Society for Maternal-Fetal Medicine Special Statement: Quality metric on the rate of postpartum diabetes screening after pregnancies with gestational diabetes mellitus.

As many as 1 in 3 patients with gestational diabetes mellitus have impaired glucose metabolism when screened postpartum. These patients have a 40% to 70% lifetime risk of progression to type 2 diabetes mellitus, but progression can be delayed or prevented by lifestyle interventions or medication. The American College of Obstetricians and Gynecologists and the American Diabetes Association recommend a glucose tolerance test at 4 to 12 weeks postpartum for all patients with gestational diabetes mellitus. Despite these recommendations, postpartum screening rates are typically <50%, representing a major healthcare "quality gap." The Society for Maternal-Fetal Medicine proposes a uniform metric that identifies the percentage of persons with gestational diabetes mellitus who completed a 75-g, 2-hour glucose tolerance test within 12 weeks after delivery. The metric is designed to be measured using diagnosis and procedure codes in payor claims data. Barriers to screening are discussed. Possible uses of the metric for quality improvement projects are outlined. Increasing the rate of postpartum diabetes screening should facilitate timely referral to implement lifestyle modifications, medication, and long-term follow-up. Use of the metric in financial incentive programs is discouraged at this time.

Society for Maternal-Fetal Medicine Special Statement: Postpartum visit checklists for normal pregnancy and complicated pregnancy.

Rising maternal morbidity and mortality rates, widening healthcare disparities, and increasing focus on cardiometabolic risk modification in at-risk patients have together catalyzed a shift in the postpartum care paradigm. What was once a single office visit in the 6 weeks after delivery is now being reimagined as a continuum of care that transitions patients from pregnancy to lifelong health optimization. However, this shift in postpartum care also comes with increased visit complexity and additional provider burden, particularly when patients have had significant pregnancy complications or have chronic diseases. To ensure that the comprehensive needs of both healthy and medically complex people are consistently met under this revised postpartum care paradigm, a postpartum visit checklist for uncomplicated postpartum patients and another checklist for those with major medical or obstetrical morbidities are presented. These checklists are designed to ensure that essential elements of physical and mental well-being are routinely considered, that adequate follow-up or specialty referrals are made, and that relevant future health risks are appropriately reviewed and discussed.

Society for Maternal-Fetal Medicine Special Statement: Quality metric for timely postpartum follow-up after severe hypertension.

Hypertensive disorders of pregnancy are a leading cause of maternal morbidity and mortality. Because postpartum exacerbation of severe hypertension is common, the American College of Obstetricians and Gynecologists recommends that patients with severe hypertension during the childbirth hospitalization be seen within 72 hours after discharge. In this statement, the Society for Maternal-Fetal Medicine proposes a uniform metric reflecting the rate of timely postpartum follow-up of patients with severe hypertension. The metric is designed to be measured using automated calculations based on billing codes derived from claims data. The metric can be used in quality improvement projects to increase the rate of timely follow-up in patients with severe hypertension during the childbirth hospitalization. Suggested steps for implementing such a project are outlined.

An in ovo chicken model to study the systemic and localized teratogenic effects of valproic acid.

BACKGROUND: The antiepileptic valproic acid (VPA) is a teratogen whose embryopathic mechanism(s) remain uncertain. Elucidating potential cellular and molecular effects of VPA is complicated by systemic application paradigms. We developed an in ovo model to reproduce the teratogenic effects of VPA and a localized VPA application procedure to determine whether VPA can selectively effect abnormal development in one region of the embryo. METHODS: VPA was applied topically to chicken embryos in ovo at different embryonic stages. Embryos were later evaluated for gross and skeletal anomalies. Pax-2 and Pax-6 protein expression in the developing eye was also evaluated because VPA-induced eye anomalies are similar to those seen by the disruption of Pax-2 and Pax-6. For localized application, a thin sheet of the synthetic polymer Elvax was impregnated with VPA. A small piece of the VPA-impregnated polymer was applied directly to the presumptive wing bud region in Stage 10-17 embryos. Embryos were examined for gross and skeletal anomalies. Sham controls were employed for all experiments. RESULTS: Chicken embryos exposed to VPA in ovo demonstrated increased mortality, growth delay and anomalies similar to ones previously seen in humans: neural tube, cardiovascular, craniofacial, limb and skeletal. Pax-2 and Pax-6 protein expression was qualitatively diminished in the eye. Localized wing bud VPA exposure caused structural abnormalities in the developing wing in the absence of other anomalies in the embryos. These wing defects were similar to those observed after topical whole-embryo VPA application. CONCLUSIONS: These results indicate that at least one mechanism for the teratogenicity of VPA involves a direct effect on developing tissue. The nature of the abnormalities observed implies that this effect may be mediated by disruption of genes that regulate pattern formation.

Relationship of plasma volume to sympathetic tone in nulliparous women.

OBJECTIVE: We sought to determine whether resting supine plasma volume is related to sympathetic tone in healthy young nulligravid normotensive women. STUDY DESIGN: Forty women were examined in the midfollicular phase. Alpha-adrenergic tone was estimated by an examination of the late phase II blood pressure response to the Valsalva maneuver. Resting heart rate was examined to evaluate the balance of sympathetic and parasympathetic input. Plasma catecholamines were measured during supine rest. Plasma volume was estimated by Evans blue dilution. RESULTS: Plasma volume corrected for body surface area was correlated inversely to late phase II blood pressure response to the Valsalva maneuver (r = -0.31, P <.05) and was correlated directly to the cardiac R-R interval (r = 0.41, P <.01). There was no relationship of plasma volume corrected for body surface area to mean arterial pressure (r = -0.13, P not significant). We found no significant relationship of plasma epinephrine concentration (r = -0.05, P =.76) or plasma norepinephrine (r = -0.09, P =.60) with plasma volume corrected for body surface area. CONCLUSION: We conclude that plasma volume is related inversely to both an estimate of alpha-adrenergic activation and heart rate. These findings are consistent with an adaptive physiologic response that is aimed at the maintenance of blood pressure in the face of reduced plasma volume.