Faculty Bibliography

OBJECTIVE:Obstetric hypertensive emergency is defined as having systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110 mmHg, confirmed 15 min apart. ACOG recommends that acute-onset, severe hypertension be treated with first line-therapy (IV labetalol, IV hydralazine or PO nifedipine) within 60 minutes to reduce risk of maternal morbidity and mortality. Therefore, our objective was to identify barriers that lead to delayed treatment of obstetric hypertensive emergency. STUDY DESIGN/METHODS:A retrospective cohort study was performed comparing women appropriately treated within 60 minutes versus those with delay in first line therapy. We identified 604 patients with discharge diagnoses of chronic hypertension, gestational hypertension or preeclampsia using ICD-10 codes and obstetric antihypertensive usage in a pharmacy database at one academic institution from January 2017 - June 2018. 267 subjects (44.2%) experienced obstetric hypertensive emergency in the intrapartum period or within two days of delivery. 213 subjects were used for analysis. We evaluated maternal characteristics, presenting symptoms and circumstances, timing of hypertensive emergency, gestational age at presentation, and administered medications. Chi square, Fisher's exact, Wilcoxon ran-sum and sample t-tests were used to compare the two groups. Univariable logistic regression was applied to determine predictors of delayed treatment. Multivariable regression model was also performed, C-statistic and Hosmer and Lemeshow goodness-of-fit test were used to assess the model fit. A result was considered statistically significant at p<0.05. RESULTS:Of the 213 women, 110 (51.6%) had delayed treatment vs. 103 (48.4%) who were treated within 60 min. Patients who had delayed treatment were 3.2 times more likely to present with an initial BP in the non-severe range vs those who had timely treatment (OR=3.24, 95% CI:1.85-5.68). Timeliness of treatment was associated with presence or absence of preeclampsia symptoms-- patients without pre-eclampsia symptoms were 2.7 times more likely to have delayed treatment (OR=2.68, 95%CI:1.50-4.80). Patients with HTN emergencies that occurred overnight between 10pm-6am were 2.7 times more likely to have delayed treatment vs. those that occurred between 6am-10pm (OR 2.72, 95% CI: 1.27-5.83). Delayed treatment also had an association with race, with Caucasian patients being 1.8 times more likely to have delayed treatment (OR=1.79; 95% CI: 1.04-3.08). Patients treated under 60 min had a lower gestational age at presentation vs those with delayed treatment (34.6±5wk vs. 36.6±4wks, respectively, p <0.001). For every 1 week increase in gestational age at presentation, there was a 9% increase in the likelihood of delayed treatment (OR 1.11; 95%CI:1.04-1.19). Another factor associated with delay of treatment was presenting complaint of labor symptoms, which made patients 2.2 times as likely to experience treatment delay (OR=2.17; 95%CI: 1.07-4.41). CONCLUSION/CONCLUSIONS:Initial blood pressure in non-severe range, absence of preeclampsia symptoms, presentation overnight, Caucasian race, presenting complaint of labor symptoms, and increasing gestational age at presentation are barriers that lead to delay in treatment of obstetric hypertensive emergency. Quality improvement initiatives targeting these barriers should be instituted to improve timely treatment.

BACKGROUND:During labor, maintenance of maternal euglycemia is critical to decrease the risk of neonatal hypoglycemia and associated morbidities. When continuous intravenous insulin infusion is needed, standardized insulin dosing charts have been used for titration of insulin to maintain glucose in target range. The GlucoStabilizer software program (Indiana University Health Inc, Indianapolis, IN) is a software-guided insulin dosing system that calculates the dose of intravenous insulin that is needed based on metabolic parameters, target glucose concentration, and an individual's response to insulin. Although this tool has been validated and shown to reduce both hypoglycemia and errors in critical care settings, the utility of this software has not been examined in obstetrics. OBJECTIVE:The purpose of this study was to determine whether the use of intravenous insulin dosing software in women with pregestational or gestational diabetes mellitus that requires intrapartum insulin infusion can improve the rate of glucose concentration in target range (70-100 mg/dL; 3.9-5.5 mmol/L) at the time delivery. STUDY DESIGN/METHODS:We performed a retrospective cohort study comparing laboring patients with diabetes mellitus that required insulin infusion who were dosed by standard insulin dosing chart vs the GlucoStabilizer software program from January 2012 to December 2017. The GlucoStabilizer software program, which was implemented in May 2016, replaced the standard intravenous insulin dosing chart. Inclusion criteria were women with pregestational or gestational diabetes mellitus who were treated with an intravenous insulin infusion intrapartum for at least 2 hours. Maternal characteristics, glucose values in labor, and neonatal outcomes were extracted from delivery and neonatal records. The primary outcome was the percentage of women who achieved the target glucose range (defined as a blood glucose between 70-100 mg/dL; 3.9-5.5 mmol/L) before delivery. Parametric and nonparametric statistics were used to compare both groups; a probability value of <.05 was considered statistically significant. RESULTS:We identified 22 patients who were dosed by a standard insulin dosing chart and 11 patients who were dosed by the GlucoStabilizer software program during intrapartum management. The GlucoStabilizer software program was superior in achieving glucose values in target range at delivery (81.8% vs 9.1%; P<.001) compared with standard insulin dosing without increasing maternal hypoglycemia (0% vs 4.3%; P=.99). Patients whose insulin dosing was managed by the GlucoStabilizer software program also had lower mean capillary blood glucose values compared with the standard insulin infusion (102.9±5.9 mg/dL [5.7±0.33 mmol/L] vs 121.7±5.9 mg/dL [6.8±0.33 mmol/L]; P=.02). Before the initiation of the infusion, both groups demonstrated mean capillary blood glucose values outside of target range (122.6±8.8 mg/dL [6.7±0.49 mmol/L] for the GlucoStabilizer software program vs 131.9±10.1 mg/dL [7.3±0.56 mmol/L] for standard insulin treatment group; P=not significant). There were no significant differences in baseline maternal characteristics between the groups or neonatal outcomes. CONCLUSION/CONCLUSIONS:This study is the first to demonstrate that the use of software-guided intravenous insulin dosing in obstetrics can improve intrapartum glycemic management without increasing hypoglycemia in women with both pregestational and gestational diabetes mellitus that is treated with an insulin infusion.

OBJECTIVES/OBJECTIVE:To determine the feasibility in visualizing placental cord insertion (PCI) during second-trimester fetal anatomical survey and the association between marginal cord insertion (MCI) and preterm delivery (PTD) and low birth weight (LBW). Our secondary objectives were to evaluate the association of MCI with adverse composite obstetrical and neonatal outcomes. METHODS:A prospective cohort study was performed over a 28-month period. Women with singleton pregnancies presenting for routine anatomical survey between 18 and 22 weeks' gestation were included. PCI site was visualized on 2D grayscale and color Doppler and the shortest distance from the sagittal and transverse planes to the placental edge were recorded. MCI was diagnosed when any of measured distances was ≤2 cm. Correlations were assessed via bivariate chi-squared, independent t-test analyses and Fisher's exact tests. Regression models evaluated associations between MCI and adverse composite outcomes. RESULTS:Three hundred one women were included and PCI was feasible in all cases. The incidence of MCI was 11.3% (n = 34). Baseline characteristics between those with and without MCI were similar, except for story of prior PTD, which was greater among those with MCI (17.65 versus 7.17%, p = .04). MCI was associated with increased likelihood of LBW (RR four; 95%CI, 1.46-10.99) and PTD (RR 3.2; 95%CI, 1.53-6.68); in multivariate analysis, we found associations between MCI and composite adverse obstetrical (RR 2.33; 95%CI, 1.30-4.19) and neonatal (RR 2.46; 95%CI, 1.26-4.81) outcomes. CONCLUSIONS:Evaluation of PCI is feasible in all cases. Second-trimester MCI is associated with increased likelihood for LBW, PTD, and composite adverse obstetrical and neonatal outcomes.