Laparoscopic supracervical hysterectomy vs. abdominal hysterectomy in a community hospital. A cost comparison.

OBJECTIVE: To evaluate the feasibility for an institution to offer laparoscopic supracervical hysterectomy as a cost-effective alternative to total abdominal hysterectomy (TAH) in a managed care environment. STUDY DESIGN: Retrospective study in which 138 consecutive laparoscopic supracervical hysterectomies performed between December 1992 and May 1996 were reviewed and compared to 354 consecutive TAHs performed during the same period. Operating time, use of operative room supplies, length of stay and actual total, fixed and variable costs of each case were calculated for the entire hospital stay and for each hospital cost center. Differences between costs were analyzed by ANCOVA using age, patient weight, specimen weight and number of operative procedures performed at the time of hysterectomy as covariants. RESULTS: The mean operative room time was significantly greater for laparoscopic supracervical hysterectomy than for TAH (167.4 [SD 51.2] vs. 103 minutes [30.3, P < .001]). In contrast, length of stay was significantly shorter for laparoscopic supracervical hysterectomy than for TAH (0.8 [SD 1.1] vs. 3.4 days [.9, P < .001]). The adjusted mean costs of both operative room time and supplies were significantly higher for laparoscopic supracervical hysterectomy than for TAH (P < .001). In contrast, the mean cost of length of stay for laparoscopic supracervical hysterectomy was significantly lower (P < .001). However, the adjusted mean total costs of the entire hospital stay were not significantly different: $2,716 for laparoscopic supracervical hysterectomy vs. $2,702 for TAH (F = .7, P = .8). The absence of significant differences between procedures resulted from our limited use of disposable supplies (no automated stapling device) and from shorter lengths of stay, which compensated well for the higher operative room costs of time and supplies incurred with laparoscopic supracervical hysterectomy. CONCLUSION: Laparoscopic supracervical hysterectomy is, at least in the short term, a cost-effective alternative to TAH in a managed care environment.

Improving the processes of care and outcomes in obstetrics/gynecology.

BACKGROUND: The obstetrics/gynecology department of York Hospital (York Health System, York, Pennsylvania) initiated a program to improve the processes of care and control costs for common women's and newborns' health care services. Twelve clinical policies were established between June 1993 and February 1995. CONDUCTING THE QUALITY IMPROVEMENT (QI) PROJECTS: Using the plan-do-check-act (PDCA) improvement cycle method, the QI group established clinical pathways for high-volume conditions or procedures known to have low rates of complications and clinical guidelines for those conditions or procedures not requiring coordinated efforts of a group of health care professionals. EXAMPLE--PYELONEPHRITIS IN PREGNANCY: The literature had indicated that the prevalence of pyelonephritis can be decreased by identifying and treating asymptomatic bacteriuria early in prenatal care. After the validity of the clinical policy was demonstrated in the resident service, the policy was extended to all private obstetric practices. Dissemination of the finding that most of the admissions for pyelonephritis were for referred patients (for whom we had no control over prenatal care) or for patients referred by private physicians who were not yet following the guidelines quickly led to complete compliance by our obstetricians and other health care providers referring patients to the York Health System. RESULTS: The 12 clinical policies resulted in the elimination of 113 admissions and 5,595 inpatient days and in the reduction of the cost of patient care by $1,306,214 for the years 1994-1995 and 1995-1996 combined, without apparent adverse effects on patient health. CONCLUSION: A voluntary clinical policies program can change the culture of a department and lead to cost-effectiveness and better quality of patient care.

Prediction of the neonatal crown-heel length from femur diaphysis length measurements.

The usefulness of the Rossavik growth model in predicting crown-heel length (CHL) was evaluated in 50 women with normal singleton pregnancies in a Dutch population. The femur diaphysis lengths (FDL) were predicted assuming growth cessation at 38, 39, 39.5, and 40 weeks, menstrual age (MA), and at birth using Rossavik growth models determined from two second-trimester FDL measurements. Predicted CHLs were then calculated from predicted FDLs using six different equations. Predicted CHLs were compared with the actual neonatal CHLs and the percent differences calculated. The growth potential realization index (GPRI) values were also determined. With all six equations, regression analysis revealed a significant relationship between the percent differences and birth ages for those infants delivering after 38 and 39 weeks, MA, respectively. The signs of the slopes of the regression lines were negative, indicating continued growth of these fetuses. With the Vintzileos equation, no evidence of continued growth was obtained after 39.5 weeks, MA. The systematic prediction error at this time point was 0.9%, whereas the random error was 3.3%. The mean GPRICHL was 99%, with a 95% range of 93% to 104%. These findings indicate that the CHL can be predicted with a high degree of accuracy in this Dutch population if the appropriate growth cessation age and FDL-CHL function are used.

Small-for-menstrual-age infants: different subgroups detected using individualized fetal growth assessment.

Our purpose was to study the individual fetal growth patterns of infants who were born small-for-menstrual-age. Growth in the second and third trimester was assessed in 98 small-for-menstrual-age infants, using individual fetal growth curves generated by the growth model: P = c(t)k+s(t). Growth indices were compared with those previously reported for that method in infants with normal growth. The small-for-menstrual-age infants were distributed into four growth patterns, ie, infants with either normal or decreased second-trimester growth indices, who, by the time of birth, succeed or fail in fulfilling their individual growth potential. These four growth patterns appear to be associated with different pathophysiological mechanisms and incidences of perinatal complications. Individual fetal growth assessment identifies differences in genetically determined growth and differentiates between fetuses who achieve their growth potential and those with growth failure who are at greater risk for fetal compromise.

Prenatal diagnosis of fetal pelvic kidney. A case report.

Published experience on prenatal diagnosis of pelvic kidney is limited. We present the ultrasonographic characteristics of a case of ectopic pelvic kidney and discuss the significance of prenatal diagnosis.

Functional asymmetry of the human myometrium documented by color and pulsed-wave Doppler ultrasonographic evaluation of uterine arcuate arteries during Braxton Hicks contractions.

OBJECTIVE: We hypothesized that arcuate arteries supplying placental and nonplacental myometrial portions would respond with different degrees of change in their resistance during Braxton Hicks contractions. STUDY DESIGN: We examined 20 healthy pregnant women between 18 and 24 weeks' gestation with pulsed-wave and color-flow Doppler during focal Braxton Hicks contractions identified by real-time ultrasonography by means of the characteristic thickening of the myometrium. Systolic/diastolic ratio was used as an expression of resistance. Statistical analysis was performed by Wilcoxon signed-ranks and Mann-Whitney test. RESULTS: When the contractions are localized in the subplacental myometrium, the resistance of the arcuate artery did not differ during and after the contraction. In contrast, when the contraction involved only nonplacental myometrium, the resistance during the contraction was significantly higher and in some patients there was complete absence of flow during the diastolic phase. During subplacental myometrial contractions, the main uterine artery resistance was not affected. When the contraction involved the nonplacental myometrium, the resistance of the main uterine artery increased with more pronounced changes when the contraction involved the lateral myometrial wall ipsilateral to the uterine artery under examination. CONCLUSION: We speculate that the differences in the degree of resistance change are the result of different degrees of contractility exhibited by the subplacental and nonplacental myometrium. We conclude that the intact human myometrium manifests functional asymmetry and our Doppler findings confirm previous in vitro studies.

Comparison of fetal cerebellar measurements by two different techniques.

We examined 53 fetuses between 15 and 40 weeks of gestation with transverse and coronal sections of the head in order to evaluate the accuracy and reproducibility of the coronal cerebellar diameter. Intraobserver coefficient of variation was less than or equal to 2.2% and the mean interobserver difference was 2.2% (range, 0 to 6%). A positive linear correlation exists between transverse and coronal measurements (coronal diameter = 1.02 x transverse diameter - 0.48; R2 = 0.99; P less than 0.0001). We conclude that the coronal cerebellar diameter is reproducible and accurate and when indicated clinically can be used instead of the transverse cerebellar diameter when the latter is not obtainable because of fetal position.

Effect of measurement variability on Rossavik growth model specification and prediction of growth outcome at birth.

We have studied how variability in second-trimester ultrasound measurements affects the process of fetal growth evaluation based on individual fetal growth curve standards specified by Rossavik growth models. The head and abdominal short axes of two second-trimester scans of a patient with normal fetal growth were increased or decreased by increments ranging from 0.1 cm to values equal to the two standard deviations of the interobserver variability for these measurements--i.e., 0.3 cm for head short axis and 0.4 cm for abdominal short axis. The largest increments affected the Growth Potential Realization Index for weight at birth by 1% to 13% when applied to head short axis, and by 2% when applied to abdominal short axis. In contrast, the same increments had little effect (1%) on the Growth Potential Realization Indices for head and abdominal circumferences. Whereas 0.1-cm increments had no effect on any of the individual growth models or predicted birth characteristics, some combinations of these small errors involving both head and abdominal short axes changed the Growth Potential Realization Index for weight by as much as 15%, and those for head and abdominal circumferences by 3% and 8%, respectively. Under some scenarios, fetal growth status could be falsely classified as normal or abnormal. These results show that the reliability of individualized growth assessment depends to a great extent on excellent ultrasound technique, at least for certain parameters.

Interrelationship and clinical significance of increased resistance in the uterine arteries in patients with hypertension or preeclampsia or both.

OBJECTIVES: This study was designed to evaluate the clinical significance of the Doppler flow velocity waveform analysis of the two uterine arteries on an individual basis and in combination expressed as the mean uterine artery. STUDY DESIGN: We evaluated uterine artery resistance by means of continuous wave Doppler ultrasonography in 123 pregnant women with chronic hypertension, preeclampsia, or both. The placental location was determined by real-time ultrasonography. Clinical outcomes were compared according to uterine artery abnormalities. The Doppler flow studies were not used in patient management. RESULTS: In patients with unilateral placentas (n = 67) the placental uterine artery was found to be a better predictor of poor pregnancy outcome than the nonplacental artery and the mean of the two arteries. There was a strong degree of correlation between abnormal nonplacental uterine artery and abnormal mean of uterine artery (r = 0.75, p less than 0.001), and there was a moderate degree of correlation between abnormal placental uterine artery and abnormal mean uterine artery (r = 0.46, p less than 0.001). Uterine artery discordance (left-right uterine artery systolic/diastolic ratio) was mostly the result of an abnormal nonplacental uterine artery (r = 0.74, p less than 0.0001) and not the result of an abnormal mean uterine artery (r = 0.44, p less than 0.003); the degree of discordance did not relate to pregnancy outcome. Unilateral placental location was associated with longer stays in neonatal intensive care units and more perinatal deaths. CONCLUSION: Because of the differences between the two uterine arteries, we conclude that for proper interpretation of uterine artery flow velocity waveforms, the placental location should be known and each vessel analyzed individually.

Treatment of fetal supraventricular tachycardia with flecainide acetate after digoxin failure.

Transplacentally administered digoxin is the drug of choice for the treatment of fetal supraventricular tachycardia. We describe a case of fetal supraventricular tachycardia associated with fetal hydrops that did not respond to digoxin treatment because of a lack of transplacental passage. In contrast, flecainide acetate crossed the placenta and cured the fetus. The clinical implications of this new treatment are discussed.

Detection of macrosomia by the individual fetal growth curve assessment method.

The value of the Rossavik growth model [P = c(t)k + s(t)] was evaluated in 39 patients with singleton pregnancy who had neonatal weight outcome above the 90th percentile of our birth weight distribution for gestational age. Individual fetal growth curve standards for head and abdominal circumferences, femur diaphysis length, and weight were determined from the data of two scans obtained before 26.1 weeks' gestation and separated by an interval of at least 5 weeks. Projected crown-heel lengths were calculated from projected femur diaphysis length values. Comparisons between actual and predicted birth characteristics were expressed by the Growth Potential Realization Index (GPRI) and Neonatal Growth Assessment Score (NGAS). Excessive growth at birth was seen in almost all cases as indicated by high GPRI for weight and abdominal circumference and abnormal NGAS values. In eight of the 33 patients who delivered after 38 weeks, excessive growth was detected only by comparing birth characteristics to their predicted values at 38 weeks' gestation. Our data suggest that individual growth curve standards may identify several patterns of excessive fetal growth that could represent different pathophysiologic mechanisms, ie, failure to terminate growth after 38 weeks versus a defect in a still unknown growth regulator. The individual fetal growth curve standards method gives additional information and discriminates well between normal and excessive fetal growth.

Twin pregnancy after orthotopic liver transplantation, with exacerbation of chronic graft rejection.

We report the sixth pregnancy and the first occurrence of twins after liver transplantation, and the second time cyclosporine was used in pregnancy for that indication. The pregnancy was interrupted at 33 weeks, menstrual age, for exacerbation of chronic graft rejection and intrauterine growth retardation of both twins with possible fetal compromise. The neonatal outcomes were good without any detected anomalies except for some neurodevelopmental problems in one twin at the long-term follow-up. The mother underwent a second liver transplant shortly after delivery.

Detection of intrauterine fetal growth retardation with abdominal circumference and estimated fetal weight using cross-sectional growth curves.

The usefulness of a cross-sectional growth curve method in the detection of intrauterine growth retardation by ultrasonography was evaluated for abdominal circumference and estimated fetal weight. The patient sample consisted of 771 women with singleton pregnancy who delivered within seven days of an ultrasound scan. One hundred fifty-one (19.6%) women had infants with birth weight below the 10th percentile for menstrual age. Of these infants, 72.2% were symmetrically growth retarded on the basis of their neonatal ponderal index. The neonatal weight outcomes were correlated with the abdominal circumference and estimated fetal weight percentile values. Both measurements were more specific than sensitive and had much higher negative than positive predictive values. The sensitivity was influenced by menstrual age, and severity and type of intrauterine growth retardation. Overall, estimated fetal weight was more accurate than abdominal circumference, but the difference was too small to be clinically important. Both measurements were better suited to confirm than to detect, exclude, or predict intrauterine growth retardation. Normal results predicted a normal neonatal weight outcome with a very high probability when the prevalence of the condition was low. In spite of the limitations of the cross-sectional method, both tests had strengths that can be advantageously used to enhance clinical decision making in the management of intrauterine growth retardation.

Effect of the pretest probability of intrauterine growth retardation on the predictiveness of sonographic estimated fetal weight in detecting IUGR: a clinical application of Bayes' theorem.

Four hundred and five women with singleton pregnancies and fetal age determination by crown-rump length were classified on the basis of their prenatal clinical findings into four risk categories for intrauterine growth retardation (IUGR), defined as a neonatal weight below the 10th percentile of age-dependent birth weight distribution curve. The incidence of IUGR in these four groups were 3.5% (very low risk), 20.6% (low risk), 49.6% (intermediate risk), and 88.0% (high risk). Severe growth retardation (birth weight less than 2.5th percentile) increased from 0% to 76.0% as the incidence of IUGR increased throughout the risk groups. The effect of these pretest risks on the prediction of severe IUGR by sonographic estimated fetal weight (EFW) was evaluated. The positive predictive value of the test, as well as the probability of having a growth-retarded infant after a normal EFW was obtained were considerably higher when the pretest probability of IUGR increased. In the very low risk group, the probability of severe IUGR was negligible regardless of the EFW. When the EFW was less than 10th percentile of our age-dependent EFW curve, the probability of severe IUGR in the other risk groups was high enough to warrant fetal well-being surveillance and/or timely interruption of gestation as appropriate. However, when the pretest probability was high, the risk of severe IUGR in spite of an EFW within the 10th percentile to 90th percentile remained sufficient to require fetal well-being surveillance as well. The study shows that placing ultrasound results in the context of the pretest risk of IUGR may improve clinical decision making in pregnancies complicated by fetal growth retardation.

Evaluation of fetal growth by ultrasonography in twin pregnancy: a comparison between individual and cross-sectional growth curve standards.

Cross sectional curves and individual fetal growth curves standards from the Rossavik growth model [P = c(t)(k + s(t]] were generated for abdominal and head circumferences, femur diaphysis length and estimated fetal weight from a sample of 59 women with twin pregnancy. These curves were compared to their counterparts in singleton pregnancies. Cross sectional curves of the four fetal anatomic parameters under study fell progressively below the curves for singletons during the last trimester of gestation. In contrast, there were few differences between individual fetal groWth curve standards for twin and singleton pregnancies. In 11 of the 59 patients, both methods were used to evaluate fetal growth in the last trimester of gestation. In 5 of these patients, fetal growth was normal by both methods in all 10 fetuses. In the 6 other patients, there were 3 fetuses with abormal estimated fetal weights (EFWs) by both population and individual standards. However, 3 fetuses had abnormal EFW's by populations standards but not by individual standards while the EFW of another fetus was abnormal by individual standards but not by population standards. These results illustrate that the cross-sectional approach to the assessment of growth in twins can be misleading and may lead to incorrect conclusions concerning the growth of these fetuses.

Individual growth curve standards in twins: prediction of third-trimester growth and birth characteristics.

The ability of Rossavik growth models, determined from measurements obtained before 24 weeks, to predict third-trimester growth and birth characteristics in normally growing twins has been investigated. Third-trimester values for head circumference, abdominal circumference, and femur diaphysis length were predicted with an accuracy of +/- 6% to 9% (95% to 98% of percent deviations). For thigh circumference and estimated weight, the comparable values were +/- 15% and +/- 16%, respectively. The head circumference at birth was predicted without bias; the random error was approximately +/- 5% (94% of percent differences). Weight, abdominal circumference, and thigh circumference were systematically overestimated (3.1%, 14.9%, and 11.3%, respectively) as a result of differences in prenatal and postnatal measurement procedures. After correction for systematic errors, these parameters could be predicted with random errors of -11.5% to 7.2% (weight), -12.8% to 5.4% (abdominal circumference), and -15.3% to 10.0% (thigh circumference). Growth Potential Realization Index values were found to have means of approximately 100% and ranges from 91% to 118%. These results are similar to those for singletons and indicate that individual assessment of growth in twins can be carried out with the same methods used for singletons.

Effect of timing of initial scan and interval between scans on Rossavik growth model specification.

The effect of the time of the initial scan and the interval between the two scans needed for Rossavik growth model specification was evaluated in 20 normally growing fetuses. Based on systematic and random prediction errors, determined by comparing predicted values to measured values obtained after 27 weeks, menstrual age, optimal results for all parameters studied were obtained with an initial scan at 18 weeks and an interval of 6 weeks between scans. For one-dimensional parameters--head circumference (HC), abdominal circumference (AC), and femur diaphysis length (FDL)--similar results were obtained with an initial scan at 15 weeks and an interval of 3 weeks, but systematic overestimations were seen with 9-week intervals for HC. Studies with three-dimensional parameters--head cube, abdominal cube, and estimated weight--indicated that the timing of the initial scan was not critical, although less variability was seen with the initial scan at 18 weeks. However, the use of 3-week and 9-week intervals (instead of 6 weeks) produced significant systematic errors that varied with the parameter studied. These results suggest that Rossavik growth model specification is possible under a variety of conditions, but both the timing of the initial scan and the interval between scans must considered for each parameter.

Influence of the interval between time points on individual fetal growth curve standards derived from Rossavik models and two ultrasound scans before 26 weeks, menstrual age.

We studied the influence of the interval between the two scans used before 26 weeks' menstrual age to generate individual fetal growth curve standards utilizing the Rossavik growth model: P = c(t) kappa + s(t) (model specification functions previously reported). Intervals of 3 weeks to 12 weeks were suitable for predicting the growth of the abdominal and head circumferences and femur diaphysis length in individual fetuses. However, large systematic and random errors were found with intervals less than 5 weeks for three-dimensional parameters such as the head and abdominal cubes and estimated fetal weight. In addition, the data suggest that the systematic errors for these latter parameters may increase with intervals of 10 weeks or more. Overall, optimal individual fetal growth curve standards were best generated from two scans before 26 weeks' menstrual age separated by 5 weeks to 9 weeks.

Prediction of normal fetal growth by the Rossavik growth model using two scans before 27 weeks, menstrual age.

Individual growth curve standards for five fetal anatomic parameters (head and abdominal circumferences, head and abdominal cubes, and femur diaphysis length) and estimated fetal weight were prospectively developed in 70 pregnant women who delivered infants with growth considered appropriate-for-menstrual age. For this purpose, we used the Rossavik growth model (P = c(t) kappa + s(t], model specification functions previously reported, and the data of two scans before 27.0 weeks of menstrual age, separated by an interval of at least 5 weeks. The anatomic parameters and estimated weights of these fetuses in the last 14 weeks of gestation were found to have values close to their projected standards. Whereas there was a significant, although small, systematic error of overprediction for most of the parameters and estimated fetal weight, deviations between observed and expected values were, with few exceptions, within the ranges established by Deter for normal growth. This study demonstrates that the Rossavik growth model could be used to predict normal fetal growth in a sample of patients different from those from which the model was developed.