Routine Multidisciplinary Review of Severe Maternal Morbidity Is Associated with a Reduction in Preventable Cases of Severe Maternal Morbidity.

OBJECTIVE: Severe maternal morbidity (SMM) has increased by 45% in the United States and is estimated to affect up to 1.5% of all deliveries. Research has not yet been conducted that demonstrates a benefit to multidisciplinary review of SMM. The aim of our study was to determine if standardized, routine review of the cases of SMM by a multidisciplinary committee results in a reduction of potentially preventable cases of SMM. STUDY DESIGN: A retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from March 1, 2012 to September 30, 2016. Our cohort was separated into two groups: a preintervention group composed of women admitted for delivery prior to the implementation of the obstetric Quality and Peer Review Committee (OBQPRC), and a postintervention group where the committee had been well established. Cases of confirmed SMM were presented to a multidisciplinary research committee, and the committee determined whether opportunities for improvement in care existed. The groups were compared with determine if there was a decreased incidence of preventable SMM following the implementation of the OBQPRC standardized review process. RESULTS: There were 30,319 deliveries during the study period; 13,120 deliveries in the preintervention group; and 13,350 deliveries in the postintervention group (2,649 deliveries during the transition period). There was no difference in the rate of SMM between the preintervention (125; 0.95%) and postintervention (129; 0.97%) groups, (p = 0.91). There was a significantly lower rate of opportunity for the improvement in care in the postintervention group (29.5%) compared with the preintervention group (46%; p = 0.005). CONCLUSION: We demonstrated a significant reduction in the rate of potentially preventable SMM following the implementation of routine review of all SMM suggesting that this process plays an important role in improving maternal care and outcomes. KEY POINTS: · Benefit to routine review of SMM has not been demonstrated.. · Routine review of SMM is associated with 36% reduction in potentially preventable SMM.. · This is the first study to demonstrate the benefit of routine review of SMM..

Opportunities for improvement in care among women with severe maternal morbidity.

BACKGROUND: Severe maternal morbidity is increasing in the United States and has been estimated to occur in up to 1.3% of all deliveries. A standardized, multidisciplinary approach has been recommended to identify and review cases of severe maternal morbidity to identify opportunities for improvement in maternal care. OBJECTIVE: The aims of our study were to apply newly described gold standard guidelines to identify true severe maternal morbidity and to utilize a recently recommended multidisciplinary approach to determine the incidence of and characterize opportunities for improvement in care. STUDY DESIGN: We conducted a retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from Jan. 1, 2012, through June 30, 2014. Electronic medical records were screened for severe maternal morbidity using the following criteria: International Classification of Diseases, Ninth Revision codes for severe illness identified by the Centers for Disease Control and Prevention; prolonged length of stay; intensive care unit admission; transfusion of ≥4 U of packed red blood cells; or hospital readmission within 30 days of discharge. A multidisciplinary team conducted in-depth review of each medical record that screened positive for severe maternal morbidity to determine if true severe maternal morbidity occurred. Each true case of severe maternal morbidity was presented to a multidisciplinary committee to determine a consensus opinion about the morbidity and if opportunities for improvement in care existed. Opportunity for improvement was described as strong, possible, or none. The incidence of opportunity for improvement was determined and categorized as system, provider, and/or patient. Morbidity was classified by primary cause, organ system, and underlying medical condition. RESULTS: There were 16,323 deliveries of which 386 (2%) screened positive for severe maternal morbidity. Following review of each case, true severe maternal morbidity was present in 150 (0.9%) deliveries. We determined by multidisciplinary committee review that there was opportunity for improvement in care in 66 (44%) cases. The 2 most common underlying causes of severe maternal morbidity were hemorrhage (71.3%) and preeclampsia/eclampsia (10.7%). In cases with opportunity for improvement in care, provider factors were present in 78.8%, followed by patient (28.8%) and system (13.6%) factors. CONCLUSION: We demonstrated the feasibility of a recently recommended review process of severe maternal morbidity at a large, academic medical center. We demonstrated that opportunity for improvement in care exists in 44% of cases and that the majority of these cases had contributing provider factors.

Lack of Association Between Race and Ethnicity and Timely Treatment of Severe Peripartum Hypertension.

BACKGROUND: Hypertensive disorders of pregnancy are a leading cause of severe maternal morbidity and mortality. National guidelines recommend treatment within 30 to 60 minutes of confirmed severe hypertension to reduce the risk of maternal stroke. The objectives of this study were to quantify the number of patients who did not receive timely treatment of severe hypertension, identify barriers to timely treatment, and evaluate if race/ethnicity was associated with timeliness of treatment. METHODS: The researchers created an automated report to identify women who experienced severe hypertension during the delivery admission. The record for each case was reviewed to determine if treatment was timely (within 30 minutes). The study team compared rates of severe peripartum hypertension and rates of timely vs. not timely treatment by race/ethnicity. RESULTS: There were 12,069 deliveries from April 1, 2019, to March 31, 2021-with 684 (5.7%) women with at least one episode of severe hypertension, of whom 241 (35.2%) did not require treatment, leaving 443 (64.8%) women requiring treatment. A total of 441 women received treatment, with 417 (94.6%) treated in a timely manner. Black, Asian, and Hispanic women were all more likely to experience severe hypertension requiring treatment than white women (10.0%, 8.8%, 7.3% vs. 4.0%, respectively, p < 0.001). However, there was no difference in the in the rates of timely treatment between groups (92.6%, 93.0%, 93.9% vs. 96.3%, respectively, p = 0.59). CONCLUSION: Among patients with severe hypertension, 94.6% were treated in a timely manner, and race/ethnicity was not associated with timeliness of treatment. Provider education at all levels at our institution seems to be effective for timely treatment of severe hypertension and suggests that this process could be beneficial at other institutions.

Impact of labor and delivery unit policy modifications on maternal and neonatal outcomes during the coronavirus disease 2019 pandemic.

Background: In response to the coronavirus disease 2019 pandemic, hospitals nationwide have implemented modifications to labor and delivery unit practices designed to protect delivering patients and healthcare providers from infection with severe acute respiratory syndrome coronavirus 2. Beginning in March 2020, our hospital instituted labor, and delivery unit modifications targeting visitor policy, use of personal protective equipment, designation of rooms for triage and delivery of persons suspected or infected with coronavirus disease 2019, delivery management, and newborn care. Little is known about the ramifications of these modifications in terms of maternal and neonatal outcomes. Objective: The objective of this study was to determine whether labor and delivery unit policy modifications we made during the coronavirus disease 2019 pandemic were associated with differences in outcomes for mothers and newborns. Study Design: We conducted a retrospective cohort study of all deliveries occurring in our hospital between January 1, 2020, and April 30, 2020. Patients who delivered in January and February 2020 before labor and delivery unit modifications were instituted were designated as the preimplementation group, and those who delivered in March and April 2020 were designated as the postimplementation group. Maternal and neonatal outcomes between the pre- and postimplementation groups were compared. Differences between the 2 groups were then compared with the same time period in 2019 and 2018 to assess whether any apparent differences were unique to the pandemic year. We hypothesized that maternal and newborn lengths of stay would be shorter in the postimplementation group. Statistical analysis methods included Student's t-tests and Wilcoxon tests for continuous variables and chi-square or Fisher exact tests for categorical variables. Results: Postpartum length of stay was significantly shorter after implementation of labor unit changes related to coronavirus disease 2019. A postpartum stay of 1 night after vaginal delivery occurred in 48.5% of patients in the postimplementation group compared with 24.9% of the preimplementation group (P<.0001). Postoperative length of stay after cesarean delivery of ≤2 nights occurred in 40.9% of patients in the postimplementation group compared with 11.8% in the preimplementation group (P<.0001). Similarly, after vaginal delivery, 49.0% of newborns were discharged home after 1 night in the postimplementation group compared with 24.9% in the preimplementation group (P<.0001). After cesarean delivery, 42.5% of newborns were discharged after ≤2 nights in the postimplementation group compared with 12.5% in the preimplementation group (P<.0001). Slight differences in the proportions of earlier discharge between mothers and newborns were due to multiple gestations. There were no differences in cesarean delivery rate, induction of labor, or adverse maternal or neonatal outcomes between the 2 groups. Conclusion: Labor and delivery unit policy modifications to protect pregnant patients and healthcare providers from coronavirus disease 2019 indicate that maternal and newborn length of stay in the hospital were significantly shorter after delivery without increases in the rate of adverse maternal or neonatal outcomes. In the absence of long-term adverse outcomes occurring after discharge that are tied to earlier release, our study results may support a review of our discharge protocols once the pandemic subsides to move toward safely shortening maternal and newborn lengths of stay.

Maternal Mortality in the Twenty-First Century.

Maternal mortality plagues much of the world. There were 303,000 maternal deaths in 2015 representing an overall global maternal mortality ratio of 216 maternal deaths per 100,000 live births. In the United States, the maternal mortality ratio had been decreasing until 1987, remained stable until 1999, and then began to increase. Racial disparities exist in the rates of maternal mortality in the United States with maternal death affecting a higher proportion of black women compared with white women. To reduce maternal mortality, national organizations in the United States have called for standardized review of cases of maternal morbidity and mortality.

Endothelin B receptor deficiency predisposes to pulmonary edema formation via increased lung vascular endothelial cell growth factor expression.

Endothelin (ET) may contribute to pulmonary edema formation, particularly under hypoxic conditions, and decreases in ET-B receptor expression can lead to reduced ET clearance. ET increases vascular endothelial cell growth factor (VEGF) production in vitro, and VEGF overexpression in the lung causes pulmonary edema in vivo. We hypothesized that pulmonary vascular ET-B receptor deficiency leads to increased lung ET, that excess ET increases lung VEGF levels, promoting pulmonary edema formation, and that hypoxia exaggerates these effects. We studied these hypotheses in ET-B receptor-deficient rats. In normoxia, homozygous ET-B-deficient animals had significantly more lung vascular leak than heterozygous or control animals. Hypoxia increased vascular leak regardless of genotype, and hypoxic ET-B-deficient animals leaked more than hypoxic control animals. ET-B-deficient animals had higher lung ET levels in both normoxia and hypoxia. Lung HIF-1alpha and VEGF content was greater in the ET-B-deficient animals in both normoxia and hypoxia, and both HIF-1alpha and VEGF levels were reduced by ET-A receptor antagonism. Both ET-A receptor blockade and VEGF antagonism reduced vascular leak in hypoxic ET-B-deficient animals. We conclude that ET-B receptor-deficient animals display an exaggerated lung vascular protein leak in normoxia, that hypoxia exacerbates that leak, and that this effect is in part attributable to an ET-mediated increase in lung VEGF content.

Pulmonary hypertension in transgenic mice expressing a dominant-negative BMPRII gene in smooth muscle.

Bone morphogenetic peptides (BMPs), a family of cytokines critical to normal development, were recently implicated in the pathogenesis of familial pulmonary arterial hypertension. The type-II receptor (BMPRII) is required for recognition of all BMPs, and targeted deletion of BMPRII in mice results in fetal lethality before gastrulation. To overcome this limitation and study the role of BMP signaling in postnatal vascular disease, we constructed a smooth muscle-specific transgenic mouse expressing a dominant-negative BMPRII under control of the tetracycline gene switch (SM22-tet-BMPRII(delx4+) mice). When the mutation was activated after birth, mice developed increased pulmonary artery pressure, RV/LV+S ratio, and pulmonary arterial muscularization with no increase in systemic arterial pressure. Studies with SM22-tet-BMPRII(delx4+) mice support the hypothesis that loss of BMPRII signaling in smooth muscle is sufficient to produce the pulmonary hypertensive phenotype.

Impact of fertility treatment on severe maternal morbidity.

OBJECTIVE: To determine if fertility treatment is associated with increased risk of severe maternal morbidity (SMM) compared with spontaneous pregnancies. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENT(S): In 2012, 6,543 women delivered live births >20 weeks gestation at our center. Women were categorized based on mode of conception: in vitro fertilization (IVF), non-IVF fertility treatment (NIFT), or spontaneous pregnancies. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The main outcome was presence of true SMM, such as eclampsia, respiratory failure, and peripartum hysterectomy. Deliveries were screened with the use of: 1) International Classification of Diseases 9 codes; 2) prolonged postpartum stay; 3) maternal intensive care unit admissions, and 4) blood transfusion. The charts of women meeting the screening criteria were reviewed to identify true SMM based on a previously validated method, recognizing that medical record review is the criterion standard. RESULT(S): Of the 6,543 deliveries, 246 (3.8%) were IVF conceptions and 109 (1.7%) NIFT conceptions. Sixty-nine cases of true SMM were identified (1.1%). In multivariate analyses, any fertility treatment (IVF + NIFT) was associated with increased risk of SMM compared with spontaneous conceptions. In a subset analysis of singletons only, the association between any fertility treatment (IVF + NIFT) and SMM was not statistically significant. CONCLUSION(S): Overall, fertility treatment increased risk for SMM events. Given the limited sample size, the negative finding with singleton gestations is inconclusive. Larger multicenter studies with accurate documentation of fertility treatment and SMM cases are needed to further clarify the risk associated with singletons.