Risk Assessment and Treatment Guide for Obstetric Thromboprophylaxis: Comprehensive Review of Current Guidelines.

OBJECTIVE: Currently, there are numerous recommendations and often conflicting guidance provided for venous thromboembolism (VTE) prophylaxis in pregnancy. Our objective was to create a one-page risk assessment and treatment guide based on a review of the most recent and evidence-based publications on this subject to simplify the approach and allow all obstetric patients to be properly assessed for risk of VTE and treated if indicated. STUDY DESIGN: We identified studies by completing a PubMed and MEDLINE search from January of 1980 through March 2017 with articles utilizing a specific combination of the selected general keywords (thrombophilia, pregnancy, VTE, prophylaxis, hypercoagulability, antepartum, postpartum, risk, etc.). We completed the search at the saturation point, meaning that all combinations of the relevant words were directing us to the same articles. After collecting the relevant sources and reviewing them, a total of 10 articles/guidelines were selected for inclusion in the analysis. RESULTS: We outlined every recommendation in the identified articles and guidelines and included any recommendation that was cited in at least three different sources in the final guide. We used American College of Obstetrics and Gynecology recommendations as the base for screening and dosing guidelines and utilized known and published absolute risk values and odds ratios to stratify risk factors. This stratification was used for both antepartum and postpartum recommendations and a single-page guideline was created. CONCLUSION: This compilation of guidelines integrates the complicated topic into a simple comprehensive guide where women can be identified early and accurately for appropriate VTE prophylaxis to protect them during and after pregnancy.

Objective Evaluation of the Effects of Deployment on Laparoscopic Skills: The Simulation and Deployment Laparoscopic Skills Study.

OBJECTIVE: To assess the effects of deployment on basic laparoscopic skills of general surgeons and obstetrics/gynecology (OB/GYN) physicians. METHODS: This was a prospective 10-site study. Active duty Army OB/GYN and general surgery physicians scheduled to deploy were invited to participate. Before deployment, they performed fundamentals of laparoscopic surgery (FLS) tasks and specialty-specific procedures on a virtual reality laparoscopic simulator. Upon returning, physicians repeated the same evaluations. Questions about perceived comfort with laparoscopic procedures were asked before and after deployment. Statistical analysis included paired t tests for continuous variables and nonparametric for ordinal data with a p value of <0.05 considered significant. RESULTS: 121 deploying providers were invited to participate; 35 agreed and 29 completed the predeployment skills assessment. After deployment, 15 providers had postassessment evaluation data collected, and their results were used for analysis. Though physicians reported a decrease in their perception of preparedness for advanced laparoscopic procedures and complications, there was no decrement in their performance of FLS tasks or the basic laparoscopic procedures. CONCLUSION: Time away from regular clinical practice during deployments did not significantly affect surgeons' performance as measured by a virtual reality laparoscopic simulator. Additional study on effects on advanced procedures should be considered.

Self-Reported Changes in Comfort Level With Basic OB/GYN Procedures After Deployment.

OBJECTIVE: To assess the specialty-specific procedures and clinical encounters U.S. Army obstetrician/gynecologist (OB/GYN) providers felt were affected by deployment and identify skills and areas that may benefit from postdeployment training. METHODS: Active duty Army OB/GYN physicians were invited to participate in an anonymous web-based survey to rate their comfort level and experience performing specialty-specific procedures before and after military deployment. Physicians rated their comfort level on a 5-point Likert scale (1 = very uncomfortable to 5 = completely comfortable). Statistical analysis included Pearson χ(2) and McNemar's χ(2) with a p value of <0.05 considered significant. RESULTS: Of the 100 physicians eligible to complete the survey, 66 responded (response rate = 66%). Their responses demonstrated a statistically significant perception of decline in their comfort level with nearly every obstetric and gynecologic procedure and clinical encounter evaluated. CONCLUSION: Time away from regular clinical practice during deployment results in providers feeling less comfortable with many common OB/GYN procedures and clinical situations. Although these results are not a measure of actual performance, this information helps define targets to focus refresher training for providers who leave their normal scope of practice for deployment. These findings apply to civilian providers leaving practice for other reasons as well.

Perceived clinical skill degradation of Army family physicians after deployment.

BACKGROUND AND OBJECTIVES: Deployment away from regular clinical practice is necessary for Army family physicians, but no current information identifies specific procedures or clinical encounters where they feel less comfortable after deployment. This study identifies specific clinical areas and amount of perceived degradation in skills after deployment to combat zones. METHODS: Active duty Army family physicians were invited to participate in a web-based and anonymous survey rating comfort level performing clinical encounters or procedures prior to and after military deployment. Participants rated their comfort level using a 5-point Likert scale. The analysis included descriptive statistics about each physician's deployment history. The composite data for each clinical encounter or procedure were analyzed with McNemar's Chi-Square test. RESULTS: A total of 179 eligible Army family physicians (54% of total) fully completed the instrument, with 39% deploying once and 10% deploying more than five times in their career. Deployments ranged from 1 to >24 months, with 42% having a last deployment of 12 months duration. With statistical significance, providers reported being less comfortable post-deployment with managing first-trimester bleeding, ACLS codes, acute abdominal pain, asthma exacerbations, central line placement, chest pain, COPD exacerbations, CVA/hypertensive emergency, lumbar puncture, neonatal fevers, pediatric codes, sepsis/septic shock, and vaginal delivery. These physicians reported statistically significant increased comfort with the care of major trauma after deployment. CONCLUSIONS: Family physicians deploying to support combat operations feel less comfortable with critical clinical skills across the spectrum of care. Refresher training could be provided with standardized approach to these needs with a goal of maintaining full scope primary care providers.

Improving knowledge about prenatal screening options: can group education make a difference?

OBJECTIVE: To determine if the addition of group education regarding maternal serum screening and diagnostic testing for aneuploidy and neural tube defects improves patient knowledge and affects the uptake of testing compared to individual education alone. METHOD: We conducted a prospective study of 443 obstetric patients to assess knowledge of prenatal testing options based on individual provider counseling (n = 331) or provider counseling with supplemental group education (n = 112). We used a chi-square test to compare the number of correct survey answers between the two groups. RESULTS: There was no difference in baseline knowledge. Patients receiving group education showed a statistically significant improvement in knowledge. After initiation of group education, the uptake of maternal serum screening declined while the uptake of amniocentesis remained unchanged. CONCLUSION: Group education in addition to individual counseling to discuss prenatal testing options appears to be effective in improving knowledge compared to individual provider counseling alone. Improved knowledge may affect uptake of prenatal screening tests due to more informed decision making.

Severe thrombocytopenia after contrast infusion in pregnancy.

BACKGROUND: Intravenous contrast-induced thrombocytopenia is a rare but potentially life-threatening complication in pregnancy. CASE: A 22-year-old woman, gravida 2 para 1, at 33 2/7 weeks of gestation presented with chest pain, shortness of breath, and tachycardia. A computed tomography angiogram was pursued to evaluate for pulmonary embolus. During contrast infusion the woman experienced facial flushing, throat tightening, and worsening dyspnea. Her platelet count was noted to decrease precipitously to 4,000/microliter several hours after the imaging study. With medical management and observation, the woman's platelet count steadily recovered without further exacerbation of thrombocytopenia during gestation. CONCLUSION: Prompt recognition and therapy for intravenous contrast-induced thrombocytopenia during pregnancy are essential to optimize maternal-fetal outcome.

Perceived effects of deployments on surgeon and physician skills in the US Army Medical Department.

BACKGROUND: The military health care system is unique in that almost every physician deploys for ≥6 months to a combat or far-forward setting. The aim of this study was to determine the perceived changes in clinical skills in this deployed population. METHODS: A survey was sent out to all specialty consultants to the Army Surgeon General to query active duty staff physicians in their specialty areas who have deployment experience in August 2007. Questions concerning specialty, length of deployment, perceived changes in skills, skill use while deployed, and time to get back to baseline clinically after deployment were asked. RESULTS: Surveys were sent to approximately 1,500 physicians, of which 673 were usable, for a 45% response rate. More than 70% of respondents were deployed for >6 months. Fifty-nine percent reported that they were used in their specialties <40% of the time deployed. Surgeons rated surgical skills before and after deployment as 6.0 ± 1.0 and 4.0 ± 1.5, respectively (on a 7-point, Likert-type scale ranging from 1 = worst to 7 = best; P = .001). Most felt that the time needed to get back to predeployment skill levels was 1 to 6 months. CONCLUSIONS: There was significant perceived degradation in both the surgical and clinical skills of those deploying for >6 months, and the degradation was correlated with the length of time deployed. Most surgical specialists felt that it took them 3 to 6 months to return to their clinical and surgical performance baseline upon returning from a deployment and that 6 months was the most amount of time they could be deployed without a significant decrement in skills.

Evaluation of force applied during deliveries complicated by shoulder dystocia using simulation.

OBJECTIVE: We sought to objectively evaluate the amount of force applied during deliveries complicated by shoulder dystocia among different providers. STUDY DESIGN: Providers who do deliveries at our institution were approached for participation. The simulation exercise used a childbirth mannequin that measures the amount of force the provider applies to the fetal head during delivery. The amount of force applied and information regarding the provider's level of experience, height, weight, and gender was recorded. This study was approved by the hospital institutional review board. RESULTS: A total of 47 providers participated. The mean force applied during each situation was not associated with the provider's experience, height, weight, or gender. CONCLUSION: Provider experience, gender, and body habitus were not associated with the amount of force applied during delivery. We found differences between family medicine and obstetrics/gynecology providers. In addition, a significant number of all providers (19/47, 40%) pulled >100 N.

Effects of deployment on depression screening scores in pregnancy at an army military treatment facility.

OBJECTIVE: To estimate the relationship of positive screening for depression during and after pregnancy with deployment status of the spouse. METHODS: We conducted a retrospective cohort study by reviewing a departmental database of women who completed the Edinburgh Postpartum Depression Scale during pregnancy from 2007 to 2009. Per departmental protocol, screening is offered at the initial obstetric visit, at 28 weeks of gestation, and at 6 weeks postpartum. A score of 14 or higher was considered high risk for having depression, and referral for additional evaluation was recommended. Included in our survey was an additional question that asked if the patient's spouse was currently deployed, returning from deployment, preparing to deploy, or if no deployment was planned. All data were entered into an electronic database and statistical analysis performed comparing Edinburgh Postpartum Depression Scale scores at each time period and deployment status. RESULTS: A total of 3,956 surveys were complete and available for analysis. The risk of a positive screen was more than doubled compared with the control group (no deployment planned) if the spouse was deployed during the 28-32 week visit (4.3% compared with 13.1%, P=.012) or the postpartum period (8.1% compared with 16.2%, P=.006). CONCLUSION: Deployment status has a measurable effect on the prevalence of elevated depression screening scores during pregnancy and in the postpartum period. These findings suggest that more intense monitoring, assessment, and treatment may be warranted for this at-risk population. LEVEL OF EVIDENCE: II.

Improvement in documentation using an electronic checklist for shoulder dystocia deliveries.

OBJECTIVE: To estimate if using an electronic checklist improved the documentation of shoulder dystocias that occurred at our institution. METHODS: A standard checklist of key elements that should be included in the delivery note after a shoulder dystocia was added to the electronic delivery note at our institution. We identified shoulder dystocia deliveries from the department's delivery database for 3 years before and after the checklist was included and compared delivery notes written from these time periods with respect to their content. RESULTS: Forty-six shoulder dystocia deliveries were identified before the checklist being available and 82 after. There was a significant increase noted in the frequency with which several elements were documented after the checklist was implemented including McRoberts maneuver (before checklist 69%, compared with after checklist 90%, P=.003), head-to-body interval (22% compared with 84%, P<.001), which shoulder was anterior (48% compared with 96%, P<.001), and if the neonate was moving its arms after delivery (50% compared with 93%, P<.001). CONCLUSION: Use of a standard checklist for shoulder dystocia in the delivery note resulted in a significant improvement in the documentation of several critical elements. LEVEL OF EVIDENCE: II.

Female soldiers' gynecologic healthcare in Operation Iraqi Freedom: a survey of camps with echelon three facilities.

OBJECTIVE: To describe female soldiers' predeployment gynecologic healthcare screening, common symptoms, and availability of gynecologic care during Operation Iraqi Freedom. METHODS: A questionnaire distributed to U.S. military females presenting to outpatient facilities in level 3 echelon of care between August 2005 and March 2006. RESULTS: Three-hundred ninety seven of 401 surveys (99%) were returned. Ten percent of deployed females (40) had no cervical cytology screening 1 year before deployment and 27% of the 399 required additional treatments for abnormal cervical cytology during deployment. Thirty-five percent reported a gynecologic problem and 44% received care at their base. Irregular bleeding was the most common gynecologic problem. Forty-four percent of women used some form of hormonal contraception; however, 43% changed methods because of unavailability. One-third of soldiers received pre-deployment menses regulation counseling, with 48% of those using continuous oral contraceptive pills for cycle control. CONCLUSION: Gaps remain in predeployment gynecologic screening and counseling. These critical predeployment medical evaluations must remain a priority for all female soldiers to ensure unit readiness.

Improved ultrasonographic estimation of birth weight in macrosomic fetuses by application of a correction factor to the gestation-adjusted projection method.

OBJECTIVE: The purpose of this study was to improve estimated birth weight (EBW) determination in macrosomic fetuses (estimated fetal weight >or=4000 g) by application of a correction factor to the gestation-adjusted projection (GAP) method. METHODS: A review was performed of 411 singleton pregnancies delivered at term. On the basis of ultrasonographic examinations previously performed between 34.0 and 36.9 weeks' gestation, an EBW was calculated for each patient by the GAP method (EBW(GAP)). Using linear regression, a correction factor was developed that minimized the systematic error in the EBW(GAP). The model was then tested retrospectively on a second group of 317 patients. RESULTS: The GAP method systematically overestimated weights of the heavier fetuses in our population. The model we derived showed improved accuracy compared with the GAP method. When applied to a second group of 317 patients, our correction to the GAP method improved specificity for macrosomia from 94.7% to 98.6% (P = .003). Stated differently, the false-positive rate was reduced from 5.3% to 1.4%. The difference in sensitivity for macrosomia was not significant: 41.2% and 35.3% (P = .68). CONCLUSIONS: Application of our model to our study population reduced the number of false-positive results for fetal macrosomia.

Use of a postpartum hemorrhage simulator for instruction and evaluation of residents.

OBJECTIVE: Postpartum hemorrhage is a common and potentially life-threatening obstetric emergency. We sought to create a realistic simulation and validate a standardized grading form to evaluate competency in the management of postpartum hemorrhage. METHODS: Residents from 3 programs underwent training with a postpartum hemorrhage simulation using a standard obstetric birthing model equipped with an inflatable uterus to simulate uterine atony. All simulations were graded by staff physicians with a standardized grading sheet constructed from the current literature on the topic. Residents were expected to recognize the hemorrhage and take appropriate steps, including asking the assistant to administer medications, to correct the problem. Objective and subjective performance was measured with standardized grading sheets, and results were analyzed for reliability using Cronbach α and intraclass correlation coefficients. This project was conducted in accordance with the hospital Institutional Review Board policies at each institution. RESULTS: Forty residents from 3 institutions underwent simulation training. The majority were unable to correct the hemorrhage within 5 minutes and almost half also made at least 1 error, either the dose or route, in the medications they requested. Reliability was evaluated with Cronbach α and demonstrated the grading sheets were valid and had good interrater reliability. DISCUSSION: A simulated postpartum hemorrhage scenario can identify important deficiencies in resident knowledge and performance, with no risk to patients. The standardized grading form worked well for our purposes and was reliable in our study. Further testing is needed to evaluate whether the training improves performance in real-life hemorrhages.

Validation of a tool to measure and promote clinical teamwork.

OBJECTIVE: Human factors and teamwork are major contributors to sentinel events. A major limitation to improving human factors and teamwork is the paucity of objective validated measurement tools. Our goal was to develop a brief tool that could be used to objectively evaluate teamwork in the field during short clinical team simulations and in everyday clinical care. STUDY DESIGN: A pilot validation study. Standardized videos were created demonstrating poor, average, and excellent teamwork among an obstetric team in a common clinical scenario (shoulder dystocia). Three evaluators all trained in Crew Resource Management, and unaware of assigned teamwork level, independently reviewed videos and evaluated teamwork using the Clinical Teamwork Scale (CTS). Statistical analysis included calculation of the Kappa statistic and Kendall coefficient to evaluate agreement and score concordance among raters, and Interclass Correlation Coefficient (ICC) to evaluate interrater reliability. The reliability of the tool was further evaluated by estimating the variance of each component of the tool based on generalizability theory. RESULTS: There was substantial agreement (Kappa 0.78) and score concordance (Kendall coefficient 0.95) among raters, and excellent interrater reliability (interclass correlation coefficient 0.98). The highest percentage of variance in scores among raters was because of rater/item interaction. CONCLUSION: The CTS was developed to efficiently measure key clinical teamwork skills during simulation exercises and in everyday clinical care. It contains 15 questions in 5 clinical teamwork domains (communication, situational awareness, decision-making, role responsibility, and patient friendliness). It is easy to use and has construct validity with median ratings consistently corresponding with the intended teamwork level. The CTS is a brief, straightforward, valid, reliable, and easy-to-use tool to measure key factors in teamwork in simulated and clinical settings.

Post-partum exacerbation of idiopathic pulmonary hemosiderosis.

Idiopathic pulmonary hemosiderosis is a disease causing diffuse alveolar hemorrhage and has rarely been reported in pregnancy. We present the first described case of a post-partum exacerbation after an uncomplicated prenatal course.

Maternal glucose levels after dexamethasone for fetal lung development in twin vs singleton pregnancies.

OBJECTIVE: Betamethasone administration in singleton pregnancies causes maternal hyperglycemia. With the increased risk of glucose intolerance in twin pregnancies, we sought to determine whether maternal hyperglycemia after dexamethasone administration is different in twin vs singleton pregnancies. STUDY DESIGN: Patients with singleton or twin pregnancies admitted between 24 and 34 weeks' gestation with diagnoses requiring steroid administration were approached. Exclusion criteria included diabetes, abnormal glucose tolerance test, infection, or medications known to interfere with glucose metabolism. Patients were NPO for 24 hours and received dexamethasone per protocol. Maternal glucose levels were checked at baseline and then at specified intervals after the initial dose; appropriate statistical analysis was performed. RESULTS: Ten singleton and 9 twin gestations were enrolled. There were no differences in mean maternal or gestational ages. Mean glucose levels were significantly higher in the twin group at 4 hours (114 mg/dL vs 95.6 mg/dL), 8 hours (121.4 mg/dL vs 90.9 mg/dL), and 24 hours (116 mg/dL vs 81 mg/dL) (P < .01 for all). CONCLUSION: Twin pregnancies had higher mean glucose values than singleton pregnancies in the first 24 hours after dexamethasone administration.

Caring for the mother, concentrating on the fetus: intravenous N-acetylcysteine in pregnancy.

Acetaminophen is one of the most common toxicities in pregnancy, thus providers should be aware of treatment options. We use a case presentation to demonstrate the successful use of a 20-hour protocol of intravenous N-acetylcysteine. A 26-year-old woman, gravid3para1102, at an estimated gestational age of 32 weeks 2 days presented with a reported ingestion of 9.75 g of acetaminophen 1.5 hours before arrival. The patient was treated with activated charcoal and intravenous N-acetylcysteine. After brief inpatient admission and management, the patient went on to deliver a full-term infant without further sequelae. Acetaminophen toxicity in pregnancy can be treated successfully with intravenous N-acetylcysteine if used in a timely manner with minimal adverse affects on the fetus and mother.

Patients presenting with birth plans: a case-control study of delivery outcomes.

OBJECTIVE: To determine if labor management and outcomes, specifically epidural use, cesarean section and episiotomy rates, are different between patients presenting with formal birth plans and matched control patients without plans. STUDY DESIGN: Patients admitted in labor with birth plans over a 3.5-year period were identified. Patients were excluded if they required a cesarean section prior to labor or if they delivered outside the institution. For each birth plan patient, 2 age- and parity-matched controls were identified. Birth plans and medical records were reviewed for all patients and delivery outcomes recorded. Statistical analysis was performed utilizing chi2 and Fisher's exact test as appropriate. This study was approved by the institutional review board. RESULTS: Seventy-one patients with birth plans were identified, with complete information available for 68. Sixty-four met the inclusion criteria, and for those 128, matched control patients were identified. There was no difference in the cesarean section rate (17% [11/64] vs. 12% [15/1281, p = 0.30) or episiotomy rate between patients with and without a birth plan (25% [13/53] vs. 23% [26/113], p = 0.83). There was a significant difference in the epidural use rate in patients having a vaginal delivery, with birth plan patients receiving an epidural less often (57% [30/53] vs. 78% [88/1131 p = 0.005). CONCLUSION: As compared to age- and parity-matched controls, patients in our study with birth plans did not have an increased incidence of episiotomy or cesarean section but were less likely to receive epidural anesthesia during labor.

Fetal growth after preterm premature rupture of membranes: is it related to amniotic fluid volume?

OBJECTIVE: Preterm premature rupture of membranes (PPROM) has been associated with an increased rate of fetal growth restriction (FGR). It is unknown whether impairment of fetal growth is mediated through external compression from decreased amniotic fluid volume or (an)other mechanism(s). METHODS: Over a three-year period all patients with singleton pregnancies experiencing PPROM at <37 weeks lasting greater than 10 days, and who underwent serial sonograms to assess fetal biometry after PPROM, were included in the study. Patients were excluded for congenital anomalies or other inherent risk factors for abnormal fetal growth. Fetal abdominal circumference (AC) percentiles were compared between the first sonographic exam after PPROM and the last exam before delivery. The median amniotic fluid index between PPROM and delivery was correlated with the change in AC percentiles while controlling for the duration of PPROM. Statistical analysis utilized one-way analysis of variance and correlation; a p value of <0.05 was considered significant. RESULTS: Twenty-two patients met our inclusion criteria with a mean duration (+/-SD) of PPROM of 58 days (+/-46). The median AFI during the PPROM period was not correlated with the change in AC percentiles after controlling for duration of PPROM (p = 0.49). CONCLUSIONS: The residual amniotic fluid volume after PPROM does not appear to correlate with fetal growth suggesting that the increased rate of FGR in PPROM is not secondary to oligohydramnios. We hypothesize that the intrauterine pathologic processes responsible for membrane rupture may also interfere with fetal growth.

17-Hydroxyprogesterone caproate reverses induced vasoconstriction of the fetoplacental arteries by the thromboxane mimetic U46619.

OBJECTIVE: This study was undertaken to determine whether 17-hydroxyprogesterone caproate (17P) has a vasoactive effect on fetoplacental vasculature. STUDY DESIGN: Two cotyledons were obtained from each of 5 placentas. Baseline perfusion was established with Hanks-based solution. One cotyledon from each pair was then infused with perfusate to which U46619 a thromboxane sympathomimetic had been added. After 30 minutes, a dose of 17P was then administered to each cotyledon. Finally, a vasoconstricting dose of angiotensin II was administered to each cotyledon. Perfusion pressures were recorded throughout. Statistical analysis of pressure change for a single cotyledon was performed by using a paired t test. Statistical analysis of mean perfusion pressure difference between U46619 exposed and nonexposed cotyledons was analyzed by using a students t test. RESULTS: 17P did not significantly alter the perfusion pressure of the control cotyledon. (30.6 +/- 8.3 mm Hg vs 30.1 +/- 7.8 mm Hg P = .48). 17P administration significantly lowered the perfusion pressure of the U46619 preconstricted vessels in comparison with preadministration. (60.1 +/- 13 mm Hg vs 27.3 +/- 7.1 mm Hg P = .03). Both groups of cotyledons responded with vasoconstriction to angiotension II with no difference in response between groups (38.3 +/- 12 mm Hg vs 45.8 +/- 8.2 mm Hg P = .63). CONCLUSION: 17P reverses induced vasoconstriction by U46619 in fetoplacental arteries.