Preventability of severe acute maternal morbidity.

OBJECTIVE: We sought to assess potential preventability of severe acute maternal morbidity (SAMM) cases admitted to intensive-care units (ICUs) or high-dependency units (HDUs). STUDY DESIGN: Inclusion criteria were admissions to ICUs or HDUs of women who were pregnant or within 42 days of delivery in 4 District Health Board areas (accounting for a third of annual births in New Zealand) during a 17-month period. Cases were reviewed by external multidisciplinary panels using a validated model for assessing preventability. RESULTS: In all, 98 SAMM cases were assessed; 38 (38.8%) cases were deemed potentially preventable, 36 (36.7%) not preventable but improvement in care was needed, and 24 (24.5%) not preventable. The most frequent preventable factors were clinician related: delay or failure in diagnosis or recognition of high-risk status (51%); and delay or inappropriate treatment (70%). The most common causes of preventable severe morbidity were blood loss and septicemia. CONCLUSION: The majority of SAMM cases were potentially preventable or required improvement in care. Themes around substandard care related to delay in diagnosis and treatment for postpartum hemorrhage and septicemia. These findings can inform clinical educational programs and policies to improve maternal outcomes. This study has now been expanded to a national New Zealand audit of all SAMM cases admitted to an ICU/HDU.

Efficacy of mifepristone for cervical priming for second-trimester surgical termination of pregnancy.

OBJECTIVE: To determine whether mifepristone plus misoprostol was as effective as misoprostol with or without laminaria (depending on gestational age) for cervical preparation for second-trimester termination of pregnancy. METHODS: A retrospective cohort study was carried out among women who underwent surgical termination between 14 and 19+6 weeks of pregnancy. Those who received preoperative mifepristone were compared with those who did not. The study group received mifepristone plus misoprostol before dilation and evacuation of the uterus between May 2008 and September 2011. The comparison (non-mifepristone) group received misoprostol with or without laminaria between January 2005 and April 2008. RESULTS: There was no difference between the groups in terms of difficulty of cervical dilation, with an overall relative risk for moderate-difficult dilation in the mifepristone group of 0.91 (95% confidence interval, 0.49-1.68). There was no difference between the groups with regard to complications arising from the procedure. CONCLUSION: Mifepristone is effective for cervical priming prior to second-trimester dilation and evacuation in both multiparous and primiparous women, without an increase in complication rates.

Audit of severe acute maternal morbidity describing reasons for transfer and potential preventability of admissions to ICU.

BACKGROUND: Maternal mortality is a rare event in the developed world. Assessment of severe acute maternal morbidity (SAMM) is therefore an appropriate measure of the quality of maternity care. AIMS: The aim of the study was to conduct a retrospective audit of SAMM cases (pregnant women admitted to a New Zealand Intensive Care Unit) to describe clinical, socio-demographic characteristics, pregnancy outcomes and preventability. METHODS: Severe acute maternal morbidity cases were reviewed by a multidisciplinary panel to determine reasons for admission to ICU, to classify organ-system dysfunction and to determine whether the SAMM case was preventable or not. Inclusion criteria were: admission to ICU between 2005 and 2007 during pregnancy or within 42 days of delivery. RESULTS: Twenty-nine SAMM cases were reviewed, of which 10 (35%) were deemed preventable. The most common reasons for transfer to ICU were: the need for invasive vascular monitoring, hypotension and disseminated intravascular coagulation. The most frequent types of preventable events were: inadequate diagnosis/recognition of high-risk status, inappropriate treatment, communication problems and inadequate documentation. All five SAMM cases of septicaemia were deemed preventable. Of the ten preventable cases, three were Maori (50% of the Maori in total audit), four were Pacific (67% of the Pacific in total audit) and three were women of 'other' ethnicities (17.6%, 3 of 17 in the audit). CONCLUSIONS: An audit of SAMM cases describing reasons for transfer to ICU and preventability is feasible. We recommend that a prospective national SAMM audit process be introduced in New Zealand as a quality of care measure.

Placenta accreta in the first trimester of pregnancy: sonographic findings.

In a case of histologically confirmed placenta increta, decidual protrusion into the myometrium was observed sonographically at 6 weeks' gestation, corresponding to placental protrusion from a disrupted placental-uterine wall interface seen in the later part of the first and second trimester. It is hypothesized that the histologic finding of decidual scarcity in placenta accreta is not a cause but rather an end result of the recruitment of trophoblasts across the decidual-placental interface in a maternal attempt at healing and/or repair in the presence of uterine injury, disease, or malformation that accounts for the associated factors and course of the condition.

Improving image annotation via useful representative feature selection.

This paper describes the automatic assignment of images into classes described by individual keywords provided with the Corel data set. Automatic image annotation technology aims to provide an efficient and effective searching environment for users to query their images more easily, but current image retrieval systems are still not very accurate when assigning images into a large number of keyword classes. Noisy features are the main problem, causing some keywords never to be assigned to their correct images. This paper focuses on improving image classification, first by selection of features to characterise each image, and then the selection of the most suitable feature vectors as training data. A Pixel Density filter (PDfilter) and Information Gain (IG) are proposed to perform these respective tasks. We filter out the noisy features so that groups of images can be represented by their most important values. The experiments use hue, saturation and value (HSV) colour feature space to categorise images according to one of 190 concrete keywords or subsets of these. The study shows that feature selection through the PDfilter and IG can improve the problem of spurious similarity.

Antenatal topographical assessment of placenta accreta with ultrasound.

The major risk of placenta accreta is severe haemorrhage when the placenta is separated at delivery. A case series of placenta accreta with antenatal sonographic topographical assessment of myometrial involvement is presented. The extent of myometrial involvement and the vascularity could be assessed by the observation of the extent of placental-uterine wall interface disruption and the vessels crossing the interface disruption sites. Such assessment results in strategic planning of management of the placenta at delivery with favourable pregnancy outcomes.

Evaluation of sonographic diagnostic criteria for placenta accreta.

PURPOSE: To compare the diagnostic value of reported sonographic criteria for placenta accreta and to develop a composite score system for antenatal evaluation. METHOD: Sixty-six women at risk for placenta accreta were examined for 9 cases of placenta accreta that were confirmed at delivery. The performance of previously reported gray-scale and Doppler sonographic criteria for the diagnosis of placenta accreta was analyzed individually. A composite score system was developed by combining selected sensitive or specific sonographic criteria, and its performance was evaluated. RESULTS: The criteria of obliteration of retroplacental clear space, a myometrial thickness of <1 mm, presence of vessels bridging placenta and uterine margin, disruption of the placental-uterine wall interface, and vessels crossing the sites of interface disruption showed a statistically significant association with placenta accreta. The disruption of the placental-uterine wall interface and the presence of vessels crossing these sites were the only 2 individual criteria that could distinguish placenta accreta from non-accreta, which could also be achieved by our composite score system using a cutoff value of 40, with a sensitivity of 89% and specificity of 98%. CONCLUSION: The diagnostic performance of the sonographic diagnostic criteria used in the diagnosis of placenta accreta varies, and a composite score system improves the overall accuracy.

The maternal outcome in placenta accreta: the significance of antenatal diagnosis and non-separation of placenta at delivery.

AIM: To evaluate the effects of antenatal diagnosis and subsequent placental non-separation at delivery on the maternal outcome in confirmed cases of placenta accreta. METHOD: The perinatal database and medical records for women who delivered in the period 2000-6 in a teaching hospital in New Zealand with a diagnosis of placenta accreta or postpartum haemorrhage or hysterectomy were reviewed. In confirmed placenta accreta cases, the amount of blood loss and blood transfused at delivery and subsequent emergency hysterectomy were analysed in respect to the presence/absence of antenatal diagnosis and the management at delivery. RESULTS: 16 women had placenta accreta confirmed (15 histologically and 1 visually). Antenatal diagnosis was made in 7 women, elective Caesarean delivery planned in all, hysterectomy to follow in 5 (4 elective, 1 emergency preterm), and elective placental separation in 2 women. When an antenatal diagnosis was not made (n=9), attempted placental separation led to emergency hysterectomy for all (p=0.001). Antenatal diagnosis and placental non-separation resulted in less mean blood loss (1.4 L vs 3.6 L, p=0.003; 1.0 L vs 3.4 L, p<0.001) and mean units of blood transfused (1.2 vs 5.1, p=0.005) in the latter. CONCLUSION: In placenta accreta, antenatal diagnosis and avoidance of placental separation may result in better maternal outcome.