Hamilton county physicians' experience with managed care.

BACKGROUND: Widespread physician participation in managed care over the last several years prompted this survey of the members of the Medical Society of Chattanooga and Hamilton County. METHODS: A 36-item questionnaire was mailed to all members of the Medical Society. RESULTS: Ninety-six responses from solo practitioners and groups representing 325 physicians were analyzed. More than 80% of respondents believed that managed care has affected the quality of patient care negatively and 71.8% believed managed care policies have compromised their patient care. More importantly, 90% said insurers have not secured their input in policy development. Referral processes were regarded as cumbersome or impossible by 78.2%. Regression analysis showed a significant relation between issues of too much managed care control, cumbersome referral processes, and physicians' opinion on impact of managed care on quality of patient care. CONCLUSIONS: Physician dissatisfaction with managed care in Hamilton County appears widespread and is mainly related to issues of too much managed care control over daily patient care, which physicians feel results in compromised quality of patient care.

Contribution of consultants to care of compromised pregnancies.

Obstetricians often seek consultative services of other specialists in the management of compromised pregnancies. However, the extent of such consultations and the contribution of these consultants have not been addressed in the literature. This study is addresses the contribution of consultants to the care of complicated pregnancies at a tertiary care center. During the 2 1/2 years of this retrospective study, 2263 antepartum admissions were made for pregnancy complications. One hundred sixty-six of those patients were hospitalized 176 times and were treated by one or more consulting physicians for a consultation rate of 7.8%. Eighteen specialties were consulted, including 54 (32%) consultations from maternal fetal medicine, 44 (24%) from internal medicine, 28 (16%) from general surgery, and 22 (12%) from endocrinology. Of the initial admission diagnoses, 87.9% were confirmed and 46 new diagnoses were made by the consultants. A significant positive correlation was noted between the number of consultants, maternal length of hospital stay, and maternal hospitalization cost.

Severe preeclampsia mimicking acute appendicitis.

Preeclampsia has been frequently misdiagnosed as an entity unrelated to pregnancy, with resultant delay in appropriate management. In the case presented here, severe preeclampsia complicated by hemolysis, elevated liver enzymes, and low platelet count ("HELLP syndrome") in a 32-week twin gestation was misdiagnosed as acute appendicitis. Delay in diagnosis and an unnecessary appendectomy resulted in loss of one of the fetuses.

Hemostatic wrapping of ruptured liver in two postpartum patients.

A variety of surgical techniques with variable success rates have been reported in the management of the spontaneously ruptured liver in pregnancy. We managed two cases of postpartum ruptured liver by wrapping the liver in hemostatic material. Hemostatic encapsulation effectively controlled massive bleeding of ruptured livers in two postpartum patients.

Captopril in severe preeclampsia.

Captopril is an inhibitor of angiotensin I converting enzyme and is used for treating intractable chronic hypertension. However, the use of captopril during pregnancy is limited because of reported fetal and neonatal side effects. This study explored the efficacy of sublingual captopril in postpartum management of severe preeclampsia. Captopril controlled the systolic and diastolic pressures within normal range in two patients. The other three patients responded moderately and were switched to hydralazine, clonidine, or nifedipine after 12 hours. The systolic and diastolic pressures of these three patients remained moderately elevated over the 24-hour duration of the study while their pulse rates increased. Captopril did not significantly increase the pulse rate in any of the patients studied, and no other side effects were noted. All patients had normal pressures at their 2- and 6-week postpartum check-up. We conclude that sublingual captopril may be used safely and effectively in managing postpartum hypertension in patients with severe preeclampsia.

A national survey on preterm labor.

A national survey was conducted to examine the American obstetricians' approach to management of preterm labor. Multiple-choice questionnaires were mailed to all current members of the Society of Perinatal Obstetricians and 750 randomly selected diplomates of the American College of Obstetricians and Gynecologists. Respondents included 249 members of the Society of Perinatal Obstetricians and 441 fellows of the American College of Obstetricians and Gynecologists. Analysis of the replies reflects wide variations among American obstetricians' criteria to diagnose preterm labor, choice of tocolytic agent, use of amniocentesis, and use of corticosteroids. Significant differences were found between the two groups in many aspects of diagnosis and management of preterm labor. However, the replies reflect a high degree of awareness of and many instances of first hand experience with severe beta-adrenergic therapy complications, including maternal death. These findings emphasize the need for caution in selection of patients for beta-adrenergic tocolytic therapy and judicious use of these agents.

Maternal-perinatal outcome associated with the syndrome of hemolysis, elevated liver enzymes, and low platelets in severe preeclampsia-eclampsia.

During an 8-year period, 112 severe preeclamptic-eclamptic patients with the above syndrome were studied. The incidence of this syndrome was significantly higher in white patients, in patients with delayed diagnosis of preeclampsia and/or delayed delivery, and in multiparous patients. Twenty-six patients had amniocentesis and 16 received epidural anesthetics. There was one maternal bleeding episode associated with epidural anesthetics. The use of steroids in 17 patients did not improve maternal platelet count. The overall perinatal mortality was 367 per 1000 and neonatal morbidity was significant. There were two maternal deaths and two patients with ruptured liver hematoma, and nine had acute renal failure. Thirty-eight percent had intravascular coagulopathy and 20% had abruptio placentae. On follow-up, 44 patients used oral contraceptives without maternal morbidity and 38 patients had 49 subsequent pregnancies. Only one patient had recurrence of the syndrome in subsequent pregnancies. The presence of a "true" syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome) in preeclampsia is associated with poor maternal-perinatal outcome.

Immunoglobulin G subclasses and isoimmunized pregnancy outcome.

Immunoglobulin G antibodies are the most frequent type of red blood cell isoantibodies. They possess the ability to traverse the placenta and may cause hemolytic disease in newborn infants. Of the four subclasses, IgG1 and IgG3 are effective at binding erythrocytes to monocyte-macrophages and therefore are potentially destructive to erythrocytes. IgG2 and IgG4 are unable to react effectively with receptor sites on phagocytic cells and so are totally inactive relative to hemolysis. IgG subclasses were identified in 22 consecutive isoimmunized antepartum patients. Fifteen patients were subsequently delivered of babies who were either affected by or susceptible to hemolytic disease of the newborn. When maternal antibodies consisted of IgG1 only, hemolytic disease of the newborn developed in four of five cases. When only IgG3 was present, each of two patients developed hemolytic disease of the newborn. In eight cases both IgG1 and IgG3 were present and all the babies were born with hemolytic disease of the newborn. Determination of IgG subclasses might prove to be a useful adjunct in evaluating isoimmunized pregnancies. However, the limited information available does not permit the use of IgG subclasses exclusive of traditional means of diagnosis and management of isoimmunized pregnancies.