Early discharge revisited: problems encountered with the home visit follow-up after the liberalization of eligibility criteria.

OBJECTIVE: To determine how changes in eligibility criteria for early discharge affected quality and costs of home nursing follow-up care for Medicaid patients. METHODS: A nurse screened women delivering vaginally to determine eligibility for discharge at 24-47 h. Maternal criteria were a vaginal delivery, no serious medical problems, > or = 8 h after bilateral tubal ligation and, if 24 h postpartum, by 21.00 on day of discharge. Newborn criteria were 36 weeks' gestation or more, 2000 g or greater and a normal examination at 24 h of age. By 48 h after discharge, a nursing visit was ordered for each mother and newborn. Nursing consultations were tracked and later entered into a database linked to hospital financial data. RESULTS: Of 3133 vaginal deliveries occurring from 1 August 1997 to 31 January 1999, eligibility criteria allowed 1799 mothers (58%) and 1587 newborns (51%) to be discharged early. Medical problems were rarely detected at follow-up (1% mothers, 2% newborns). To perform the increased number of visits, more personnel were hired and home nursing costs rose 150%. Despite the increased staff and costs, 19 mothers (1%) and ten newborns (0.6%) were lost to follow-up and 25 mothers (1%) and 20 newborns (1%) were visited beyond 72 h after discharge. CONCLUSIONS: Liberal changes in maternal and newborn eligibility criteria did not adversely affect the quality of home nursing follow-up care following early discharge. For hospitals performing a large number of early discharges, follow-up care using only a home nursing visit may be too expensive and difficult to organize. Alternative follow-up plans, such as clinic visits or phone calls, may also need to be utilized.

Puerperal infection after cesarean delivery: evaluation of a standardized protocol.

OBJECTIVE: Our goal was to evaluate an antibiotic protocol for treatment of postcesarean endometritis. STUDY DESIGN: Endometritis was diagnosed as a persistent fever > or =100.4 degrees F beyond 24 hours after cesarean delivery and one or more of the following: uterine tenderness, tachycardia, foul lochia, or leukocytosis. Antibiotic therapy included gentamicin plus clindamycin and ampicillin (or vancomycin) as a triple antimicrobial in 148 women. Antibiotic failure was defined as persistent fever after 5 days of antibiotics and 72 hours of triple antibiotics. RESULTS: Between 1993 and 1996, 322 of 1643 (20%) women were diagnosed with postcesarean endometritis. One hundred seventy-four patients (54%) were cured with clindamycin-gentamicin, and 129 who additionally received ampicillin or vancomycin (40%) were cured. Nineteen of the 322 (6%) women had persistent fever despite triple antibiotics. Of these, 6 had a wound complication, 12 were suspected to have antimicrobial resistance, and 1 had an infected hematoma. CONCLUSION: A prospective protocol consisting of clindamycin-gentamicin plus the selective addition of ampicillin or vancomycin cured 303 of 322 (94%) women with postcesarean endometritis.

Ultrasound findings and multiple marker screening in trisomy 18.

OBJECTIVE: To compare detection of trisomy 18 in the second trimester by ultrasound and multiple-marker testing. METHODS: A computerized genetics database was used to identify fetuses of 14-22 weeks' gestation who had comprehensive ultrasound examinations, multiple-marker screening tests (alpha-fetoprotein [AFP]), hCG, unconjugated estriol [E3], and trisomy 18 karyotype. A positive trisomy 18 screen was defined as AFP up to 0.75 multiples of the median (MoM), hCG up to 0.55 MoM, and unconjugated E3 up to 0.60 MoM. A risk of at least 1:190 defined a positive Down syndrome screen. Ultrasound abnormalities were diagnosed prospectively and were confirmed later by retrospective review of sonographic images. RESULTS: From 1988-1997, 30 trisomy 18 fetuses who had comprehensive ultrasounds and multiple-marker testing were identified. Twenty-one (70%) had abnormalities detected by ultrasound, of which the most common isolated finding was choroid plexus cyst. Eleven fetuses (37%) had positive trisomy 18 screens, and two had positive Down syndrome screens, for a total of 13 of 30 (43%) fetuses with positive multiple-marker screening tests. CONCLUSION: We found that ultrasound was more likely to be abnormal than multiple-marker screening tests in fetuses with trisomy 18 (70%) (95% confidence interval [CI] 54, 86 versus 43% CI 25, 61). However, combining the two testing methods yielded the highest detection rate (80% [CI 66%, 94%]).

Prenatally diagnosed hypoplastic left heart syndrome--outcomes after postnatal surgery.

OBJECTIVE: To identify prenatally diagnosed cases of hypoplastic left heart syndrome (HLHS) and then to determine postnatal outcomes after surgical interventions. METHODS: An ultrasound and pediatric cardiology database was used to identify all fetuses diagnosed prenatally from 1991-1996 with HLHS. Fetal karyotypes were performed on cultured amniocytes. After diagnosis, parents were given several management options: pregnancy termination before 22 weeks, postnatal hospice care, or surgery using the Norwood procedure or cardiac transplantation. Ultrasound and echocardiography findings were later compared to karyotype results and postnatal outcome data. RESULTS: Fifteen fetuses with HLHS were identified. Two (16%) chromosome abnormalities and three (20%) structural defects were detected. Three mothers (20%) opted for pregnancy termination, two (13%) chose postnatal hospice care, and one aneuploid fetus had an intrauterine death. Nine parents (60%) chose surgery for their infants; however, one infant was not an appropriate surgical candidate due to a coexisting diaphragmatic hernia. Eight infants underwent surgery and two survived (25%). Of the four infants scheduled to undergo the Norwood procedure, one died preoperatively, two died intraoperatively, and one infant survived and is doing well at age 8 months. Of the four infants scheduled for cardiac transplantation, two died awaiting transplant and one died postoperatively. One infant survived cardiac transplantation but has microcephaly and developmental delay at age two. CONCLUSIONS: In prenatally diagnosed HLHS at our institution, the survival rate following surgery for infants felt to be the best candidates was only 25%.

Pregnancy outcomes following sonographic nonvisualization of the fetal stomach.

OBJECTIVE: To review pregnancy outcomes when two or more ultrasound scans persistently fail to visualize the fetal stomach. METHODS: A computerized ultrasound database was used to identify all fetuses in which two or more serial ultrasound examinations failed to visualize the fetal stomach. Sonographic images were reviewed retrospectively, with the reviewer blinded to outcome data, to confirm persistent nonvisualization. Pregnancy outcome data were obtained from hospital charts and physicians' office records. Fetal karyotypes, when performed, were obtained from amniotic fluid (AF) culture. The ultrasound findings then were compared with fetal karyotype results and pregnancy outcome data. RESULTS: Of 35,569 ultrasound scans performed during 1991-1996, 26 fetuses (0.07%) with persistently nonvisualized stomachs were identified. Structural defects were detected in 17 fetuses (65%), most often involving the cardiothoracic (n = 5), genitourinary (n = 4), and central nervous systems (n = 4). Karyotypes were obtained in 12 fetuses, and four of them were abnormal. Only five of 17 fetuses (29%) with a structural defect survived. In nine of 26 fetuses (35%) with persistently nonvisualized stomachs, no structural defect was identified. Each of these nine fetuses had abnormal AF volume in its surrounding sac, and the overall perinatal survival in fetuses without a structural defect was only 50%. CONCLUSION: Fetuses with persistently nonvisualized stomachs have an increased incidence of structural defects and AF abnormalities and are more likely to have a poor outcome. A detailed ultrasound examination and fetal karyotype analysis should be performed to evaluate fetuses with persistently nonvisualized stomachs.

72-hour discharge after cesarean delivery: results in a selected Medicaid population.

The purpose of this study was to determine the safety and cost savings of discharging low income patients at 72 hours following cesarean delivery. Predetermined criteria were used to allow discharge. Selection criteria were no medical problems, an afebrile postoperative course, documented bowel function, to have tolerated at least one regular meal, and to have reached 72 hours postdelivery by 6 o'clock PM at discharge. Each patient returned to clinic 2-3 days postdischarge for staple removal. Physicians also discharged some low income patients home at 72 hours even though strict eligibility criteria were not met. Maternal outcome and financial data were compared between patients discharged after meeting eligibility criteria versus those who did not. Of 1,299 cesareans performed from July 1, 1993-July 31, 1995, 906 (70%) were performed in low income patients and 399 (44%) of these women were discharged at 72 hours. Twenty-seven women were lost to follow-up and 286 (77%; Group A) met the eligibility criteria for 72-hour discharge. Eighty-six women (23%; Group B) who did not meet criteria were also discharged at 72 hours. When maternal outcome data from the two groups were compared, Group B patients (did not meet criteria) were more likely to have been readmitted at < or = 30 days (7 of 86; 8% vs. 8 of 286; 3%; P = 0.05) and had longer hospital stays (27 days vs. 22 days) than Group A patients (met criteria). Net cost savings in 2 years was $448 per discharge for Group A, but only $333 per discharge for Group B. In our selective 72-hour discharge program, failure to abide by predetermined guidelines established to select only low risk, afebrile patients for 72-hour discharge resulted in more hospital readmissions, and longer stays and thus was not as cost effective.

Significance of a false-positive trisomy 18 multiple-marker screening test.

OBJECTIVE: To determine if a false-positive trisomy 18 multiple-marker screening test (all three analytes low: maternal serum alpha-fetoprotein [AFP] at most 0.75 multiples of the median [MoM], unconjugated estriol at most 0.60 MoM, and hCG at most 0.55 MoM) indicates increased risk for obstetric complications or is related to maternal weight. METHODS: We accessed our genetic database to obtain multiple-marker screening test results, fetal karyotypes, and pregnancy outcomes from all patients with a normal multiple-marker screening test (n = 3900) and from all patients with a positive trisomy 18 screening test (n = 103) seen in the prenatal diagnosis clinic from 1992 to 1996. During this period, only maternal serum AFP was adjusted for maternal weight. RESULTS: A positive trisomy 18 screen identified five of 12 trisomy 18 fetuses. Women with a false-positive trisomy 18 screen were heavier (175.6 +/- 43.8 lb versus 159.9 +/- 37.9 lb, P < .001) and younger (29.7 +/- 6.5 years versus 32.3 +/- 6.5 years, P < .001) than women with a normal multiple-marker screening test, but were not at increased risk for pregnancy complications. Weight-adjusting all three analytes reduced the false-positive trisomy 18 screen rate by 42% (from 1.9% to 1.1%) but did not change the trisomy 18 detection rate. CONCLUSION: A false-positive trisomy 18 screening test does not indicate increased risk to develop pregnancy complications and may be related to inadequate correction for increased maternal weight.

Management options in women with preterm uterine contractions: a randomized clinical trial.

OBJECTIVE: Our purpose was to evaluate three management strategies and to assess pregnancy outcomes in women with preterm uterine contractions. STUDY DESIGN: Consenting women seen in our hospital triage area with preterm uterine contractions were randomly assigned to observation alone, intravenous hydration, or one dose of subcutaneous terbutaline sulfate (0.25 mg). Eligible women had a singleton gestation between 20 and 34 weeks, intact membranes, more than three contractions in 30 minutes, and a cervical dilation < or = 1 cm and effacement < 80%. Women who had progressive cervical change at < 34 weeks were treated with intravenous tocolysis. Women with recurrent preterm uterine activity remained in their assigned group during subsequent triage visits. RESULTS: One hundred seventy-nine women were randomized: observation (56), hydration (62), and terbutaline (61). Women in these three groups were similar with respect to maternal age, race, parity, prior preterm births, gestational age at randomization, contraction frequency, and mean cervical dilatation. There were no intergroup differences in the mean days to delivery, the number of repeat triage visits, the incidence of preterm labor at < 34 weeks, or the frequency of preterm deliveries at < 34 weeks and < 37 weeks. Women assigned to terbutaline had contractions stopped and were discharged earlier (terbutaline 4.1 +/- 5.1 hours, observation 5.2 +/- 5.3 hours, hydration 6.0 +/- 5.7 hours; p = 0.006). No complications of therapy were observed. CONCLUSIONS: The use of intravenous hydration in the management of preterm contractions was of no benefit. The use of one dose of subcutaneous terbutaline resulted in the shortest length of triage stay but did not affect pregnancy outcome.

Pregnancy outcomes following false-positive multiple marker screening tests.

Pregnancy outcomes in women with a false-positive midtrimester multiple marker screening test (MMST) were reviewed. A genetic database was used to identify all women > or = age 30 who had a MMST at 15-20 weeks of gestation, a targeted ultrasound, and amniocentesis, and complete pregnancy outcome data. All patients with an abnormal fetal ultrasound (US) or karyotype were excluded. The incidence of adverse outcomes (defined as fetal death, preterm delivery, or a birth weight less than the 10th percentile for gestational age), in those women with a positive MMST (risk of Down's syndrome > or = 1:190) was compared to the incidence of adverse outcomes in control women with negative MMST. Chi-square analysis and Fisher's exact tests were used for comparisons as appropriate. Complete data was available from 1135 women. Seventy-seven percent were over age 35. Two hundred and forty-six women (22%) had a positive multiple marker test. No significant differences in outcomes were discovered after comparisons to controls: fetal death 1 of 246 (0.4%) versus 12 of 889 (1.3%), p = 0.32; preterm delivery 32 of 246 (13.0%) versus 147 of 889 (16.5%), p = 0.17; birth weight less than the 10th percentile, 9 of 246 (3.7%) versus 30 of 889 (3.4%), p = 0.83. Our data suggest that women > or = age 30 with a false-positive MMST and a normal midtrimester obstetrical sonogram are not at an increased risk for adverse pregnancy outcomes in later gestation.

Second-trimester cystic hygroma: prognosis of septated and nonseptated lesions.

OBJECTIVE: To compare karyotypic, ultrasonographic, and prognostic features of septated cystic hygromas and nonseptated cystic hygromas in second-trimester fetuses. METHODS: A computerized ultrasound data base was used to identify fetuses diagnosed with cystic hygromas at 14-22 weeks' gestation. Photographs from the initial ultrasound were reviewed retrospectively for hygroma type (septated or nonseptated) and any abnormal structural findings. Fetal karyotypes were obtained from amniotic fluid, aspiration of hygroma pouches, or fetal tissue culture. Pregnancy outcome information was obtained from hospital charts and physician office records. Ultrasound findings were then compared with fetal karyotype results and pregnancy outcome data. RESULTS: From 1990 to 1995, 61 fetuses with cystic hygromas were identified. Karyotypes were obtained in 55 fetuses, and pregnancy outcome was available for 59. Abnormal karyotype was present in 42 of 55 fetuses (76%). The most common chromosomal abnormality in septated hygromas was the 45,X karyotype. Trisomy 21 was the most common chromosomal abnormality in nonseptated hygromas. Compared with fetuses with nonseptated cystic hygromas, those with septated cystic hygromas were more likely to be aneuploid (33 of 39 [85%] versus nine of 16 [56%]; P = .03), more likely to develop hydrops (27 of 45 [60%] versus three of 16 [19%]; P = .005), and less likely to be live-born (one of 44 [2%] versus four of 15 [27%]; P = .01). CONCLUSIONS: Fetuses with septated cystic hygromas are more likely to be aneuploid and to develop hydrops, and thus are less likely to be survive than fetuses with nonseptated hygromas.

24-hour mother-infant discharge with a follow-up home health visit: results in a selected medicaid population.

OBJECTIVE: To determine safety and cost-effectiveness of 24-hour discharge in selected mothers and newborns. METHODS: Women delivering at University Hospital (the University of Alabama at Birmingham) were screened to determine their eligibility for 24-hour discharge. Mothers were eligible if they had no medical problems and no history of substance abuse, had an uncomplicated vaginal delivery and postpartum course, were 12 or more hours after postpartum bilateral tubal ligation, and had reached 24 hours after delivery by 6:00 PM on the day of discharge. Newborns were eligible if they were term (37 weeks or greater), weighted 2500 g or greater, and had a normal examination at 24 hours of age. At 48 hours after delivery, each mother and infant pair was examined by a home health nurse. Telephone consultations with a staff physician were noted and outcomes were entered into a data base linked to hospital financial data. RESULTS: Of 5621 deliveries from October 1, 1993 to September 30, 1995, 972 mothers (17%) and 856 (15%) newborns were discharged at 24 hours. One mother was lost to follow-up after discharge. Nine-hundred fifty-six of 971 mothers (98.5%) had a normal examination at the home visit. Fifteen of 971 mothers (1.5%) had problems that required obstetrician telephone consultation. Seven mothers (0.7%) required a physician visit; two of these women were readmitted for treatment of an infection. Seven-hundred ninety-five of 856 (93%) newborns had a normal examination. Sixty-one newborns (7%) had problems that required pediatrician telephone consultation, primarily for jaundice, infant care questions, and a cardiac murmur. Twelve infants (1.4%) required a pediatric clinic visit. No infant was readmitted to the hospital. Net cost savings to our hospital for 24-hour discharge in these selected patients was $ 506,139 during a 2-year period. CONCLUSION: In a selected, low-risk, low-income population, mother-infant discharge 24 hours after delivery with a home follow-up visit is safe and cost-effective.

The significance of non-visualization of the fetal bladder during an ultrasound examination to evaluate second-trimester oligohydramnios.

Our objective was to determine the pregnancy outcome after targeted sonography performed for the evaluation of second-trimester oligohydramnios fails to visualize the fetal bladder. A retrospective review identified patients in 1990-94 who were referred for targeted sonography from 16 to 24 weeks to evaluate oligohydramnios. The ultrasound records and photographs from the initial examination were reviewed and compared to later pregnancy outcome data obtained by reviewing delivery and neonatal records, neonatal renal ultrasound reports or autopsy information. Complete outcome data were available in 98 patients. The fetal bladder was not visualized in 29 patients (30%). Post-delivery analysis of the fetal urinary tract was performed in 25 patients either by autopsy or by neonatal renal ultrasound scanning. A severe anatomic malformation of the urinary system was present and had been detected by targeted sonography in 23 of 25 cases (92%). The remaining two fetuses were found to have anatomically normal urinary tracts at autopsy, but other pathological findings suggested that a functional derangement of the urinary system had led to non-visualization of the bladder at ultrasound examination. Non-visualization of the fetal bladder during targeted sonography to evaluate oligohydramnios indicates a severe anatomic or functional problem of the fetal urinary tract. In our study, this ultrasound finding was associated with universal fetal or neonatal death.

Pregnancy outcome following genetic amniocentesis at 11-14 versus 16-19 weeks' gestation.

OBJECTIVE: To compare pregnancy complications in women having genetic amniocentesis at 11-14 weeks versus those undergoing amniocentesis at 16-19 weeks' gestation. METHODS: A genetics data base was used to identify patients retrospectively, those who had genetic amniocenteses by three experienced operators during a 4-year period. The study group consisted of women who had amniocenteses at 11-14 weeks' gestation. For each study patient (early amniocentesis), two controls (amniocentesis at 16-19 weeks) were identified and matched for maternal age, race, and the number of prior spontaneous abortions. An immediate post-procedure complication was defined as any vaginal bleeding, rupture of membranes, or fetal loss occurring up to 30 days after the amniocentesis. A later complication was defined as any fetal death longer than 30 days after the amniocentesis, any preterm delivery, any infant weighing less than the tenth percentile for gestational age, and any neonatal death. Immediate and later complications were compared between the study and control groups. RESULTS. The study group consisted of 314 patients who were matched to 628 controls. Women who had a genetic amniocentesis performed at 11-14 weeks were significantly more likely to have post-procedure amniotic fluid leakage (2.9 versus 0.2%), post-procedure vaginal bleeding (1.9 versus 0.2%), and a fetal loss within 30 days of the amniocentesis (2.2 versus 0.2%) than women undergoing genetic amniocentesis at 16-19 weeks' gestation. Four of the seven patients (57%) with a fetal loss within 30 days of an early amniocentesis had procedure-related complications, such as amniotic fluid leakage, bleeding, and infection, that caused the pregnancy to be lost. No differences were noted between the two groups in the number of preterm deliveries, later fetal deaths, neonatal deaths, or newborns weighing less than the tenth percentile for gestational age. CONCLUSION: Genetic amniocentesis at 11-14 weeks is associated with more post-procedure complications and a higher fetal loss rate within 30 days of the procedure than a genetic amniocentesis performed at 16-19 weeks' gestation.

Prognostic significance of unexplained elevated amniotic fluid alpha-fetoprotein.

OBJECTIVE: To compare the prognostic values of unexplained elevated amniotic fluid alpha-fetoprotein (AF AFP > or = 2.0 multiples of the median [MoM]) and unexplained elevated maternal serum alpha-fetoprotein (MSAFP > or = 2.5 MoM). METHODS: We accessed a data base containing the results of MSAFP screening tests, genetic amniocenteses, and pregnancy outcome data on all women undergoing second-trimester genetic amniocentesis from October 1988 through August 1994. After excluding all patients whose elevated AFP levels had any identifiable cause (positive AF acetylcholinesterase, AF blood contamination, fetal malformation or aneuploidy, multiple gestation, etc), 5743 cases were analyzed. Relative risks (RR) for selected pregnancy complications were determined. RESULTS: Elevated MSAFP, with any AF AFP, was associated with fetal growth restriction (RR 2.5, 95% confidence interval [CI] 1.4-4.4), stillbirth (RR 3.5, 95% CI 1.4-8.3), preeclampsia (RR 2.8, 95% CI 1.1-7.0), and preterm delivery (RR 2.8, 95% CI 2.3-3.4). Elevated AF AFP, with any MSAFP, was associated with preeclampsia (RR 4.4, 95% CI 2.0-10.0) and preterm delivery (RR 1.7, 95% CI 1.3-2.4). Elevation of both AF AFP and MSAFP was associated with preterm delivery (RR 4.0, 95% CI 2.8-5.7). When elevated AF AFP was found in association with a normal MSAFP, the RR to develop preeclampsia was 4.6 (95% CI 1.9-11.2). CONCLUSION: Maternal serum alpha-fetoprotein is a better predictor of late pregnancy complications than AF AFP. However, unexplained elevated AF AFP appears to be especially predictive of preeclampsia.

Successful delivery of mature twins after a ruptured interstitial heterotopic pregnancy. A case report.

A 31-year-old primigravida had a combined pregnancy consisting of intrauterine twins and an interstitial ectopic after in vitro fertilization/embryo transfer. The patient underwent repair of the ectopic pregnancy at 15 weeks of gestation, with subsequent delivery of mature twins close to term.

Fetal myelomeningocele. Is antenatal ultrasound useful in predicting neonatal outcome?

The objective of this study was to determine if an ultra-sound examination, when performed in the third trimester immediately preceding delivery, is useful in predicting outcome in infants with a myelomeningocele. A retrospective review was undertaken of prenatal ultrasound records and pediatric outcome data on fetuses with isolated myelomeningocele referred to our institution after 28 weeks' gestation during a three-year period. Macrocephaly proved to be the one antenatal ultrasound finding that most correlated with later poor outcomes in infants with myelomeningocele. Macrocephalic fetuses had a longer mean hospital stay after birth and were more likely to have significant respiratory and feeding difficulties. No fetus with macrocephaly had a normal mental score, and all had severe motor deficits on later follow-up testing. The ultrasound diagnosis of macrocephaly identified a group of fetuses with myelomeningocele, who were at highest risk of neonatal problems and developmental delay. Cesarean delivery and aggressive medical treatment of complications did not improve the outcome in these infants. This finding will be useful when counseling patients regarding route of delivery and in pediatric decisions regarding treatment of complications.

Fetal biparietal diameter, head circumference, abdominal circumference and femur length. A comparison by race and sex.

Biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL) were compared by race and sex in 5,405 ultrasound examinations done on 2,831 women. Black fetuses had significantly longer FL than white fetuses; male fetuses had larger BPD, HC and AC than females. The differences in BPD, HC and AC correlated with the different birth weights observed between male and female infants, 3,253 vs. 3,153 g. The difference in birth weight between black and white infants, 3,152 vs. 3,331 g, did not correlate with differences in their respective BPD, HC and AC. Earlier delivery accounted for some but not all of the birth weight difference between black and white infants. Our data suggest that there may be differences in body length proportions (longer legs and shorter trunks in black infants) that are important factors in understanding the birth weight difference between black and white infants. Furthermore, fetal race and sex differences could account for some degree of error in the ultrasound estimation of gestational age.