Society for Maternal-Fetal Medicine Special Statement: Clinical quality measures in obstetrics.

This article provides an updated overview and critique of clinical quality measures relevant to obstetrical care. The history of the quality movement in the United States and the proliferation of quality metrics over the past quarter-century are reviewed. Common uses of quality measures are summarized: payment programs, accreditation, public reporting, and quality improvement projects. We present listings of metrics that are reported by physicians or hospitals, either voluntarily or by mandate, to government agencies, payers, "watchdog" ratings organizations, and other entities. The costs and other burdens of extracting data and reporting metrics are summarized. The potential for unintended adverse consequences of the use of quality metrics is discussed along with approaches to mitigating adverse consequences. Finally, some recent attempts to develop simplified core measure sets are presented, with the promise that the complex and burdensome quality-metric enterprise may improve in the near future.

Society for Maternal-Fetal Medicine Special Statement: Emergency checklist, planning worksheet, and system preparedness bundle for placenta accreta spectrum.

Placenta accreta spectrum is a life-threatening complication of pregnancy that is underdiagnosed and can result in massive hemorrhage, disseminated intravascular coagulation, massive transfusion, surgical injury, multisystem organ failure, and even death. Given the rarity and complexity, most obstetrical hospitals and providers do not have comprehensive expertise in the diagnosis and management of placenta accreta spectrum. Emergency management, antenatal interdisciplinary planning, and system preparedness are key pillars of care for this life-threatening disorder. We present an updated sample checklist for emergent and unplanned cases, an antenatal planning worksheet for known or suspected cases, and a bundle of activities to improve system and team preparedness for placenta accreta spectrum.

Selection of Standards for Sonographic Fetal Femur Length by Use of z-scores.

OBJECTIVES: This study aimed to evaluate which of four established norms should be used for sonographic assessment of fetal femur length (FL). STUDY DESIGN: Cross-sectional study using pooled data from four maternal-fetal medicine practices. Inclusion criteria were singleton fetus, gestational age (GA) 220/7 to 396/7 weeks, biometry measured, and fetal cardiac activity present. Four norms of FL were studied: Hadlock et al, the INTERGROWTH-21st Project (IG-21st), the World Health Organization Fetal Growth Curves (WHO), and the National Institutes of Child Health and Human Development Fetal Growth Studies, unified standard (NICHD-U). The fit of our FL measurements to each norm was assessed by these criteria: mean z-score close to 0, standard deviation (SD) of z close to 1, Kolmogorov-Smirnov D-statistic close to zero, Youden J-statistic close to 1, approximately 5% of exams <5th percentile, and approximately 5% of exams >95th percentile. RESULTS: In 26,177 ultrasound exams, our FL measurements had the best fit to the WHO standard (mean z-score 0.15, SD of z 1.02, D-statistic <0.01, J-statistic 0.95, 3.4% of exams <5th percentile, 7.0% of exams >95th percentile). The mean of the IG-21st standard was smaller than the other norms and smaller than our measurements, resulting in underdiagnosis of short FL. The mean of the Hadlock reference was larger than the other norms and larger than our measurements, resulting in overdiagnosis of short FL. The SD of the NICHD-U standard was larger than the other norms and larger than our observations, resulting in underdiagnosis of both short and long FL. Restricting the analysis to a subgroup of 7,144 low-risk patients without risk factors for large- or small-for- GA produced similar results. CONCLUSION: Of the norms studied, the WHO standard is likely best for diagnosis of abnormal FL. KEY POINTS: · There are >30 norms for fetal FL.. · It is unknown which norm should be used.. · Our data fit the World Health Organization standard better than the other norms..

Prediction and Prevention of Preterm Birth: Secondary Analysis of a Randomized Intervention Trial.

Our objective was to evaluate whether pregnancy is prolonged by the use of a proteomics-based maternal serum screening test followed by treatment interventions. This is a secondary analysis of the PREVENT-PTB randomized trial comparing screening with the PreTRM test versus no screening. The primary trial analysis found no significant between-group difference in the preterm birth rate. Rather than considering a dichotomous outcome (preterm versus term), we treated gestational age at birth as a continuous variable using survival analysis. We also evaluated between-group difference in NICU length of stay and duration of respiratory support. Results indicated that pregnancy was significantly prolonged in subjects screened with the PreTRM test compared to controls (adjusted hazard ratio 0.53, 95% confidence interval 0.36-0.78, p < 0.01). Newborns of screened subjects had significantly shorter NICU stays but no significant decrease in duration of respiratory support. In the PreTRM screen-positive group, interventions that were associated with pregnancy prolongation included care management and low-dose aspirin but not 17-hydroxyprogesterone caproate. We conclude that screening with the PreTRM test followed by interventions for screen-positive pregnancies may prolong pregnancy and reduce NICU LOS, but these observations need to be confirmed by additional research.

Selection of Standards for Sonographic Fetal Head Circumference by Use of z-Scores.

OBJECTIVE: This study aimed to evaluate which of five established norms should be used for sonographic assessment of fetal head circumference (HC). STUDY DESIGN: Cross-sectional study using pooled data from four maternal-fetal medicine practices. Inclusion criteria were singleton fetus, gestational age 220/7 to 396/7 weeks, biometry measured, and fetal cardiac activity present. Five norms of HC were studied: Jeanty et al, Hadlock et al, the INTERGROWTH-21st Project (IG-21st), the World Health Organization Fetal Growth Curves (WHO), and the National Institutes of Child Health and Human Development Fetal Growth Studies unified standard (NICHD-U). The fit of our HC measurements to each norm was assessed by these criteria: mean z-score close to 0, standard deviation (SD) of z close to 1, low Kolmogorov-Smirnov D-statistic, high Youden J-statistic, close to 10% of exams >90th percentile, close to 10% of exams <10th percentile, and close to 2.28% of exams >2 SD below the mean. RESULTS: In 23,565 ultrasound exams, our HC measurements had the best fit to the WHO standard (mean z-score 0.10, SD of z = 1.01, D-statistic <0.01, J-statistic 0.83-0.94). The SD of the Jeanty reference was much larger than all the other norms and our measurements, resulting in underdiagnosis of abnormal HC. The means of the IG-21st and NICHD-U standards were smaller than the other norms and our measurements, resulting in underdiagnosis of small HC. The means of the Hadlock reference were larger than all the other norms and our measurements, resulting in overdiagnosis of small HC. Restricting the analysis to a low-risk subgroup of 4,423 exams without risk factors for large- or small-for-gestational age produced similar results. CONCLUSION: The WHO standard is likely best for diagnosis of abnormal HC. The Jeanty (Chervenak) reference suggested by the Society for Maternal-Fetal Medicine had poor sensitivity for microcephaly screening. KEY POINTS: · There are >30 norms for fetal HC.. · It is unknown which norm should be used.. · The WHO standard fits our data best.. · The Chervenak reference is not sensitive for microcephaly..

Society for Maternal-Fetal Medicine Special Statement: Checklists for transabdominal cerclage.

The recent Society for Maternal-Fetal Medicine Consult Series #65 provides a comprehensive review of transabdominal cerclage. The current article condenses the Consult recommendations regarding patient selection, counseling, and management into 2 simple one-page checklists, one for the primary obstetrical provider and the other for the maternal-fetal medicine consultant or cerclage provider. Moreover, we provide sample templates for medical record notes to document preprocedure counseling and informed consent.

Society for Maternal-Fetal Medicine Special Statement: Prophylactic low-dose aspirin for preeclampsia prevention-quality metric and opportunities for quality improvement.

Prophylactic low-dose aspirin reduces the rates of preeclampsia, preterm birth, fetal growth restriction, and perinatal death in patients with risk factors for preeclampsia. Despite recommendations from the US Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine, low-dose aspirin use is reported in <50% of patients with high-risk factors and <25% of patients with >1 moderate-risk factor. These low use rates represent an important "quality gap" and demonstrate the need for quality improvement activities. In this article, we outline the specifications for a process metric to standardize the measurement of the rate of aspirin use. Furthermore, we outline an approach to conducting a quality improvement project to increase the use of aspirin by patients with risk factors for preeclampsia.

Progestogen maintenance therapy for prolongation of pregnancy after an episode of preterm labour: A systematic review and meta-analysis.

BACKGROUND: Evidence for progestogen maintenance therapy after an episode of preterm labour (PTL) is contradictory. OBJECTIVES: To assess effectiveness of progestogen maintenance therapy after an episode of PTL. SEARCH STRATEGY: An electronic search in Central Cochrane, Ovid Embase, Ovid Medline and clinical trial databases was performed. SELECTION CRITERIA: Randomised controlled trials (RCT) investigating women between 16+0 and 37+0 weeks of gestation with an episode of PTL who were treated with progestogen maintenance therapy compared with a control group. DATA COLLECTION AND ANALYSIS: Systematic review and meta-analysis were conducted. The primary outcome was latency time in days. Secondary neonatal and maternal outcomes are consistent with the core outcome set for preterm birth studies. Studies were extensively assessed for data trustworthiness (integrity) and risk of bias. MAIN RESULTS: Thirteen RCT (1722 women) were included. Progestogen maintenance therapy demonstrated a longer latency time of 4.32 days compared with controls (mean difference [MD] 4.32, 95% CI 0.40-8.24) and neonates were born with a higher birthweight (MD 124.25 g, 95% CI 8.99-239.51). No differences were found for other perinatal outcomes. However, when analysing studies with low risk of bias only (five RCT, 591 women), a significantly longer latency time could not be shown (MD 2.44 days; 95% CI -4.55 to 9.42). CONCLUSIONS: Progestogen maintenance therapy after PTL might have a modest effect on prolongation of latency time. When analysing low risk of bias studies only, this effect was not demonstrated. Validation through further research, preferably by an individual patient data meta-analysis is highly recommended.

Booster course of antenatal corticosteroids after preterm prelabor rupture of membranes: a double-blind randomized trial.

BACKGROUND: Preterm prelabor rupture of membranes is a leading cause of preterm birth and is responsible for 18% to 20% of perinatal deaths in the United States. An initial course of antenatal corticosteroids has been shown to reduce morbidity and mortality in patients with preterm prelabor rupture of membranes. For patients who remain undelivered for 7 days or more after the initial course of antenatal corticosteroids, it is uncertain whether a booster course of antenatal corticosteroids reduces neonatal morbidity or increases the infection risk. The American College of Obstetricians and Gynecologists has concluded that the current evidence is insufficient to make a recommendation. OBJECTIVE: This study aimed to evaluate if a single booster course of antenatal corticosteroids improves neonatal outcomes after preterm prelabor rupture of membranes. STUDY DESIGN: We conducted a multicenter, placebo-controlled randomized clinical trial. The inclusion criteria were preterm prelabor rupture of membranes, gestational age of 24.0 to 32.9 weeks, singleton, initial antenatal corticosteroid course administered at least 7 days before randomization, and planned expectant management. Consenting patients were randomized in gestational age blocks to either receive booster antenatal corticosteroids (12 mg betamethasone every 24 hours for 2 days) or a saline placebo. The primary outcome was composite neonatal morbidity or death. A sample size of 194 patients was calculated to yield 80% power at P<.05 to detect a reduction in primary outcome from 60% in placebo group to 40% in antenatal corticosteroids group. RESULTS: From April 2016 through August 2022, 194 patients consented and were randomized (47% of 411 eligible patients). Intent-to-treat analysis was performed on 192 patients (2 placebo patients left hospital, outcomes unknown). The groups had similar baseline characteristics. The primary outcome occurred in 64% of patients who received booster antenatal corticosteroids vs in 66% of patients who received the placebo (odds ratio, 0.82; 95% confidence interval, 0.43-1.57; gestational age-stratified Cochran-Mantel-Haenszel test). Individual components of the primary outcome and secondary neonatal and maternal outcomes were not significantly different between the antenatal corticosteroids and placebo groups. Specifically, chorioamnionitis (22% vs 20%), postpartum endometritis (1% vs 2%), wound infections (2% vs 0%), and proven neonatal sepsis (5% vs 3%) were not different between the groups. CONCLUSION: A booster course of antenatal corticosteroids at least 7 days after the first antenatal corticosteroids course in patients with preterm prelabor rupture of membranes did not improve neonatal morbidity or any other outcome in this adequately-powered, double-blind randomized clinical trial. Booster antenatal corticosteroids did not increase maternal or neonatal infection.

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: Telemedicine in obstetrics-quality and safety considerations.

The frequency of telemedicine encounters has increased dramatically in recent years. This review summarizes the literature regarding the safety and quality of telemedicine for pregnancy-related services, including prenatal care, postpartum care, diabetes mellitus management, medication abortion, lactation support, hypertension management, genetic counseling, ultrasound examination, contraception, and mental health services. For many of these, telemedicine has several potential or proven benefits, including expanded patient access, improved patient satisfaction, decreased disparities in care delivery, and health outcomes at least comparable to those of traditional in-person encounters. Considering these benefits, it is suggested that payers should reimburse providers at least as much for telemedicine as for in-person services. Areas for future research are considered.

Disseminated intravascular coagulation complicating mild or asymptomatic maternal COVID-19.

BACKGROUND: Hypercoagulability frequently complicates moderate or severe COVID-19 and can result in venous thromboembolism, arterial thrombosis, or microvascular thrombosis. Disseminated intravascular coagulation, however, is uncommon. OBJECTIVE: We sought to describe the clinical presentation and outcome in a series of pregnant patients with mild or asymptomatic COVID-19 who had disseminated intravascular coagulation. STUDY DESIGN: This was a retrospective case series. Cases were solicited via e-mails targeted to obstetrical providers in the Mednax National Medical Group and a restricted maternal-fetal medicine Facebook page. Inclusion criteria were: hospital admission during pregnancy, positive test for SARS-CoV-2 within 2 weeks of admission, and maternal disseminated intravascular coagulation defined as ≥2 of the following: platelet count ≤100,000 per mm3, fibrinogen ≤200 mg/dL, and prothrombin time ≥3 seconds above the upper normal limit. Exclusion criteria were severe COVID-19 requiring ventilation within an hour of diagnosis of coagulopathy or use of anticoagulants at the time of diagnosis. Maternal and newborn records were abstracted and summarized with descriptive statistics. RESULTS: Inclusion criteria were met in 19 cases from October 2020 through December 2021. Of these, 18 had not received any COVID-19 vaccine, and 1 had unknown vaccination status. Median gestational age on hospital admission was 30 weeks (interquartile range, 29-34 weeks). The main presenting symptom or sign was decreased fetal movement (56%) or nonreassuring fetal heart rate pattern (16%). COVID-19 was asymptomatic in 79% of cases. Two of the 3 defining coagulation abnormalities were found in 89% of cases and all 3 in the remaining 11%. Aspartate aminotransferase was elevated in all cases and ≥2 times the upper normal limit in 69%. Only 2 cases (11%) had signs of preeclampsia other than thrombocytopenia or transaminase elevation. Delivery was performed on the day of admission in 74% and on the next day in the remaining 26%, most often by cesarean delivery (68%) under general anesthesia (62%) because of nonreassuring fetal heart rate pattern (63%). Postpartum hemorrhage occurred in 47% of cases. Blood product transfusions were given in 95% of cases, including cryoprecipitate (89% of cases), fresh/frozen plasma (79%), platelets (68%), and red cells (63%). Placental histopathology was abnormal in 82%, with common findings being histiocytic intervillositis, perivillous fibrin deposition, and infarcts or necrosis. Among the 18 singleton pregnancies and 1 twin pregnancy, there were 13 live newborns (65%) and 7 stillbirths (35%). Among liveborn neonates, 5-minute Apgar score was ≤5 in 54%, and among cases with umbilical cord blood gases, pH ≤7.1 was found in 78% and base deficit ≥10 mEq/L in 75%. Positive COVID-19 tests were found in 62% of liveborn infants. CONCLUSION: Clinicians should be alert to the possibility of disseminated intravascular coagulation when a COVID-19 patient complains of decreased fetal movement in the early third trimester. If time allows, we recommend evaluation of coagulation studies and ordering of blood products for massive transfusion protocols before cesarean delivery if fetal tracing is nonreassuring.

Choice of standards for sonographic fetal abdominal circumference percentile.

BACKGROUND: The diagnosis of abnormal fetal abdominal circumference is based on values >90th or <10th percentile. There are dozens of established norms that can be used to determine the percentile of a given abdominal circumference measurement, but there is no established method to determine which norms should be used. OBJECTIVE: This study aimed to evaluate the applicability of 5 established abdominal circumference norms to our measurements and to determine which, if any, should be used for the diagnosis of abnormal fetal abdominal circumference. STUDY DESIGN: Data were pooled from 6 maternal-fetal medicine practices to conduct a cross-sectional study. The inclusion criteria were a singleton fetus at 22.0 to 39.9 weeks of gestation with cardiac activity present, complete fetal biometry measured, and examination from 2019 or 2020. For patients with >1 eligible examination during the study period, a single examination was chosen at random for inclusion. Five norms of abdominal circumference were studied: the Hadlock formula, the World Health Organization Fetal Growth Curves, the International Fetal and Newborn Growth Consortium for the 21st-Century Project; and the National Institutes of Child Health and Human Development Fetal Growth Studies (fetuses of White patients and unified standard). Using formulas relating abdominal circumference to gestational age, we calculated the z scores of abdominal circumference (standard deviations from the mean), standard deviation of the z score, Kolmogorov-Smirnov D statistic, and relative mean squared error. The 5 norms were assessed for fit to our data based on 6 criteria: mean z score close to 0, standard deviation of the z score close to 1, low D statistic, low mean squared error, fraction of values >90th percentile close to 10%, and fraction of values <10th percentile close to 10%. RESULTS: The inclusion criteria were met in 40,684 ultrasound examinations in 15,042 patients. Considering the 6 evaluation criteria, observed abdominal circumferences had the best fit to the World Health Organization standard (mean z score of 0.11±1.05, D statistic of 0.041, mean squared error of 0.84±1.46, 13% of examinations >90th percentile, and 7% of examinations <10th percentile). The Hadlock reference had an anomaly in its assumption of a constant standard deviation, resulting in the underdiagnosis of abnormal values at early gestational ages and overdiagnosis at late gestational ages. The International Fetal and Newborn Growth Consortium for the 21st-Century Project standard had a mean circumference smaller than all the other norms, resulting in the underdiagnosis of small circumferences and the overdiagnosis of large circumferences. Similar results were observed when restricting the analyses to a low-risk subgroup of 5487 examinations without identified risk factors for large for gestational age or small for gestational age. CONCLUSION: The diagnosis of abnormal abdominal circumference depends on the norms used to define abdominal circumference percentiles. The World Health Organization standard had the best fit for our data.

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.

Timing of Delivery for Twins With Growth Discordance and Growth Restriction: An Individual Participant Data Meta-analysis.

OBJECTIVE: First, to evaluate the risks of stillbirth and neonatal death by gestational age in twin pregnancies with different levels of growth discordance and in relation to small for gestational age (SGA), and on this basis to establish optimal gestational ages for delivery. Second, to compare these optimal gestational ages with previously established optimal delivery timing for twin pregnancies not complicated by fetal growth restriction, which, in a previous individual patient meta-analysis, was calculated at 37 0/7 weeks of gestation for dichorionic pregnancies and 36 0/7 weeks for monochorionic pregnancies. DATA SOURCES: A search of MEDLINE, EMBASE, ClinicalTrials.gov, and Ovid between 2015 and 2018 was performed of cohort studies reporting risks of stillbirth and neonatal death in twin pregnancies from 32 to 41 weeks of gestation. Studies from a previous meta-analysis using a similar search strategy (from inception to 2015) were combined. Women with monoamniotic twin pregnancies were excluded. METHODS OF STUDY SELECTION: Overall, of 57 eligible studies, 20 cohort studies that contributed original data reporting on 7,474 dichorionic and 2,281 monochorionic twin pairs. TABULATION, INTEGRATION, AND RESULTS: We performed an individual participant data meta-analysis to calculate the risk of perinatal death (risk difference between prospective stillbirth and neonatal death) per gestational week. Analyses were stratified by chorionicity, levels of growth discordance, and presence of SGA in one or both twins. For both dichorionic and monochorionic twins, the absolute risks of stillbirth and neonatal death were higher when one or both twins were SGA and increased with greater levels of growth discordance. Regardless of level of growth discordance and birth weight, perinatal risk balanced between 36 0/7-6/7 and 37 0/7-6/7 weeks of gestation in both dichorionic and monochorionic twin pregnancies, with likely higher risk of stillbirth than neonatal death from 37 0/7-6/7 weeks onward. CONCLUSION: Growth discordance or SGA is associated with higher absolute risks of stillbirth and neonatal death. However, balancing these two risks, we did not find evidence that the optimal timing of delivery is changed by the presence of growth disorders alone. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42018090866.

Society for Maternal-Fetal Medicine Special Statement: Cognitive bias and medical error in obstetrics-challenges and opportunities.

The processes of diagnosis and management involve clinical decision-making. However, decision-making is often affected by cognitive biases that can lead to medical errors. This statement presents a framework of clinical thinking and decision-making and shows how these processes can be bias-prone. We review examples of cognitive bias in obstetrics and introduce debiasing tools and strategies. When an adverse event or near miss is reviewed, the concept of a cognitive autopsy-a root cause analysis of medical decision-making and the potential influence of cognitive biases-is promoted as part of the review process. Finally, areas for future research on cognitive bias in obstetrics are suggested.