Multidisciplinary obstetric critical care delivery: The concept of the "virtual" intensive care unit.

With an increasing prevalence of chronic medical conditions and the associated potential for decompensation to critical illness among modern day parturients, we present here the concept of the "virtual" intensive care unit. We challenge the traditional association of the word "unit" to extend beyond a fixed physical setting to portray an individualized, predetermined patient care team capable of managing these complex patients in a variety of settings. In this model, obstetric critical care is provided through a multidisciplinary patient care team, with emphasis on early identification of complicated pregnancies, detailed antepartum planning, anticipation of complications, and retrospective review of clinical outcomes aimed at continued quality improvement. This structured approach in the provision of care to the critically ill pregnant patient will serve as a foundation for future attempts at reduction in rates of maternal morbidity and mortality.

Correlation of placental pathology and perinatal outcomes with Hemoglobin A1c in early pregnancy in gravidas with pregestational diabetes mellitus.

INTRODUCTION: Data on the correlation among Hemoglobin A1c (HbA1c), placental pathology, and perinatal outcome in the pregestational diabetic population is severely lacking. We believe that this knowledge will enhance the management of pregnancies complicated by pregestational diabetes. We hypothesize that placental pathology correlates with glycemic control at an early gestational age. METHODS: This is a retrospective cohort study conducted from 2003 to 2011 at a large tertiary care center. Women included had a singleton gestation, preexisting diabetes mellitus, and information about delivery and placental pathology available for review. Placental pathology and perinatal outcomes were compared across three groups of patients with differing HbA1c levels (<6.5%, 6.5-8.4%, and ≥8.5%). RESULTS: 293 placentas were examined. HbA1c was measured at a mean of 9.5week gestation. Median HbA1c was 7.5%, interquartile range 6.5%-8.9%. 23% of the cohort had HbA1c <6.5%, 41.9% between 6.5% and 8.4%, and 34.8% > 8.5%. BMI varied significantly by group (35.4 vs. 34.4 vs. 32.0 respectively, P = 0.04). Individual placental lesions did not vary with HbA1c levels. The incidence of acute chorioamnionitis differed significantly in the type 1 population and "distal villous hypoplasia" varied in the type 2 population. DISCUSSION: The results show that HbA1c values in early pregnancy are poor predictors of future placental pathologies. As a result, HbA1c values obtained during early gestation (which reflect the level of glycemic control over an extended period of time) do not correlate with any particular placental pathology, despite reflecting the potential for placental insults secondary to pre-gestational diabetes.

The "virtual" obstetrical intensive care unit: providing critical care for contemporary obstetrics in nontraditional locations.

Management of the critically ill pregnant patient presents a clinical dilemma in which there are sparse objective data to determine the optimal setting for provision of high-quality care to these patients. This clinical scenario will continue to present a challenge for providers as the chronic illness and comorbid conditions continue to become more commonly encountered in the obstetric population. Various care models exist across a broad spectrum of facilities that are characterized by differing levels of resources; however, no studies have identified which model provides the highest level of care and patient safety while maintaining a reasonable degree of cost-effectiveness. The health care needs of the critically ill obstetric patient calls for clinicians to move beyond the traditional definition of the intensive care unit and develop a well-rounded, quickly responsive, and communicative interdisciplinary team that can provide high-quality, unique, and versatile care that best meets the needs of each particular patient. We propose a model in which a virtual intensive care unit team composed of preselected specialists from multiple disciplines (maternal-fetal medicine, neonatology, obstetric anesthesiology, cardiology, pulmonology, etc) participate in the provision of individualized, precontemplated care that is readily adapted to the specific patient's clinical needs, regardless of setting. With this team-based approach, an environment of trust and familiarity is fostered among team members and well thought-out patient care plans are developed through routine prebrief discussions regarding individual clinical care for parturients anticipated to required critical care services. Incorporating debriefings between team members following these intricate cases will allow for the continued evolution of care as the medical needs of this patient population change as well.

Can hemoglobin A1c in early pregnancy predict adverse pregnancy outcomes in diabetic patients?

OBJECTIVE: To examine the association of elevated early pregnancy hemoglobin A1c (HbA1c) levels with adverse pregnancy outcomes in women with preexisting diabetes mellitus. STUDY DESIGN: Retrospective cohort study of 330 women with preexisting diabetes enrolled in a Diabetes in Pregnancy Program at an academic institution between 2003 and 2011 who had an early HbA1c determination. The frequencies of composite maternal adverse pregnancy outcomes (birth at<37 weeks, preeclampsia, and medically indicated birth <39 weeks), and composite fetal adverse pregnancy outcomes [shoulder dystocia, Apgar scores<7 at 5 minutes, small for gestational age (SGA), large for gestational age (LGA), and stillbirth] were compared between HbA1c categories (<6.5, 6.5-7.4, 7.5-8.4 and ≥ 8.5%). RESULTS: There was no statistically significant difference between composite adverse maternal pregnancy outcomes and composite adverse fetal pregnancy outcomes as well as other individual outcomes between different HbA1c categories. Of the vaginally delivered women in our cohort, the 37 patients with HbA1c levels of ≥ 8.5% had a significantly higher frequency of fetal shoulder dystocia than the 62 with HbA1c levels of < 8.5% (24.2 vs. 1.6%, P = 0.002). Neonates of patients with HbA1c ≥ 8.5% were more likely to have low five minute Apgar scores than neonates of patients with HbA1c < 8.5%, but this was of borderline statistical significance (7.4% vs. 0.5%, P = 0.05). CONCLUSION: In patients with preexisting diabetes mellitus, HbA1c levels of ≥ 8.5% during early pregnancy are not useful in predicting most adverse outcomes, although there may be an increased risk for shoulder dystocia.

Utility of fetal echocardiography after normal cardiac imaging findings on detailed fetal anatomic ultrasonography.

OBJECTIVE: The purpose of this study was to assess the utility of fetal echocardiography (FE) after normal fetal cardiac imaging findings during detailed fetal anatomic ultrasonography (FAU). METHODS: We conducted a retrospective cohort review of obstetric ultrasonographic studies from November 2001 through July 2005. We identified women with a singleton gestation with increased risk for congenital heart disease who received FAU performed by a maternal-fetal medicine specialist at 16 to 20 weeks' gestation with subsequent FE. These records were compared with newborn outcomes. RESULTS: Of 789 pregnancies that had FAU and FE, 481 had satisfactory cardiac imaging. Of those, only 1 fetus had abnormal FE findings. After delivery, 4 of the 480 neonates with normal FAU and FE findings had a diagnosis of a heart defect. CONCLUSIONS: Fetal echocardiography does not substantially increase the detection rate of major cardiac anomalies after normal findings on detailed FAU performed by a maternal-fetal medicine specialist.