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Special Statement: Proposed Quality Metrics to Assess Accuracy of Prenatal Detection of Congenital Heart Defects
Congenital heart defects (CHD) are a leading cause of neonatal morbidity and mortality. Accurate prenatal diagnosis of CHD can reduce morbidity and mortality by improving prenatal care, facilitating predelivery pediatric cardiology consultation, and directing delivery to facilities with resources to manage the complex medical and surgical needs of newborns with CHD. Unfortunately, less than one-half of CHD cases are detected prenatally, resulting in lost opportunities for counseling, shared decision-making, and delivery at an appropriate facility. Quality improvement initiatives to improve prenatal CHD detection depend on the ability to measure the rate of detection at the level of providers, facilities, or populations, but no standard metric exists for measuring the detection of CHD at any level. The need for such a metric was recognized at a Cooperative Workshop held at the 2016 Annual Meeting of the Society for Maternal-Fetal Medicine, which recommended the development of a quality metric to assess the rate of prenatal detection of clinically significant CHD. In this paper, we propose potential quality metrics to measure prenatal detection of "critical" CHD, defined as defects with a high rate of morbidity or mortality or that require surgery or tertiary follow-up. One metric is based on a retrospective approach, assessing whether postnatally diagnosed CHD had been identified prenatally. Other metrics are based on a prospective approach, assessing the sensitivity and specificity of prenatal diagnosis of CHD by comparing prenatal ultrasound findings with newborn findings. Potential applications, limitations, challenges, barriers, and value for both approaches are discussed. We conclude that future development of these metrics will depend on an expansion of the International Classification of Diseases (ICD) system to include specific codes that distinguish fetal CHD from newborn CHD and on the development of record systems that facilitate the linkage of fetal records (in the maternal chart) with newborn records.
PMID: 32114082
ISSN: 1097-6868
CID: 4339562
Comparison of postoperative opioid use in mothers whose neonates are in regular nursery versus in neonatal intensive care [Meeting Abstract]
INTRODUCTION: Postoperative opioid use presents pain management dilemmas because mothers should be alert and engaged with their neonates. Mothers with neonates in intensive care (NICU) have additional stresses and may desire 'round the clock' vs 'prn' pain management. We compared post-operative opioid usage in mothers with neonates in regular nursery ('regular') vs. NICU.
METHOD(S): From January 1, 2013 through December 12, 2018, postoperative opioid use for days 0 until discharge was retrospectively reviewed. Mothers with 'regular' neonates constituted Group 1, and NICU neonates were Group 2. Perioperative substance abusers or chronic opioid users were excluded.
RESULT(S): All the 8136 charts reviewed had orders for narcotic and non-narcotic analgesics. Both agents were used by 84% and only nonnarcotic analgesics by 16% of mothers. None used narcotics exclusively. All received narcotic prescriptions at discharge, regardless of postoperative opioid use. Group 1 had 6509 and Group 2 had 1627 mothers. Group 2 diagnoses included prematurity (12%), sepsis (4%), neonates with life threatening anomalies requiring major surgery (3%). No differences occurred in opioid usage between the 2 Groups (43% vs 45%, POD1; 81% vs 80%, POD2; 72% vs 70%, POD3; 20% vs 23%, POD4). Significantly more opioid usage occurred in mothers of neonates with life threatening anomalies.
CONCLUSION(S): Mothers with NICU neonates did not demonstrate increased postoperative opioid usage, in spite of the perceived added stresses. However, mothers with neonates having life threatening diagnoses utilized larger amounts of narcotics post-operatively. These findings may have future implications for post discharge pain management
METHOD(S): From January 1, 2013 through December 12, 2018, postoperative opioid use for days 0 until discharge was retrospectively reviewed. Mothers with 'regular' neonates constituted Group 1, and NICU neonates were Group 2. Perioperative substance abusers or chronic opioid users were excluded.
RESULT(S): All the 8136 charts reviewed had orders for narcotic and non-narcotic analgesics. Both agents were used by 84% and only nonnarcotic analgesics by 16% of mothers. None used narcotics exclusively. All received narcotic prescriptions at discharge, regardless of postoperative opioid use. Group 1 had 6509 and Group 2 had 1627 mothers. Group 2 diagnoses included prematurity (12%), sepsis (4%), neonates with life threatening anomalies requiring major surgery (3%). No differences occurred in opioid usage between the 2 Groups (43% vs 45%, POD1; 81% vs 80%, POD2; 72% vs 70%, POD3; 20% vs 23%, POD4). Significantly more opioid usage occurred in mothers of neonates with life threatening anomalies.
CONCLUSION(S): Mothers with NICU neonates did not demonstrate increased postoperative opioid usage, in spite of the perceived added stresses. However, mothers with neonates having life threatening diagnoses utilized larger amounts of narcotics post-operatively. These findings may have future implications for post discharge pain management
EMBASE:633633546
ISSN: 1873-233x
CID: 4721112
Characteristics of Category II Tracings during Last Hour of Second Stage Labor in Predicting Fetal Acidosis [Meeting Abstract]
INTRODUCTION: Intrapartum fetal heart rate (FHR) monitoring although sensitive, lacks specificity for predicting fetal acidosis. Category II tracings, within the last hour of labor, occur in >/=96% of uncomplicated, term, laboring patients. Most result in delivery of well oxygenated neonates. Neonatal acidosis occurs in <3% of term neonates and may result in neonatal encephalopathy. Currently, there is no standard approach to management of Category II tracings.
METHOD(S): We retrospectively reviewed Category II tracings in singleton, uncomplicated, term patients, during the last hour prior to delivery, in women who delivered neonates with cord blood pH /=8 (Group 1) and pH >= 7.20, base excess.
RESULT(S): In Group 1 (n=414), 91% of tracings exhibited good/moderate variability, 17.5% demonstrated minimal/absent variability, 13% had accelerations (>=15 bpm, lasting >=15 secs). In Group 2 (n = 913), 97% showed moderate/good variability, 9% minimal/absent variability, 92% demonstrated accelerations (P<0.05). Duration of second stage labor was comparable in both Groups, (Group 1 = 3.5 hours, Group 2 = 3.1 hours), as were rates of chorioamnionitis, Pitocin use. Apgar scores and rates of NICU interventions were also similar in the two Groups.
CONCLUSION(S): Minimal/decreased variability and the absence of accelerations, in Category II tracings, reliably predict fetal acidosis. Thus, expedited delivery should be considered in this clinical setting
METHOD(S): We retrospectively reviewed Category II tracings in singleton, uncomplicated, term patients, during the last hour prior to delivery, in women who delivered neonates with cord blood pH /=8 (Group 1) and pH >= 7.20, base excess.
RESULT(S): In Group 1 (n=414), 91% of tracings exhibited good/moderate variability, 17.5% demonstrated minimal/absent variability, 13% had accelerations (>=15 bpm, lasting >=15 secs). In Group 2 (n = 913), 97% showed moderate/good variability, 9% minimal/absent variability, 92% demonstrated accelerations (P<0.05). Duration of second stage labor was comparable in both Groups, (Group 1 = 3.5 hours, Group 2 = 3.1 hours), as were rates of chorioamnionitis, Pitocin use. Apgar scores and rates of NICU interventions were also similar in the two Groups.
CONCLUSION(S): Minimal/decreased variability and the absence of accelerations, in Category II tracings, reliably predict fetal acidosis. Thus, expedited delivery should be considered in this clinical setting
EMBASE:633844265
ISSN: 1873-233x
CID: 4749432
Impact of decision to delivery times upon maternal and neonatal outcomes [Meeting Abstract]
Introduction: Category III tracings occur in 1-2% of labors and require rapid interventions to avoid serious fetal compromise or death. ACOG states that a "stat" or emergency delivery should occur within 30 minutes after the decision has been made. The purpose of this study was to review the outcomes of a performance improvement initiative whereby a Labor Response Team (LRT) consisting of Obstetrics, Pediatrics, Anesthesia and Nursing is initiated for expeditiously managing Category III tracings.
Method(s): A retrospective chart review from January 2013 to August 2018, identified patients with Category III tracings in whom an LRT alert was initiated. The decision to delivery times were divided into 3 groups of 15 minute segments. Group 1 was delivery within 15 minutes, Group 2 was delivery between 16 to 30 minutes, Group 3 was delivery after 31 minutes. Neonatal outcomes in each of the 3 groups were reviewed.
Result(s): There were 6632 patients with Category 3 tracings. Of these, 6035 (91%) were delivered by Cesarean section (C/S), 597 (9%) by operative vaginal delivery. There were 2851 (43%) patients in Group 1, 3449 (52%) in Group 2, 332 (5%) in Group 3. Cord pH values Conclusion(s): Fetal compromise (low cord pH, 5 minute Apgar scores) were least likely to occur when decision to delivery time was
Method(s): A retrospective chart review from January 2013 to August 2018, identified patients with Category III tracings in whom an LRT alert was initiated. The decision to delivery times were divided into 3 groups of 15 minute segments. Group 1 was delivery within 15 minutes, Group 2 was delivery between 16 to 30 minutes, Group 3 was delivery after 31 minutes. Neonatal outcomes in each of the 3 groups were reviewed.
Result(s): There were 6632 patients with Category 3 tracings. Of these, 6035 (91%) were delivered by Cesarean section (C/S), 597 (9%) by operative vaginal delivery. There were 2851 (43%) patients in Group 1, 3449 (52%) in Group 2, 332 (5%) in Group 3. Cord pH values Conclusion(s): Fetal compromise (low cord pH, 5 minute Apgar scores) were least likely to occur when decision to delivery time was
EMBASE:626672053
ISSN: 1933-7205
CID: 3751332
Reproductive sciences (Thousand Oaks, Calif.). 2019:Conference:(66th):160A-161A.DOI: 10.1177/1933719119834079
Uterine rupture "alarm criteria" in patients undergoing trial of labor after cesarean section (TOLAC) [Meeting Abstract]
Introduction: Uterine rupture is a rare but catastrophic complication with significant perinatal morbidity and mortality. The initial signs and symptoms can be non-specific, thus delaying definitive, life saving interventions. The purpose of this study was to identify maternal and/ or fetal "alarm criteria" in patients at risk for uterine rupture whole undergoing TOLAC.
Method(s): A retrospective chart review was conducted of patients undergoing TOLAC, from March 2013 through December 2017. Inclusion criteria: patients aged 18-54 years, with 1 or 2 previous Cesarean sections (C/S), with singleton, vertex, >/= 34 weeks gestations. Exclusion criteria: patients with fetal demise, preterm gestation, contraindications to vaginal birth.
Result(s): There were 30,000 deliveries during the study period. Of these, 12,900 (43%) underwent TOLAC and 2486 of these patients had 2 prior C/S. Uterine rupture at delivery was confirmed in 193 (1.5%) women, with 172 (88.8%) being identified at C/S and 21 (11.1%) at vaginal delivery. Anterior or side wall ruptures occurred in 136 (70.4%) patients. Of these, 86 (63%) were located in the previous uterine scar. Category II or III fetal heart tracings occurring within the last hour of the diagnosis of rupture and/ or delivery, were noted in 164 (85.2%) patients. Abdominal pain, rated by the patients as "moderate/severe" in spite of previously adequate epidural analgesia, occurred in 185 (96%) patients. Intrapartum vaginal bleeding (>/=75 cc), occurred in 78 (40.7%) and loss of station of the presenting part in 57 (29.6%) patients. Loss of adequate uterine contraction pattern occurred in 57 (29.6%) patients.
Conclusion(s): The most frequent indicator of uterine rupture was moderate/ severe pain in spite of previously adequate analgesia versus FHR abnormalities, which are noted in the literature as being the most frequent and reliable indicator. We suggest that pain in this clinical setting is THE alarm criterion which should initiate interventions to mitigate adverse outcomes in these patients
Method(s): A retrospective chart review was conducted of patients undergoing TOLAC, from March 2013 through December 2017. Inclusion criteria: patients aged 18-54 years, with 1 or 2 previous Cesarean sections (C/S), with singleton, vertex, >/= 34 weeks gestations. Exclusion criteria: patients with fetal demise, preterm gestation, contraindications to vaginal birth.
Result(s): There were 30,000 deliveries during the study period. Of these, 12,900 (43%) underwent TOLAC and 2486 of these patients had 2 prior C/S. Uterine rupture at delivery was confirmed in 193 (1.5%) women, with 172 (88.8%) being identified at C/S and 21 (11.1%) at vaginal delivery. Anterior or side wall ruptures occurred in 136 (70.4%) patients. Of these, 86 (63%) were located in the previous uterine scar. Category II or III fetal heart tracings occurring within the last hour of the diagnosis of rupture and/ or delivery, were noted in 164 (85.2%) patients. Abdominal pain, rated by the patients as "moderate/severe" in spite of previously adequate epidural analgesia, occurred in 185 (96%) patients. Intrapartum vaginal bleeding (>/=75 cc), occurred in 78 (40.7%) and loss of station of the presenting part in 57 (29.6%) patients. Loss of adequate uterine contraction pattern occurred in 57 (29.6%) patients.
Conclusion(s): The most frequent indicator of uterine rupture was moderate/ severe pain in spite of previously adequate analgesia versus FHR abnormalities, which are noted in the literature as being the most frequent and reliable indicator. We suggest that pain in this clinical setting is THE alarm criterion which should initiate interventions to mitigate adverse outcomes in these patients
EMBASE:626672368
ISSN: 1933-7205
CID: 3751422
A multi-strategy approach for cesarean section reduction at an urban community medical center
OBJECTIVE: To develop a multi-strategy approach to reduce the cesarean section (C/S) rate at a community hospital serving a multiethnic patient population. STUDY DESIGN: A combination of antepartum and intrapartum strategies to reduce C/S were created and implemented over a period of 10 months. These were applied as clinically indicated for every patient who was being considered for undergoing a primary C/S or an elective repeat C/S. The resulting total C/S rate was retrospectively compared with the total C/S rate of a cohort of patients within the same department who underwent C/S prior to the implementation of these strategies. RESULTS: In the period prior to implementing the strategies, there were 3,566 deliveries and a total C/S rate of 39% versus 3,425 deliveries and a total C/S rate of 29% in the study period. This was statistically significant (p<0.05). CONCLUSION: Implementing a combined approach of strategies that addressed the issues both in the antepartum and the intrapartum periods resulted in a significant decrease in the total C/S rate. This was accomplished by getting greater buy-in from the providers and also by formally including the patients into the decision-making process. Of note, these results were achieved without any compromise to the safety and quality of patient care in the department.
SCOPUS:85031307197
ISSN: 0024-7758
CID: 2770472
Correlation of Blood Lactate Levels as a Predictor for Blood Transfusion in Postpartum Hemorrhage [Meeting Abstract]
ISI:000402705800077
ISSN: 0029-7844
CID: 2615592
Higher Order (>/=3) Repeat Cesarean Sections: Complications and Outcomes in the Setting of a Unique OB Safety Officer Program in an Urban Academic Medical Center [Meeting Abstract]
ISI:000372879200199
ISSN: 1933-7205
CID: 2128002
A case of fatal fulminant myocarditis presenting as an acute ST-segment elevation myocardial infarction and persistent ventricular tachyarrhythmia associated with influenza A (H1N1) virus in a previously healthy pregnant woman
Several studies have reported influenza A (H1N1) virus as a cause of fulminant myocarditis. We report the first fatal case of fulminant myocarditis presenting as an acute ST-segment elevation myocardial infarction and ventricular tachyarrhythmia associated with influenza A (H1N1) in a previously healthy pregnant woman. A 38-year-old Asian woman, gravida 3, para 1-0-1-1, presented with flu-like symptoms. Initially, she developed wide-complex tachycardia requiring several defibrillations and was later intubated. Electrocardiogram showed ST-segment elevation. Coronary angiogram was negative and a pulmonary angiogram ruled out pulmonary embolism. Fetal compromise was noted on the monitor, and the patient underwent an emergent cesarean section. She subsequently expired. Autopsy confirmed severe myocarditis. Further testing confirmed influenza A (H1N1) virus. This case of a rare, yet lethal, complication of H1N1 infection underscores the importance of increased awareness among health care professionals to provide pregnant women with vaccination and prompt treatment.
PMID: 23018755
ISSN: 0008-6312
CID: 248592
Maternal-neonatal outcome with Staphylococcus aureus rectovaginal colonization
OBJECTIVE: To estimate prevalence of rectovaginal colonization by Staphylococcus aureus among pregnant women with group B streptococcus (GBS) screening results and its association with maternal and infant outcomes. STUDY DESIGN: Cultures that detected both group B streptococcus (GBS) and S. aureus were obtained at > or = 35 weeks of gestation. Computerized database search and chart review determined invasive neonatal infection and maternal outcomes at the time of delivery through 6 months postpartum. RESULTS: A total of 6,626 GBS screening cultures met study criteria, and 769 (11.6%) GBS isolates and 67 (1.0%) S. aureus were identified. No maternal S. aureus-related outcomes were found. The rate of maternal methicillin-resistant S. aureus colonization was 0.1% (7 in 6,626). GBS-positive patients were twice as likely to be colonized with methicillin-susceptible S. aureus than GBS-negative patients. GBS-positive culture rates differed significantly by primary language: Spanish 10.0%, English 13.7%, Russian 26.9%, Cantonese 13.2%, Mandarin 11.5%, Arabic 15.9%, and other 17.8%. CONCLUSION: In our population, S. aureus colonization percentage (1.0%) was lower than the 7.5-8.2% reported by other medical centers, as was overall GBS carriage rate. S. aureus did not predispose to maternal or infant morbidity or mortality up to 6 months postpartum.
PMID: 22010527
ISSN: 0024-7758
CID: 224222
