Preventing Maternal Morbidity from Obstetric Hemorrhage: Implications of a Provider Training Initiative.

Objective The objective of this study was to compare severe morbidity due to obstetrical hemorrhage and its potential preventability before and after a mandated provider training initiative on obstetric hemorrhage. Study Design Cases of severe morbidity due to obstetric hemorrhage during 2006 (n = 64 before training initiative) and 2010 (n = 71 after training initiative) were identified by a two-factor scoring system of intensive care unit admission and/or transfusion of ≥ 3 units of blood products and reviewed by an expert panel. Preventable factors were categorized as provider, system, and/or patient related. Results Potential preventability did not differ between 2006 and 2010, p = 0.19. Provider factors remained the most common preventable factor (88.2% in 2006 vs. 97.4% in 2010, p = 0.18), but the distribution in types of preventable factors improved over time for delay or failure in assessment (20.6 vs. 0%, p < 0.01) and delay or inappropriate treatment (76.5 vs. 39.5%, p < 0.01). System factors also differed (32.4 vs. 7.9%, p = 0.015) with a notable decline in factors related to policies and procedures (26.5 vs. 2.6%, p < 0.01) between 2006 and 2010. Conclusion We found significant improvement in provider assessment and treatment of obstetric hemorrhage and a significant reduction in preventable factors related to policies and procedures after the training initiative.

Influence of gestational age and reason for prior preterm birth on rates of recurrent preterm delivery.

OBJECTIVE: We sought to compare rates of recurrent spontaneous preterm birth (SPTB) in women receiving 17-α-hydroxyprogesterone caproate (17P) with prior SPTB due to preterm labor (PTL) vs preterm premature rupture of membranes (PPROM). STUDY DESIGN: Women with singleton gestation having 1 prior SPTB enrolled at 16-24.9 weeks' gestation for weekly outpatient 17P administration were identified from a database. Rates of recurrent SPTB were compared between those with prior SPTB due to PTL or PPROM overall and by gestational age at prior SPTB. RESULTS: Records from 2123 women were analyzed. The prior PTL group vs the prior PPROM group experienced higher rates of recurrent SPTB at <37 weeks (29.7% vs 22.9%, P = .004), <35 weeks (14.0% vs 9.1%, P = .004), and <32 weeks (5.9% vs 3.3%, P = .024), respectively. CONCLUSION: Reason and gestational age of prior SPTB influence the likelihood of recurrent SPTB in women receiving 17P prophylaxis.

The effect of new antepartum weight gain guidelines and prepregnancy body mass index on the development of pregnancy-related hypertension.

We evaluated the impact of adherence to the new Institute of Medicine weight gain guidelines within each prepregnancy body mass index (PPBMI) category on the development of pregnancy-related hypertension (PRH). Patients with singleton term deliveries (≥37 weeks) with documented PPBMI and pregnancy weight gain information were identified from a database of women enrolled for outpatient nursing services. Included were women without history of cardiovascular disease, PRH, or diabetes at initiation of services (N = 7676). Data were stratified by PPBMI (underweight = < 18.5 kg/m(2); normal weight = 18.5 to 24.9 kg/m(2); overweight = 25.0 to 29.9 kg/m(2); obese = ≥ 30.0 kg/m(2)). PRH rates were compared overall and within each PPBMI group for those women gaining less than recommendations, within recommendations, and above recommendations using Pearson's chi-square and Kruskal-Wallis H test statistics. Overall, PRH rates were 5.0%, 5.4%, and 10.8% for less than, within, and above recommendation groups, respectively (P < 0.001). Above recommendation weight gain resulted in higher PRH incidence in each PPBMI category (underweight 7.6%, normal weight 6.2%, overweight 12.4%, and obese 17.0%), reaching statistical significance in all but the underweight PPBMI group. Excessive weight gain above established guidelines was associated with increased rates of PRH. Regardless of PPBMI, women should be counseled to avoid excessive weight gain during pregnancy.

The influence of maternal age on pregnancy outcome in nulliparous women with twin gestation.

We sought to determine if outcomes of nulliparous twin pregnancies differ based on maternal age. Nulliparous women with current twin pregnancies were identified from a database of women enrolled for outpatient nursing surveillance. Data were stratified into four groups by maternal age: less than 20, 20 to 34, 35 to 39, and greater than or equal to 40 years. Maternal and neonatal outcomes for women less than 20, 35 to 39, and 40 or more were compared with 20- to 34-year-old controls using Kruskal-Wallis, Mann-Whitney, and Pearson chi-square analyses. We analyzed 2144 nulliparous twin pregnancies. Patients ≥35 years (34 to 39, 78.5% or ≥40, 85.9%) were more likely to have cesarean deliveries compared with controls 20 to 34 years old (71.2%). Women aged 35 to 39 were less likely to deliver at <37 weeks, and women in the ≥40 group were less likely to deliver at <35 weeks due to spontaneous preterm labor compared with the controls. Neonates born to women aged 35 to 39 had a greater gestational age at delivery and larger average birth weight than controls. Maternal and neonatal outcomes were not adversely influenced by advanced maternal age in nulliparous women carrying twin gestations.