A multidisciplinary approach to improving process and outcomes in unscheduled cesarean deliveries.

BACKGROUND: Effective communication between providers of various disciplines is crucial to the quality of care provided on labor and delivery. The lack of standardized language for communicating the clinical urgency of cesarean delivery and the lack of standardized processes for responding were identified as targets for improvement by the Obstetric Patient Safety Committee at the Hospital of the University of Pennsylvania. The committee developed and implemented a protocol aimed at improving the performance of our multidisciplinary team and patient outcomes. OBJECTIVE: To evaluate whether implementation of a multidisciplinary protocol that standardizes the language and process for performing unscheduled cesarean deliveries had reduced the decision to incision interval and improved maternal and neonatal outcomes. MATERIALS AND METHODS: This was a retrospective cohort study of patients who underwent unscheduled cesarean delivery pre- and postimplementation of a protocol standardizing language, communication, provider roles, and processes. The primary outcome was cesarean decision to incision interval overall and stratified by fetal and nonfetal indications for delivery. Secondary outcomes included decision to operating room and operating room to incision intervals, operative complications, use of general anesthesia, maternal transfusion, 5-minute Apgar score <6, and umbilical cord arterial pH <7.2. Descriptive statistics were calculated. Continuous variables were tested for normality and compared using the Student t test or Mann-Whitney U test as appropriate. Categorical variables were characterized by proportions and compared by the χ2 or Fisher exact test as appropriate. RESULTS: There were 121 and 119 subjects in the pre-and postimplementation groups respectively, collected from corresponding 3-month periods. There were no significant differences in demographics, comorbidities, or indications for cesarean delivery between groups. Overall median decision to incision interval did not differ between the pre- and postimplementation groups. There was a significant decrease in median decision to incision interval (63 versus 50 minutes, P = .02) in cesarean deliveries performed for nonfetal indications. This was driven by a shorter median decision to operating room interval (32.5 versus 23 minutes, P = .01). The incidences of operative complications (35% [19/55] versus 11% [6/53], P < .01) and cord pH <7.2 (36% [20/55] versus 17% [9/53], P = .02) were also decreased in cesarean deliveries performed for nonfetal indications. The incidences of general anesthesia, maternal transfusion, and 5-minute Apgar score <6 did not differ. Outcomes did not differ between the pre- and postimplementation groups in cesarean deliveries performed for fetal indications. CONCLUSION: Implementation of a multidisciplinary process improvement protocol that standardizes language, roles, and processes for unscheduled cesarean deliveries was associated with a reduced decision to incision interval and improved maternal and neonatal outcomes in cesarean deliveries performed for nonfetal indications. Standardized process implementation on labor and delivery has the potential to improve patient outcomes.

Spontaneous Adrenal Hemorrhage in Pregnancy: A Case Series.

Background. Abdominal pain during pregnancy has a broad differential diagnosis which includes spontaneous adrenal hemorrhage (SAH). There is scant literature available on optimal mode of delivery in stable patients. Cases. Patient 1 was a 35-year-old nullipara who presented at 36 weeks of gestation with left flank pain. Patient 2 was a 27-year-old multipara at 38 weeks who presented with left upper quadrant pain. Diagnosis of SAH was made by CT scan and both were managed with pain control, serial hemoglobin assessments, and abdominal exams resulting in uncomplicated vaginal deliveries. Conclusion. SAH, although rare, is an important consideration when evaluating abdominal and flank pain in pregnancy. Management options vary from conservative management to surgical intervention depending on the stability of the patient.

Second-Trimester 3-Dimensional Placental Sonography as a Predictor of Small-for-Gestational-Age Birth Weight.

OBJECTIVES: We previously reported the association between first-trimester 3-dimensional (3D) placental measurements and small-for-gestational-age (SGA) neonates. In this study, we sought to determine whether second-trimester measurements further contribute to the antenatal detection of SGA and preeclampsia. METHODS: We prospectively collected 3D sonographic volume sets and uterine artery pulsatility indices of singleton pregnancies at 18 to 24 weeks. Placental volume, placental quotient (placental volume/gestational age), mean placental diameter and chorionic diameter, placental morphologic index (mean placental diameter/placental quotient), placental chorionic index (mean chorionic diameter/placental quotient), and placental growth (volume per week) were assessed and evaluated as predictors of SGA and preeclampsia as a composite and alone. RESULTS: Of 373 pregnancies, the composite outcome occurred in 67 (18.0%): 36 (9.7%) manifested SGA alone; 27 (7.2%) developed preeclampsia alone, and 4 (1.1%) developed both. The placental volume, placental quotient, mean placental diameter, mean chorionic diameter, and volume per week were significantly smaller, whereas the placental morphologic index and chorionic index were significantly larger in pregnancies with the composite outcome (P < .01). Further analyses revealed that the significant associations with placental parameters were limited to the SGA outcome. Each placental measure remained significantly associated with SGA after adjusting for confounders. The mean uterine artery pulsatility index was not associated with either outcome. Placental parameters were moderately predictive of SGA, with adjusted areas under the curve ranging from 0.72 to 0.76. Sensitivity for detection of SGA ranged from 32.5% to 45.0%, with positive predictive values ranging from 17.3% to 22.7%. CONCLUSIONS: Second-trimester 3D placental measurements can identify pregnancies at risk of SGA. However, there appears to be no significant improvement compared to those obtained in the first trimester.

Transabdominal ultrasonography as a screening test for second-trimester placenta previa.

OBJECTIVE: To determine the test characteristics of transabdominal ultrasonography as a screening test for second-trimester placenta previa. METHODS: This secondary analysis of a prospective cohort study evaluated the distance from the placental edge to the internal os (placenta-cervix distance) through both transabdominal and transvaginal ultrasonography during the anatomic survey. Patients were recruited in the Maternal-Fetal Medicine Ultrasound Unit at the Hospital of the University of Pennsylvania, an urban tertiary care center. Transabdominal placenta-cervix distance cutoffs with high sensitivity for detection of previa and low-lying placenta were identified, and test characteristics were calculated. Follow-up ultrasound data, pregnancy, and delivery outcomes for those with second-trimester previa or low-lying placenta were obtained. RESULTS: One thousand two hundred fourteen women were included in the analysis. A transabdominal placenta-cervix distance cutoff of 4.2 cm was 93.3% sensitive and 76.7% specific for detection of previa with a 99.8% negative predictive value at a screen-positive rate of 25.0%. A cutoff of 2.8 cm was 86.7% sensitive and 90.5% specific with a 99.6% negative predictive value at a screen-positive rate of 11.4%. Only 9.8% (four of 41) of previas and low-lying placentas persisted through delivery. CONCLUSION: Transabdominal ultrasonography is an effective screening test for second-trimester placenta previa. At centers not performing universal transvaginal ultrasonography at the time of the anatomic survey, evidence-based transabdominal placenta-cervix distance cutoffs can optimize the identification of patients who require further surveillance for previa.

Isolated abdominal circumference < 5% or estimated fetal weight 10 to 19% as predictors of small for gestational age infants.

OBJECTIVES: To determine whether (1) isolated fetal abdominal circumference < 5% (AC5) in absence of growth restriction (estimated fetal weight < 10% [EFW10]) or (2) borderline fetal growth 10 to 19% (EFW10-19) predicts subsequent fetal and/or neonatal growth restriction. STUDY DESIGN: The authors performed a retrospective cohort study (January 2008 to December 2011) of women with singleton pregnancies between 26 and 36 weeks who had ≥ 1 growth ultrasound. Univariable and multivariable analyses were performed to determine the association between isolated AC5 or EFW10-19 with both subsequent sonographic diagnosis of EFW10 and neonatal diagnosis of small for gestational age (SGA). Test characteristics were calculated. RESULTS: Out of the 10,642 pregnancies, prevalence of isolated AC5, EFW10-19, EFW10, and SGA were as follows: AC5, 5.31%; EFW10-19, 13.30%; EFW10, 7.95%; and SGA, 17.63%. While screening for SGA using EFW10 alone would miss 68.34% of SGA neonates, using isolated AC5 would identify an additional 16.15% of SGA neonates with a 3.7% false positive rate. Using EFW10-19 would identify an additional 40.20% of SGA neonates with a 9.0% false positive rate. CONCLUSION: Fetuses with isolated AC5 or EFW10-19 are at an increased risk of growth restriction. Using isolated AC5 or composite EFW10-19 would identify SGA neonates that are missed using conventional sonographic definitions of growth restriction alone.

Reproductive implications of psychological distress for couples undergoing IVF.

OBJECTIVE: To study implications of psychological distress on in vitro fertilization (IVF) outcome of an infertile couple. METHODS: Prospective study in an academic infertility practice setting. Couples undergoing embryo transfer (ET) following IVF were offered participation. Female patient (n = 89) and partner (n = 77) completed questionnaires reflecting dysphoria (POMS) and pessimism (LOT) after undergoing ET. Relationship between dysphoria and pessimism and implications of individual and couple's psychological distress on IVF cycle parameters and outcomes were assessed using multivariable analyses. RESULTS: Statistically significant correlations between dysphoria and pessimism were observed within the individual and between partners, (p < 0.01). Higher couple pessimism correlated with longer duration of controlled ovarian hyperstimulation (COH, p = 0.02); higher partner psychological distress related to lower fertilization rate (FR, p = 0.03). On adjusted analyses, partner's depression score was an independent predictor of reduced likelihood of clinical pregnancy (p = 0.03). CONCLUSIONS: Our data validate the concept of a "stressed couple". Adverse implications of a couple's psychological distress for gamete biology (longer duration of COH and lower FR with increasing distress) are suggested. Partner's depressive scores negatively correlated with IVF success. These findings suggest the importance of including partner's evaluation in studies that focus on effects of psychological stress on IVF outcome; future studies should examine whether interventions aimed at reducing psychological stress for the infertile couple may improve IVF cycle success.

Angiogenic factors and pregnant woman with new onset seizures.

BACKGROUND: In patients with new onset seizures during pregnancy, it can be challenging to differentiate between eclampsia and other etiologies. Soluble fms-like tyrosine kinase (sFlt1) is an antiangiogenic protein that is elevated in preeclampsia and eclampsia. CASE: A multiparous woman presented at 22 weeks gestation with seizures. The initial presentation was highly suspicious for eclampsia, but blood pressure and laboratory data were equivocal. Further investigation suggested primary seizure disorder. Serum sFlt1 was normal for gestational age, supporting the exclusion of eclampsia. CONCLUSION: History, physical exam, and traditional laboratory data are the mainstays of eclampsia diagnosis; however, sFlt1 may help clinicians when the diagnosis is uncertain at preterm gestational ages.

The Impact of Magnesium Sulfate Therapy on Angiogenic Factors in Preeclampsia.

OBJECTIVE: The objective was to evaluate whether intravenous magnesium sulfate (magnesium) alters levels of angiogenic factors in women with preeclampsia. STUDY DESIGN: This was a prospective cohort study comparing women with preeclampsia treated with magnesium for seizure prophylaxis to those who were not. Serum levels of angiogenic factors, soluble fms-like tyrosine kinase 1, soluble endoglin and placental growth factor, were measured at the time of diagnosis and approximately 24 hours later. Secondary analysis compared women receiving magnesium for preeclampsia to women receiving magnesium for preterm labor. Analysis of covariance was used to compare levels at 24 hours, adjusting for levels at enrollment and potential confounders. RESULTS: Angiogenic factor levels did not differ between preeclampsia groups with and without magnesium or between preeclampsia and preterm labor groups treated with magnesium (all P > 0.05). CONCLUSION: Magnesium likely decreases seizure risk in preeclampsia by a mechanism other than altering angiogenic factor levels.