Comparing State-Level and Facility-Based Review to Assess Quality of Severe Maternal Morbidity Reviews.

OBJECTIVE: To compare results from facility-level and state-level severe maternal morbidity (SMM) reviews in Illinois. DESIGN: We report descriptive characteristics about SMM cases and compare the results of both review processes, including the primary cause, assessment of preventability, and factors that contributed to the severity of the SMM cases. SETTING: All birthing hospitals in Illinois. PARTICIPANTS: A total of 81 SMM cases were reviewed by a facility-level committee and the state-level review committee. SMM was defined as any intensive care or critical care unit admission and/or transfusion of 4 or more units of packed red blood cells from conception to 42 days postpartum. RESULTS: Among the cases reviewed by both committees, hemorrhage was the primary cause of morbidity, with 26 (32.1%) and 38 (46.9%) hemorrhage cases identified by the facility-level and state-level committees, respectively. Both committees identified infection/sepsis (n = 12) and preeclampsia/eclampsia (n = 12) as the next most common causes of SMM. State-level review found more cases potentially preventable (n = 29, 35.8% vs n = 18, 22.2%) and more cases not preventable but improvement in care needed (n = 31, 38.3% vs n = 27, 33.3%). State-level review found more provider and system opportunities to alter the SMM outcome and fewer patient opportunities than facility-level review. CONCLUSION: State-level review found more SMM cases potentially preventable and identified more opportunities to improve care than facility-level review. State-level review has the potential to strengthen facility-level reviews by identifying opportunities to improve the review process and develop recommendations and tools to aid facility-level reviews.

Reducing the cesarean delivery rate.

BACKGROUND: The cesarean delivery rate has been rising in recent years, having associated maternal morbidities. Elective induction of labor has also been seen to rise during this same time period. OBJECTIVE: This current study investigated the difference in the cesarean delivery rate between induction of labor and spontaneous labor among nulliparous, term, singleton, and vertex-presenting women. STUDY DESIGN: A retrospective cohort in a single institution over a seven-year period was used for this analysis, observing the difference in cesarean delivery rate at different term gestational ages and neonatal morbidity using the 5-minute Apgar score < 5. RESULTS: A statistically significant difference was found in cesarean delivery rate between those women whose labor was induced and those whose labor began spontaneously, at each term gestational age of labor initiation (P < 0.001). The proportion of indications for induction was described (i.e. elective vs. medically-indicated), and no difference was found for neonatal morbidity between the groups analyzed, using the 5-minute Apgar score as the perinatal outcome measure. CONCLUSION: A comparison was made between spontaneous and induced labor regarding the resultant cesarean delivery rate, and a significant difference was found favoring spontaneous labor. This should be considered when electing to deliver using an induction methodology for nulliparous women, especially when there are no medical indications for it.

Prevalence and Neighborhood Geomapping of COVID-19 in an Underserved Chicago Pregnant Population.

Objective The Chicago area is known to harbor some of the deepest racial and ethnic socioeconomic inequalities in the United States. We studied the prevalence and neighborhood distribution of patients who tested positive for COVID-19 after implementation of universal screening at an academic hospital providing obstetrical services to an underserved Chicago population. Study Design From April 16 to June 16, 2020, a total of 369 patients were screened for COVID-19 at University of Illinois at Chicago with either the Abbott Point-of-Care (POC, n = 266) or reverse transcription polymerase chain reaction test (RT-PCR, n = 101). Patient residential data mapped using ESRI ArcGIS Pro was integrated in ESRI's Living Atlas with the Neighborhood Socioeconomic Status Index (NSEI). Results Precisely, 7.9% (29/369) of screened patients tested positive; 69% (17/29) with the POC test and 31% (12/29) by RT-PCR. The prevalence of an outpatient RT-PCR positive result was 8.9% (9/101). All but one of the 29 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive patients were either Hispanic or Black, and the majority resided in disadvantaged neighborhoods. Conclusion The disproportionate hit of COVID-19 pandemic on the Hispanic and Black communities reflects in SARS-CoV-2 positivity rates in the obstetrical population. Our report provides data that may be useful to policy makers when prioritizing resources to communities in need.

Clinical Value of 3-Dimensional Ultrasound in Gynecology.

This report provides examples of using 3-dimensional ultrasound diagnostically in gynecology. The cost efficiency it provides and the wide range of applications it has support the routine use of this ultrasound technology in the practice of gynecology.

Management of perforated essure with migration into small and large bowel mesentery.

The Essure permanent birth control system (Conceptus Inc, San Carlos, CA) is currently the only Food and Drug Administration-approved hysteroscopic sterilization method and has been widely accepted as a safe and effective procedure. We present a rare case of tubal perforation, coil fragmentation, and distal migration into small and large bowel mesentery 8 days after the insertion of the Essure device. We describe the successful management of this complication using laparoscopy and intraoperative fluoroscopy. Providers using Essure must be aware of the possibility of fragmentation of the Essure coils. Intraoperative imaging, ideally fluoroscopy, should be strongly considered in the management of Essure migration to ensure localization and full retrieval of Essure material.

Diagnosis and management of intramural ectopic pregnancy.

Intramural pregnancy, a gestation completely surrounded by the myometrium located within the uterine wall with separation from the uterine cavity, is an extremely unusual form of pregnancy. Complications resulting from intramural pregnancy include inevitable uterine rupture with resultant hemorrhage and possible hysterectomy if diagnosis is not made early and treatment is not initiated. An asymptomatic patient was initially diagnosed with a missed abortion at approximately 6 weeks of gestation after a routine ultrasound. Suction curettage was performed approximately 1 month after the initial diagnosis. The pathology specimen failed to reveal placental villi. Ultimately, the diagnosis of intramural pregnancy was made via ultrasound and a computed tomography scan. She was treated with a single dose of systemically administered methotrexate. Over a period of 4 months, ß-human chorionic gonadotropin levels trended downward; however, the intramural pregnancy failed to resolve completely, and a persistent mass remained. The intramural pregnancy was removed using the da Vinci laparoscopic procedure (Intuitive Surgical, Sunnyvale, CA). If the diagnosis of intramural ectopic pregnancy is made sufficiently early, conservative measures can be taken, which can preserve a patient's future fertility.

Robotic-assisted total laparoscopic hysterectomy versus conventional total laparoscopic hysterectomy.

OBJECTIVES: To compare patient characteristics, operative variables, and outcomes of 24 patients who underwent robotic-assisted total laparoscopic hysterectomy (TLH) with 44 patients who underwent conventional TLH. We retrospectively reviewed the charts of 44 patients with TLH and 24 patients with robotic TLH. RESULTS: Robotic TLH was associated with a shorter hospital stay (1.0 vs 1.4 days, P=0.011) and a significant decrease in narcotic use (1.2 vs 5.0 units, P=0.002). EBL and droP in hemoglobin were not significantly different. The operative time was significantly longer in patients undergoing robotic TLH (142.2 vs 122.1 minutes, P=0.027). However, only need for laparoscopic morcellation, BMI, and uterine weight, not robotic use, were independently associated with increased operative times. CONCLUSIONS: Robotic hysterectomy can be performed safely with comparable operative times to those of conventional laparoscopic hysterectomy. Postoperative measures were improved over measures for conventional laparoscopy.