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.

Society for Maternal-Fetal Medicine Special Statement: Checklist for pregnancies resulting from in vitro fertilization.

The management of pregnancies resulting from in vitro fertilization includes several recommended interventions at various times by various providers. To minimize the chance of errors of omission, the Society for Maternal-Fetal Medicine presents a patient-oriented checklist summarizing the recommended management of such pregnancies.

Enhancing Obstetric Safety Through Best Practices.

The pregnancy-related mortality rate in the US exceeds that of other developed nations and is marked by significant disparities in outcome by race. This article reviews the evidence supporting the implementation of a variety of best practices designed to reduce maternal mortality. Evidence from maternal mortality review committees suggests that delays in diagnosis, delays in initiation of treatment and use of ineffective treatments contribute to preventable cases of maternal death. We review several protocols for maternal warning signs that have been used successfully to facilitate early identification and intervention. Care bundles, a collection of best practices, have been developed and implemented to address several maternal emergencies. We review the evidence that supports reduction in adverse outcomes with consistent implementation of obstetric hemorrhage and severe hypertension bundles in a collaborative, team-based setting. The article concludes with suggestions for the future.

Society for Maternal-Fetal Medicine Special Statement: Reducing the risk of transmitting infection by transvaginal ultrasound examination.

Recent surveys have shown widespread lapses in the procedures used to reduce the risk of transmitting infection via medical devices. Transvaginal ultrasound examination has the potential to transmit vaginal infections, including human papillomavirus. Areas of particular concern are the use of probe covers with high rates of leakage, disinfectants that are not effective against human papillomavirus, and coupling gel from multiple-use containers. We reviewed these issues, and we recommend 4 steps to reduce the risk of transmitting infection. First, during every transvaginal ultrasound exam, the probe should be covered with a sterile, single-use "viral barrier" cover or a condom. Second, sterile, single-use ultrasound gel packets should be used. Third, after every examination, the probe should be cleaned to remove any visible gel or debris. Finally, after cleaning, the probe should undergo high-level disinfection using an agent with proven efficacy against the human papillomavirus, including hydrogen peroxide, hypochlorite, or peracetic acid. Glutaraldehyde, orthophthalaldehyde, phenols, and isopropyl alcohol have virtually no efficacy against the human papillomavirus.

Maternal comorbidity index and severe maternal morbidity during delivery hospitalizations in Texas, 2011-2014.

BACKGROUND: Severe maternal morbidity (SMM) prevalence was 194.0 per 10 000 deliveries in Texas in 2015. Chronic, behavioral, and pregnancy-induced conditions, as captured by a maternal comorbidity index, increase the risk for delivery-related morbidity and mortality. The objective of the study was to examine the association between maternal comorbidity index and SMM among delivery hospitalizations in Texas. METHODS: Delivery-related hospitalizations among Texan women aged 15-49 years were identified using the 2011-2014 Texas all-payer inpatient hospitalization public use data files (n = 1 434 441). The primary outcome of interest was SMM, based on the Alliance for Innovation on Maternal Health's coding scheme. The exposure of interest was a maternal comorbidity index. Multivariable logistic regression model was used to examine the association between maternal comorbidity index and SMM. RESULTS: SMM prevalence remained consistent between 2011 and 2014 (196.0-197.0 per 10 000 deliveries, P > .05; n = 1 434 441). Nearly 40% of delivery-related hospitalizations had a maternal comorbidity index of at least 1, and the proportion of deliveries in the highest risk category of comorbidity index (≥5) increased by 12.0% from 2011 to 2014. SMM prevalence was highest among the youngest and oldest age groups. With each unit increase in maternal comorbidity index, the odds of SMM increase was 1.43 (95% CI 1.42-1.43). CONCLUSIONS: Maternal comorbidity index is associated with SMM; however, the low predictive power of the model suggests that other, unmeasured factors may influence SMM in Texas. These findings highlight a need to understand broader contextual factors (practitioner, facility, systems of care, and community) that may be associated with SMM to reduce maternal morbidity and mortality in Texas.

Association of copper-zinc superoxide dismutase (SOD1) and manganese superoxide dismutase (SOD2) genes with nonsyndromic myelomeningocele.

BACKGROUND: A common and severe neural tube defect (NTD) phenotype, myelomeningocele (MM), results from the defective closure of the caudal end of the neural tube with herniation of the spinal cord and meninges through the vertebral column. The exact mechanisms for NTDs are unknown, but excessive oxidative stress, particularly in association with maternal diabetes, has been postulated as a mechanism for MM. METHODS: The SNPlex Genotyping (ABI, Foster City, CA) platform was used to investigate single nucleotide polymorphisms (SNPs) across the superoxide dismutase (SOD) 1 and 2 genes to assess their association with MM risk. The study population included 329 trio (affected child and both parents) and 281 duo (affected child and one parent) families. Only cases with documented MM were studied. Seventeen SNPs across the SOD1 and SOD2 genes met the quality-control criteria to be considered for statistical analysis. Genetic association was assessed using the family-based transmission disequilibrium test in PLINK (a genome association analysis toolset). RESULTS: Four SNPs in the SOD1 gene (rs 202446, rs202447, rs4816405, and rs2070424) and one SNP in the SOD2 gene ( rs5746105) [corrected] appeared to be associated with MM risk in our population. After adjusting for multiple testing, these SNPs remained significant. CONCLUSION: This study provides the first genetic evidence to support association of myelomeningocele with superoxide scavenging. The rare alleles of the five specific SNPs within SOD1 and SOD2 appear to confer a protective effect on the susceptibility for MM risk in the MM population tested. Further evaluation of the roles of superoxide scavenging and neural tube development is warranted.

Utilization of obstetrical ultrasound in a referral population.

OBJECTIVE: To determine the number of ultrasounds performed prior to presentation to a maternal-fetal medicine (MFM) sub-specialist and the patient's perceived reason for referral. STUDY DESIGN: Women presenting for their first targeted ultrasound at an MFM unit in an urban center between November 2003 and April 2004 reported the number, location, and gestational age (GA) of prior ultrasounds and whether their insurance company had been billed for these studies. They also reported their current GA, insurance type, and perceived reason for referral. Pearson correlation and Kruskal-Wallis were used where appropriate; p < 0.05 was considered significant. RESULTS: Six hundred fifty-five women were invited to participate; 207 declined, leaving 448 available for the final analysis. The median number of prior ultrasounds was two (range 0-11). Twelve percent reported no prior ultrasound, 30% reported having had one, 28% reported having had two, and 29% reported having had three or more. Women presented at a mean GA of 21.3 +/- 5.4 weeks. They reported having had their first ultrasound at 9.9 +/- 2 weeks and their most recent prior ultrasound at 16.9 +/- 6.7 weeks. GA at presentation did not correlate with the number of prior ultrasounds (r = 0.17). Of 396 women with at least one prior ultrasound, 336 had at least one performed in their doctor's office and 74 had at least one performed in an ultrasound clinic; 183 stated that their insurance had been billed and 168 did not know if their insurance had been billed. The majority, 60%, had private insurance, 37% had Medicaid, and 2% had no insurance. Women with private insurance had a higher number of prior ultrasounds than women with Medicaid (2.3 +/- 1.4 vs. 1.5 +/- 1.3, p < 0.001). In response to the perceived reason for referral, 280 women stated their reason for referral to the MFM unit was for a routine ultrasound or to determine gender, 158 women reported that they were referred because their doctor was concerned about 'something', and 10 were unsure of their indication. CONCLUSION: Most women have at least one ultrasound prior to presenting to an MFM unit for a targeted scan. Many, especially those with private insurance, have had several prior ultrasounds. Patient education is needed about reasons for referral to an MFM unit for ultrasound and the possible increased financial burden of multiple ultrasounds.

Genes in glucose metabolism and association with spina bifida.

The authors test single nucleotide polymorphisms (SNPs) in coding sequences of 12 candidate genes involved in glucose metabolism and obesity for associations with spina bifida. Genotyping was performed on 507 children with spina bifida and their parents plus anonymous control DNAs from Hispanic and Caucasian individuals. The transmission disequilibrium test was performed to test for genetic associations between transmission of alleles and spina bifida in the offspring (P < .05). A statistically significant association between Lys481 of HK1 (G allele), Arg109Lys of LEPR (G allele), and Pro196 of GLUT1 (A allele) was found ( P = .019, .039, and .040, respectively). Three SNPs on 3 genes involved with glucose metabolism and obesity may be associated with increased susceptibility to spina bifida.