changes of pregnancy. Key to management is early fluid resuscitation and early initiation of appropriate antimicrobial therapy directed toward the likely source of infection or, if the source is unknown, empiric broad-spectrum therapy. Efforts directed at identifying the source of infection and appropriate source control measures are critical. Development of an illness severity scoring system and treatment algorithms validated in pregnant women needs to be a research priority.

CT, computed tomography. Data are n (%), mean6SD, or median (interquartile range). * Left ventricular fractional shortening5(left ventricular end diastolic dimension2left ventricular end systolic dimension)3100/(left ventricular end diastolic dimension).

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BackgroundCardiovascular severe maternal morbidity (CSMM) is rising and has become the leading cause of maternal mortality. Research using administrative data sets may allow for better understanding of this critical group of diseases.ObjectiveTo validate a composite variable of CSMM for use in epidemiologic studies.MethodsWe analysed delivery hospitalisations at an obstetric teaching hospital from 2007 to 2017. We utilised a subset of indicators developed by the Centers for Disease Control and Prevention based on ICD codes to form the composite variable for CSMM. Two expert clinicians manually reviewed all qualifying events using a standardised tool to determine whether these represented true CSMM events. Additionally, we estimated the number of CSMM cases among delivery hospitalisations without qualifying ICD codes by manually reviewing all hospitalisations with severe preeclampsia, a population at high risk of CSMM, and a random sample of 1000 hospitalisations without severe preeclampsia. We estimated validity of the composite variable.ResultsAmong 91 355 admissions for delivery, we captured 113 potential CSMM cases using qualifying ICD codes. Of these, 65 (57.5%) were true CSMM cases. Indicators for acute myocardial infarction, cardiac arrest, and cardioversion had the highest true‐positive rates (100% for all). We found an additional 70 CSMM cases in the 2102 admissions with severe preeclampsia and a single CSMM case in the random sample. Assuming a rate of 1 CSMM case per 1000 deliveries in the remaining cohort, the composite variable had a positive predictive value of 57.5% (95% CI 47,9, 66.8), a negative predictive value of 99.8% (95% CI 99.8, 99.9), a sensitivity of 29.0% (95% CI 23.2, 35.4), and a specificity of 100% (95% CI 99.9, 100.0).ConclusionA novel composite variable for CSMM had reasonable PPV but limited sensitivity. This composite variable may enable epidemiologic studies geared towards reducing maternal morbidity and mortality.