Predictors of maternal mortality and near-miss maternal morbidity.

OBJECTIVE: To identify risk factors for life-threatening maternal outcomes. STUDY DESIGN: Hospital charts were reviewed for cases of maternal mortality or near-miss and for controls overmatched 1:3. Significant risk factors were identified through simple and best subsets multiple logistic regression. RESULT: Eight cases of mortality and 69 near-miss cases were found. Significant risk factors with their odds ratios and 95% confidence intervals are: age 35 to 39 years (2.3, 1.2 to 4.4) and >39 years (5.1, 1.8 to 14.4); African-American race (7.4, 2.5 to 22.0) and Hispanic ethnicity (4.2, 1.3 to 13.2); chronic medical condition (2.7, 1.5 to 4.8); obesity (3.0, 1.7 to 5.3); prior cesarean (5.2, 2.8 to 9.8) and gravidity (1.2, 1.1 to 1.5 per pregnancy). In multivariable logistic regression, race remained significant while controlling for other significant factors and markers of socioeconomic status. CONCLUSION: Some risk factors can be modified through medical care, education or social support systems. Racial disparity in outcome is confirmed and is unexplained by traditional risk factors.

Improving preconception care.

OBJECTIVE: To improve the documentation and delivery of preconception care to all women of reproductive age attending an inner city hospital's outpatient gynecology clinic. A secondary goal was to evaluate the knowledge and awareness of providers regarding preconception care. STUDY DESIGN: A preintervention chart review of a convenience sample of non-pregnant women with reproductive potential who attend an inner city hospital gynecology clinic (n = 100) was conducted to evaluate delivery of preconception care. Items screened for included: family planning services, domestic violence, nutrition and medical risk factors, medication use, appropriate counseling and use of referral services. All providers in the clinic were surveyed to assess their knowledge of and attitudes toward preconception care. A two-part intervention was then carried out: (1) a one-hour lecture for all providers, and (2) a standardized preconception care form inserted in all charts. A postintervention chart review of a second convenience sample (n = 100) and repeat provider survey were then conducted to evaluate the effectiveness of the two interventions. RESULTS: Following the two-pronged intervention, there was evidence of improved documentation of the delivery of preconception care. Documentation of screening in almost all categories was significantly improved (P < .05). The greatest improvements were noted in complete screening for medical risk factors (from 15% to 44%), for over-the-counter and prescription medication use (from 10% to 70% and 30% to 77%, respectively), domestic violence (from 10% to 57%) and nutrition (from 9% to 50%). However, provider knowledge of and attitudes toward preconception care were not significantly changed. CONCLUSION: The combination of education about preconception care and insertion of a standardized form into a patient's chart led to a clear improvement in the documentation of preconception care. Given the significance of preconception care, insertion of a standardized form should be considered to help providers complete and appropriate care to their patients.

Methods to encourage the use of antenatal corticosteroid therapy for fetal maturation: a randomized controlled trial.

CONTEXT: Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth. OBJECTIVE: To evaluate dissemination strategies aimed at increasing appropriate use of this therapy. DESIGN AND SETTING: Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13). SUBJECTS: Obstetricians and their preterm delivery cases at participating hospitals. INTERVENTION: Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback. MAIN OUTCOME MEASURE: Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122). RESULTS: Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, oran 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways. CONCLUSION: An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices.

Evaluation of the readability of ACOG patient education pamphlets. The American College of Obstetricians and Gynecologists.

OBJECTIVE: To evaluate whether ACOG's patient education pamphlets comply with the recommended readability level for health education materials intended for the general public. METHODS: All 100 English-language pamphlets available during 1997 (created or revised between 1988 and 1997) were evaluated using four standard readability formulas. RESULTS: Mean readability levels of ACOG's pamphlets were between grade 7.0 to grade 9.3, depending on the formula used. Analysis of readability over the 10 years showed a trend toward lower readability levels. Analysis by category of pamphlet found that the lowest readability levels were in "Especially for teens" pamphlets. CONCLUSION: Our data suggested that most of ACOG's patient education pamphlets currently available are written at a higher readability level than recommended for the general public. The readability of those pamphlets improved in the 10 years since the organization published its first pamphlet, but the goal of sixth-grade readability level has not been reached.

Informed consent for maternal serum alpha-fetoprotein screening in an inner city population: how informed is it?

OBJECTIVE: To determine if women who received information from a provider and viewed a videotape about maternal serum alpha-fetoprotein (MSAFP) screening understood enough to sign informed consent. DESIGN: A prospective qualitative design using tape recorded interviews of women who were provided information regarding MSAFP testing from a provider and from viewing a videotape. PARTICIPANTS: Fifty-three inner city pregnant women (58% Hispanic, 39% African-American, 3% white). RESULTS: Two women answered all questions correctly; no one answered all questions incorrectly. Sixty-two percent correctly answered "What is MSAFP?" Sixteen percent thought "something has to be taken from my belly" for the test. Fifty-nine percent understood that children with spina bifida could have difficulty walking or urinary problems. Seventy-two percent thought their infant would be healthy in all respects if the test was negative. Only 45% could describe the follow-up to a positive test. Eighty percent planned to have the test. Many misconceptions were apparent, and for some knowledge items, as many as 80% of the women answered incorrectly. CONCLUSIONS: Obtaining truly informed consent for a complex test is not a simple process. Participants met a few, but not all, of the criteria for informed consent. Women understood that the test was voluntary, but their comprehension of the meaning and implication of a positive test results was deficient. Despite this, they signed the informed consent document. The larger question of just how much comprehension is required to consider a woman "informed" has not been answered.

Modified open laparoscopy through placement of an optical surgical obturator.

OBJECTIVE: To describe a new technique for open laparoscopy. DESIGN: Prospective case series. SETTING: Ambulatory surgical unit. PATIENT(S): Fifty-six women undergoing laparoscopic sterilization. INTERVENTION(S): Intra-abdominal placement of an optical surgical obturator. MAIN OUTCOME MEASURE(S): Evaluation of surgical technique. RESULT(S): The technique was completed successfully in all cases. CONCLUSION(S): This new surgical approach may assist surgeons in avoiding inadvertent injuries.

Biocompatible electric current attenuates HIV infectivity.

The number of individuals infected by the human immunodeficiency virus type-l (HIV) continues to increase on a worldwide basis.' A significant percentage, ifnot all, of these individuals will eventually develop the acquired immunodeficiency syndrome (AIDS).2 While horizontal transmission in the homosexual population may be contained or decreasing,' heterosexual transmission and infection through contaminated blood supplies continues to increase: Additionally, vertical transmission from infected females to their fetuses is also on the rise with a resultant increase in the number of children with AIDS.S New strategies, therefore, must be devised in order to limit more effectively the spread of this virus.

Visually guided trocar entry: experience with the optical trocar.

Blind insertion of the Veressneedle and the conventional primary trocar have remained troublesome steps during laparoscopic surgical procedures. The standard primary trocar can be inserted directly without preexisting pneumoperitoneum, thus avoiding use of the Veressneedle. This approach still requires blind insertion, and inadvertent traumatic injuries have been reported.' Complications from such trocar insertions can be severe and at times lethal. Although the rate of such complications is acknowledged to be small, the ab- solute number becomes a relevant public health issue in light ofthe high frequency of both operative and di- agnostic laparoscopic procedures worldwide. Traumatic injuries to vessels, bowel, and other abdominal or- gans continue to occur despite proper surgical training, operator experience, and use of up-to-date equipment.

Abdominal wall stability: a comparison of the optical trocar with a reusable laparoscopic trocar.

The principal reason for employing an optical trocar has been described by Kaali.' The potential clinical benefits of a visually directed trocar entry system have been identified in a follow-up clinical series. 2 Current experience with the commercially developed Endopath Opt.iview" trocar has suggested an ad- ditional surgical advantage through an enhanced abdominal wall stability of the trocar sheath. The purpose of the current investigation was to determine whether or not this clinical observation could be mechanically quantified.

Impact of an inner-city, hospital-based preterm prevention program on preterm births in twin gestation.

The objective of this study was to determine the impact of an inner-city, hospital-based preterm-birth prevention program on the outcome of twin pregnancies. A retrospective study of delivery outcomes from 1985 to 1992 of eligible consecutive twin deliveries that were > or = 20 weeks' gestation compared two inner-city hospitals in the Bronx, New York: one with a preterm prevention program for twin births and a comparable site offering conventional prenatal care. A group of patients receiving no prenatal care was also included. Outcomes were evaluated by prenatal-care site, except for those who received no prenatal care and delivered at either site. Data were analyzed by chi-square analysis and analysis of variance. Of the 377 twin pregnancies, 330 pregnancies were eligible deliveries. One hundred thirty-four women received prenatal care from the preterm prevention program, 161 received conventional prenatal care at a comparable site, and 35 received no prenatal care. Maternal age, parity, and mode of delivery were similar in the two delivery sites. There was an increased incidence of complications in the no-prenatal-care group compared with the groups who received the preterm prevention or conventional prenatal care. The percentage of low-birth-weight (< 2500 g) and very-low-birth-weight (< 1000 g) infants was similar in the preterm prevention and the conventional care groups. The percentage of extremely low-birth-weight (< 1000 g) infants was significantly lower in twin births of the preterm prevention site (9.7%) and the conventional site (11.3%) compared with the no-prenatal-care group (28.6%) (P < .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of visual and tactile localization of the trocar tip during abdominal entry.

We attempted to determine whether video-aided visual imaging during laparoscopic insertion of the trocar would improve the surgeon's ability to localize the sharp penetrating tip of the instrument. A newly described, visually directed laparoscopic trocar was inserted in 184 subjects to correlate visual localization of the tip with the accuracy of the conventional tactile sensory approach. In 164 of the 184 cases the fascia was recognized visually at the same time that the surgeon acknowledged tactile resistance. However, partial intraabdominal penetration was noted in 102 of these cases just before the anticipated loss of resistance could be felt manually. More important, in 20 women there was no subjective manual confirmation of the tip location by the time intraabdominal placement of the trocar was confirmed visually. In this limited series there were no multiple insertions or complications under visually directed trocar entry. Video-aided direct visualization improves the surgeon's ability to localize the tip of the trocar throughout the insertion. It may help the surgeon to recognize and possibly avoid some inadvertent distant intraabdominal organ injuries.

Placental histology and placental/fetal weight ratios in pregnant women with sickle cell disease: relationship to pregnancy outcome.

Although the adverse effects of sickle cell disease on pregnancy outcome are well recognized, the contribution of placental pathology to these events remains controversial. Placentas from single, term deliveries of 21 women with sickle cell (SS) disease and 63 low-risk control women with hemoglobin AA, matched for maternal age, gestational age, and parity, were examined and findings correlated with neonatal outcome. Gross and microscopic examinations of these placentas were performed by a pathologist unaware of the pregnancy outcome. All placentas were weighed, and the relative placental weight was calculated and examined for the presence of infarction, villous sclerosis, and intervillous fibrin deposits. The mean birth weight of infants of the SS women was significantly lower than that of the low-risk controls (2830 +/- 310 g versus 3415 +/- 250 g, P < .05). The mean placental weight was also lower in the SS group compared with controls (445 +/- 78 g versus 568 +/- 86 g). The mean relative placental weight for the SS women was 12.9 +/- 4% and for the controls, 15.2 +/- 3.4%. Moderate-to-severe villous sclerosis, infarction, and intervillous fibrin deposits were present in 7 of 21 SS placentas but absent in placentas of low-risk controls. These 7 pregnancies with SS disease and abnormal placental findings had small-for-gestational-age infants, and their relative placental weight was less than 10%. We conclude that in SS disease, relative placental weight less than 10% and placental lesions of moderate-to-severe villous sclerosis, intervillous fibrin deposits, and infarction are associated with small-for-gestational-age infants.

Are there differences in information given to private and public prenatal patients?

OBJECTIVES: In 1989 the United States Public Health Service Expert Panel on the Content of Prenatal Care reported that health education should become a more integral part of prenatal care. Key questions about providing this education have not been examined. Our study compared the type of information provided to women who sought prenatal care in a public clinic and to those who were seen in a private practice and the degree to which the patients were satisfied with the information they received. STUDY DESIGN: One hundred fifty-nine pregnant women (80 seen in a public clinic, 79 seen in a private practice) completed two questionnaires about 38 topics commonly cited as important during pregnancy. At the first prenatal visit, the women reported their level of interest in each of the topics. At 36 to 40 weeks' gestation the women completed a second questionnaire to assess whether information was provided for each topic and whether they had learned as much as desired. RESULTS: Overall, the women in the public sector received more information than did the women who were cared for privately. This was statistically significant at the p < 0.05 level for 25 of the 38 topics. Satisfaction with information learned was highly correlated with information received during prenatal care, but, surprisingly, it was not shown to be associated with the patient's interest level at the first visit. Fewer than 50% of private patients reported having received information about such important topics as acquired immunodeficiency syndrome, sexually transmitted diseases, preterm birth prevention, family planning, and family violence. CONCLUSIONS: The one-on-one approach to health education in pregnancy usually used in the private setting may not facilitate addressing many topics believed to be important components of contemporary prenatal care. Providers of private prenatal care should initiate discussion of prenatal health education topics rather than relying on patient interest in requesting information. Just as public prenatal care programs have devoted significant resources to more comprehensive prenatal education, the providers in the private sector must assure that pregnant women receive the same comprehensive information. In so doing, these providers can help promote an optimal outcome for their patients, their patients' unborn children, and the family unit.

Twin gestation: fetal presentation as a function of gestational age.

OBJECTIVE: Our objective in this study was to evaluate the rate of spontaneous version in twin gestation throughout the third trimester. STUDY DESIGN: Serial ultrasonographic examinations were performed on 119 consecutive patients with twin gestation. The incidence of spontaneous version as a function of gestational age was calculated. RESULTS: The mean birth weight and gestational age at delivery were 2640 gm and 37 weeks, respectively. Nineteen percent had birth weight discordancy, and 37% were delivered by cesarean section. The incidence of spontaneous version decreased from 60% at 28 to 30 weeks' gestation to 25% to 30% at term. The lowest incidence of spontaneous version was observed in pregnancies with a cephalic-cephalic presentation (7%). All other presentations were relatively unstable. Neither the patients' parity nor the presence of birth weight discordancy, the placental location, or the amniotic fluid volume had a significant association with the incidence of spontaneous version. CONCLUSION: These data should be incorporated into the routine antepartum counseling of patients with twin gestation. Their use in this capacity may result in a decreased cesarean delivery rate if clinicians realize that malpresentations may spontaneously resolve before the onset of labor.

What pregnant women want to know: a comparison of client and provider perceptions.

OBJECTIVE: To compare client and health-care provider perceptions concerning health topics. DESIGN: A survey conducted at the first prenatal visit asked women to indicate levels of interest in 38 topics. Providers answered the same survey, indicating perceptions of clients' interests. SETTING: A prenatal clinic and a private office, both in an inner city area. PARTICIPANTS: Two groups of prenatal clients (n = 135 private care and n = 250 public care) and their health-care providers (n = 32 nurses and physicians). RESULTS: Significant differences were found (p < .01 for four topics, p < .05 for six topics) between the clients' interests and the providers' perceptions. Women in private and public care differed significantly (p < .01) in their levels of interest. Interest was significantly affected by parity, but not maternal education. CONCLUSIONS: Nurses and other health professionals should be aware of the range of topics in which clients express interest. This study suggests that site of care and parity should be considered when developing prenatal health education.