Severe Maternal Morbidity among Women in the U. S. Military, 2003-2015.

OBJECTIVE: This study aimed to assess trends and correlates of severe maternal morbidity at delivery among active duty women in the U.S. military, all of whom are guaranteed health care and full employment. STUDY DESIGN: Linked military personnel and medical encounter data from the Department of Defense Birth and Infant Health Research program were used to identify a cohort of delivery hospitalizations among active duty military women from January 2003 through August 2015. Cases of severe maternal morbidity were identified by applying 21- and 20-condition algorithms (with and without blood transfusion) developed by the Centers for Disease Control and Prevention. Rates (per 10,000 delivery hospitalizations) were reported overall and by specific condition. Multivariable Poisson regression models estimated associations with demographic, clinical, and military characteristics. RESULTS: Overall, 187,063 hospitalizations for live births were included for analyses. The overall 21- and 20-condition severe maternal morbidity rates were 111.7 (n = 2089) and 37.4 (n = 699) per 10,000 delivery hospitalizations, respectively. The 21-condition rate increased by 184% from 2003 to 2015; the 20-condition rate increased by 40%. Compared with non-Hispanic White women, the adjusted 21-condition rate of severe maternal morbidity was higher for Hispanic (adjusted rate ratio [aRR] = 1.28, 95% confidence interval [CI]: 1.13-1.46), non-Hispanic Black (aRR = 1.34, 95% CI: 1.21-1.49), Asian/Pacific Islander (aRR = 1.35, 95% CI: 1.13-1.61), and American Indian/Alaska Native (aRR = 1.39, 95% CI: 1.06-1.82) women. Rates also varied by age, clinical factors, and deployment history. CONCLUSION: Active duty U.S. military women experienced an increase in severe maternal morbidity from 2003 to 2015 that followed national trends, despite protective factors such as stable employment and universal health care. Similar to other populations, military women of color were at higher risk for severe maternal morbidity relative to non-Hispanic White military women. Continued surveillance and further investigation into maternal health outcomes are critical for identifying areas of improvement in the Military Health System. KEY POINTS: · Cesarean delivery and multiple birth were the strongest correlates of severe maternal morbidity in this population.. · Racial disparities persisted across indicators of severe maternal morbidity.. · Rates of disseminated intravascular coagulation were higher than those reported nationally..

Quantification of Blood Loss Improves Detection of Postpartum Hemorrhage and Accuracy of Postpartum Hemorrhage Rates: A Retrospective Cohort Study.

Objective To evaluate the ability of estimated blood loss (EBL) and quantitative blood loss (QBL) to predict the need for blood transfusion in postpartum patients. Methods This is a retrospective observational study involving all deliveries one year before and after the change from EBL to QBL assessment in June 2017. Blood loss, need for blood transfusion, admission hematocrit, and postpartum nadir hematocrit were collected. Descriptive and bivariable analyses were performed. Receiver operator curves were compared. Results Overall, the baseline characteristics between the EBL (n=2743) and QBL (n=2,712) groups were similar. Although there was a higher rate of blood loss ≥ 1,000 mL in QBL vs EBL (6.5% vs 2.1%, P<0.001), there was no difference in the rate of blood transfusions (2.0% vs 2.0%, P=1). Among cesarean deliveries, QBL outperformed EBL for predicting blood transfusion and/or ≥10 point drop in hematocrit (AUC 0.75 vs 0.66, P=0.02). QBL also outperformed EBL for predicting transfusion after vaginal delivery (AUC 0.93 vs 0.81, P=0.03).  Conclusion QBL is a more sensitive test for detecting clinically significant blood loss, which could lead to earlier recognition of hemorrhage and interventions.

Attendance and Quality and Quantity of Research Presentations at an Obstetrics and Gynecology Regional Meeting Pre- and Postchanges in Federal Funding.

INTRODUCTION: Participating in scientific meetings offers value to physician trainees and faculty. In 2012, the U.S. Government (including the Department of Defense) instituted restrictions on conference travel, requiring central approval to attend. Hence, our objective was to determine the academic impact of research presented at the American College of Obstetricians and Gynecologists (ACOG) Armed Forces District Meeting and the effect of this federally mandated policy change on attendance and the quality and quantity of research. MATERIALS AND METHODS: Attendance logs and meeting programs were reviewed for the 3 years immediately before and after institution of travel regulations. A PubMed search of each abstract was performed to determine if it resulted in publication and the mean duration in months from presentation to publication was calculated and compared between oral and poster presentations. The top journals accepting manuscripts were noted along with the corresponding impact factor. RESULTS: The overall meeting publication rate was 22%. Oral presentations were significantly more likely than posters to achieve publication (P < 0.001). Following implementation of travel regulations, mean faculty attendance declined from 130 per year to 105 (P < 0.05). Declines in resident attendance and publication rates were not statistically significant. The top journals publishing investigations included Obstetrics and Gynecology (n = 15), Military Medicine (n = 12), and Fertility and Sterility and Gynecologic Oncology (tied, both n = 11). CONCLUSION: Approximately one in five presentations at the ACOG Armed Forces District Meeting are published, many in high impact journals within the specialty. Implementation of stricter travel regulations adversely impacted faculty physician attendance, but not trainee participation or the publication rate.

Pyelonephritis in Pregnancy: Relationship of Fever and Maternal Morbidity.

Objective To evaluate the relationship between maternal fever at the time of hospital admission and subsequent maternal morbidity in pregnant patients with pyelonephritis. Study Design In this retrospective cohort study, inpatient records were reviewed for all obstetric patients discharged from a single tertiary care hospital between June 1, 2011, and May 30, 2017, with the diagnosis of pyelonephritis. Patients were stratified into two groups, those with and without fever at the time of admission. Descriptive statistics were utilized to evaluate the association of fever at the time of presentation with subsequent morbidity. Using admission vital signs, maternal early warning criteria (MEWC) were applied and odds ratios calculated to predict intensive care unit (ICU) admission. Results A total of 110 patients were admitted with pyelonephritis in pregnancy; 24 patients were febrile and 86 patients were afebrile on admission. There was no difference in rates of maternal ICU admission between both groups. Positive MEWC was predictive of ICU admission with an adjusted odds ratio of 16.54 (95% confidence interval: 1.29-212.5; p = 0.03). Conclusion Afebrile pregnant patients with pyelonephritis remain at risk of significant maternal morbidity. Application of the MEWC on admission identifies patients at higher risk of ICU admission.

Multimodal Stepwise Approach to Reducing In-Hospital Opioid Use After Cesarean Delivery: A Quality Improvement Initiative.

OBJECTIVE: To evaluate the association of a standardized, structured approach to in-hospital postcesarean delivery pain management with maternal opioid use after cesarean delivery. METHODS: We conducted a retrospective cohort study of women who underwent cesarean delivery before and after a quality improvement intervention at a single tertiary care center. A multidisciplinary task force revised electronic order sets for all patients who underwent cesarean delivery with neuraxial anesthesia. The revised order set separated acetaminophen from opioids, scheduled acetaminophen and nonsteroidal antiinflammatory drug administration, and limited opioid use to breakthrough pain. Data were collected by electronic chart review. The primary outcome was median morphine milligram equivalents per hospital stay. Secondary outcomes included median morphine milligram equivalents per day, median pain scores, time to discharge, and opioid-nonopioid pain medication use. Descriptive and bivariable analyses were performed. RESULTS: There were no significant differences in baseline characteristics in the preintervention (n=283) and postintervention (n=286) groups. There was a 75% reduction in median morphine milligram equivalents per stay from 120 (90-176 interquartile range) preintervention to 30 (5-68) postintervention (P<.001) and a 77% reduction in median morphine milligram equivalents per day (51 [41-60] vs 12 [2-25], P<.001). There was no difference between groups in time to discharge or median pain scores. There was no difference in ketorolac use (80% preintervention vs 75% postintervention, P=.14) or in median ibuprofen mg per day (1,391 preintervention vs 1,347 postintervention, P=.22). There was an increase in median acetaminophen mg per day (753 preintervention vs 2,340 postintervention, P<.001). There was a significant increase in patients who used no opioids during their hospital stay (6% preintervention vs 19% postintervention, P<.001). CONCLUSION: A multimodal stepwise approach to postcesarean delivery pain control was associated with markedly reduced opioid consumption without increasing hospital stay or median pain scores. By separating acetaminophen from opioids and limiting opioids to breakthrough pain, we were able to operationalize a tier-based approach to pain management.

Obstetric Hemorrhage Outcomes by Intrapartum Risk Stratification at a Single Tertiary Care Center.

Introduction Postpartum hemorrhage is a leading cause of maternal mortality worldwide. Performance of a postpartum hemorrhage risk assessment prior to delivery has been recommended to identify patients at higher risk for hemorrhage to support advanced planning for optimal response. The objective of this quality improvement initiative is to evaluate the transfusion and hemorrhage rates for patients at low, moderate, and high risk for postpartum hemorrhage by utilizing standardized risk assessment. Methods and materials A historic cohort study was performed among women delivering from March 2017 to June 2018 at a single United States military tertiary medical center. A postpartum hemorrhage risk assessment was performed utilizing the California Maternal Quality Care Collaborative toolkit for all patients admitted to Labor and Delivery and when the postpartum hemorrhage risk increased during the intrapartum period. An electronic log was reviewed to determine blood loss volume, change in hematocrit, and transfusion rates in patients at low, moderate, and high risk for postpartum hemorrhage for all deliveries, stratified by delivery type. Results There were 3,377 deliveries during the study period with 145 excluded due to lack of assigned risk category. The high-risk group (12.3% of deliveries) was 4.3 times more likely to receive a blood transfusion, 2.9 times more likely to have a blood loss over 1000 mL, and 2.1 times more likely to have a transfusion or hematocrit drop of 10 points when compared with the low-risk group (69.4% of deliveries). Of those transfused, the majority were classified as low risk as this was the most common assignment. Conclusion Risk stratification can differentiate low from high-risk patients for postpartum hemorrhage and associated transfusion or change in hematocrit. However, the majority of patients who receive a transfusion will be classified as low or moderate risk. Thus, all patients should be monitored closely and treated aggressively to prevent morbidity.

Introduction of Posterior Axilla Sling Traction in Simulated Shoulder Dystocia.

Objective Aim of this study was to introduce posterior axilla sling traction (PAST) in delivering providers and nursing staff as an adjunct to the management of shoulder dystocia and evaluate comfort in performing the maneuver. Methods A presimulation questionnaire had given to all participants. A brief training on how to perform PAST was also given. A simulated shoulder dystocia was run where usual maneuvers failed. Participants used PAST for delivery of posterior shoulder, delivery of posterior arm, and to assist with rotation. Participants were then given a post-simulation questionnaire. A Chi-squared test was used to evaluate comfort with performing the procedure pre and post-simulation. Results Data were collected from 43 participants at pre and post-simulation. Designations (attending, resident, midwife, registered nurse) and responses were recorded to the questionnaires. There was a statistically significant increase in the number of providers and nurses who would feel comfortable using PAST for shoulder dystocia management and for rotational maneuvers. Ninety-three percent of participants would consider using PAST in future shoulder dystocia when usual maneuvers failed. Conclusion PAST is an adjunct to management of shoulder dystocia that has not previously been taught in our facility. The majority of participants in our simulation felt comfortable with using PAST.

Hemostatic Resuscitation in Peripartum Hysterectomy Pre- and Postmassive Transfusion Protocol Initiation.

Background Massive transfusion protocols (MTPs) have been examined in trauma. The exact ratio of packed red blood cells (PRBC) to other blood replacement components in hemostatic resuscitation in obstetrics has not been well defined. Objective The objective of this study was to evaluate hemostatic resuscitation in peripartum hysterectomy comparing pre- and postinstitution of a MTP. Study Design We conducted a retrospective, descriptive study of women undergoing peripartum hysterectomies from January 2002 to January 2015 who received ≥ 4 units of PRBC. Individuals were grouped into either a pre-MTP institution group or a post-MTP institution group. The post-MTP group was subdivided into those who had the protocol activated (MTP) versus not activated (no MTP). Primary outcomes were estimated blood loss (EBL) and need for blood product replacement. The secondary outcome was a composite of maternal morbidity, including need for mechanical ventilation, venous thromboembolism, pulmonary edema, acute kidney injury, and postpartum infection. A Mann-Whitney U test was used to compare continuous variables, and a chi-squared test was used for categorical variables with significance of p < 0.05. Results Of the 165 women who had a peripartum hysterectomy during the study period, 62 received four units or more of PRBC. No significant differences were noted in EBL or blood product replacement between the pre-MTP (n = 39) and post-MTP (n = 23) groups. Similarly, the MTP (n = 6) and no MTP (n = 17) subgroups showed no significant difference between EBL and overall blood product replacement. Significant differences were seen in transfusion of individual blood products, such as fresh frozen plasma (FFP) (MTP = 4, no MTP = 2; p = 0.02) and platelets (plts) (MTP = 6, no MTP = 0; p = 0.03). The use of high ratio replacement therapy for both plasma and plts was more common in the MTP group (FFP/PRBC ratio [MTP = 0.5, no MTP = 0.3; p = 0.02]; plts/PRBC ratio [MTP = 0.7, no MTP = 0; p = 0.03]). There were no differences in the secondary outcome between pre- and post-MTP or MTP and no MTP. Conclusion Initiation of the MTP did result in an increase in transfusion of FFP and plts intraoperatively. At our institution, the MTP is underutilized, but it appears that providers are more cognizant of the use of high transfusion ratios.

Adipose Tissue Insulin Resistance in Gestational Diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM) is a metabolic disorder characterized by insulin resistance (IR) and altered glucose-lipid metabolism. We propose that ectonucleotide pyrophosphate phosphodiesterase-1 (ENPP1), a protein known to induce adipocyte IR, is a determinant of GDM. Our objective was to study ENPP1 expression in adipose tissue (AT) of obese pregnant women with or without GDM, as well as glucose tolerance in pregnant transgenic (Tg) mice with AT-specific overexpression of human ENPP1. METHODS: AT biopsies and blood were collected from body mass index-matched obese pregnant women non-GDM (n = 6), GDM (n = 7), and nonpregnant controls (n = 6) undergoing cesarian section or elective surgeries, respectively. We measured the following: (1) Expression of key molecules involved in insulin signaling and glucose-lipid metabolism in AT; (2) Plasma glucose and insulin levels and calculation of homeostasis model assessment of IR (HOMA-IR); (3) Intraperitoneal glucose tolerance test in AtENPP1 Tg pregnant mice. RESULTS: We found that: (1) Obese GDM patients have higher AT ENPP1 expression than obese non-GDM patients, or controls (P = 0.01-ANOVA). (2) ENPP1 expression level correlated negatively with glucose transporter 4 (GLUT4) and positively with insulin receptor substrate-1 (IRS-1) serine phosphorylation, and to other adipocyte functional proteins involved in glucose and lipid metabolism (P < 0.05 each), (3) AT ENPP1 expression levels were positively correlated with HOMA-IR (P = 0.01-ANOVA). (4) Pregnant AT ENPP1 Tg mice showed higher plasma glucose than wild type animals (P = 0.046-t test on area under curve [AUC]glucose). CONCLUSIONS: Our results provide evidence of a causative link between ENPP1 and alterations in insulin signaling, glucose uptake, and lipid metabolism in subcutaneous abdominal AT of GDM, which may mediate IR and hyperglycemia in GDM.

A Novel Mutation in ACTG2 Gene in Mother with Chronic Intestinal Pseudoobstruction and Fetus with Megacystis Microcolon Intestinal Hypoperistalsis Syndrome.

Background. A novel mutation in the ACTG2 gene is described in a pregnant patient followed up for chronic intestinal pseudoobstruction (CIPO) during pregnancy and her fetus with megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS). Case. 24-year-old gravida 1 para 1 with CIPO and persistent nausea and vomiting in pregnancy, admitted at 28 weeks of gestation. Ultrasound revealed a fetus measuring greater than the 95th percentile, polyhydramnios, and megacystis. At delivery, the newborn was noted to have an enlarged bladder, microcolon, and intolerance of oral intake. Genetic testing of mother and child revealed a novel mutation in the ACTG2 gene (C632F>A, p.R211Q). Conclusion. This is the first case in the literature describing a novel mutation in ACTG2 associated with visceral myopathy affecting both mother and fetus/neonate. Visceral myopathy should be included in the differential diagnosis of megacystis diagnosed by ultrasound, and suspicion should increase with family history of CIPO or MMIHS.

Effect of lactation on maternal postpartum cardiac function and adiposity: a murine model.

OBJECTIVE: Lactation is associated with reduction in maternal metabolic disease and hypertension later in life; however, findings in humans may be confounded by socioeconomic factors. We sought to determine the independent contribution of lactation on cardiovascular parameters and adiposity in a murine model. STUDY DESIGN: Following delivery, CD-1 female mice were randomly divided into 2 groups: lactated (L; nursed pups for 3 weeks, n = 10), and nonlactated (NL; pups were removed after birth, n = 12). Blood pressure (BP) was assessed prepregnancy and at 1 and 2 months' postpartum. Visceral and subcutaneous adipose tissue determined by computed tomography and left ventricular ejection fraction, cardiac output, and the E/A ratio determined by microultrasound were evaluated at 1 and 2 months' postpartum. The results were analyzed using a Student t test (significance at P < .05). RESULTS: We observed a significantly different maternal BP at 2 months' postpartum with relatively greater BP in NL (systolic BP: NL, 122.2 ± 7.2 vs L, 96.8 ± 9.8 mm Hg; P = .04; diastolic BP: NL, 87.0 ± 6.8 vs L, 65.9 ± 6.2 mm Hg; P = .04). Visceral adipose tissue was significantly increased in NL mice at 1 (22.0 ± 4.1% vs 10.7 ± 1.8%, P = .04) and 2 months' postpartum (22.9 ± 3.5% vs 11.2 ± 2.2%, P = .02), whereas subcutaneous adipose tissue did not differ between the groups. At 2 months' postpartum, ejection fraction (51.8 ± 1.5% vs 60.5 ± 3.8%; P = .04), cardiac output (14.2 ± 1.0 vs 18.0 ± 1.3 mL/min; P = .02) and mitral valve E/A ratio (1.38 ± 0.06 vs 1.82 ± 0.13; P = .04) were significantly lower in NL mice than L mice. CONCLUSION: Our data provide evidence that interruption of lactation adversely affects postpartum maternal cardiovascular function and adiposity.

Randomized clinical trial evaluating the frequency of membrane sweeping with an unfavorable cervix at 39 weeks.

BACKGROUND: Despite the widely accepted use of membrane sweeping to prevent postmaturity pregnancies, the optimal frequency for this procedure has not been established. AIM: To determine if the frequency of membrane sweeping in women with an unfavorable cervix at term results in fewer labor inductions. METHODS: This was a randomized trial of women with an unfavorable cervix (Bishop's score of ≤4) at 39 weeks randomized into three groups: control, once-weekly membrane sweeping, and twice-weekly membrane sweeping. RESULTS: Between January 2005 and June 2008, 350 women were randomized into the study (groups: control [n = 116], once weekly [n = 117], and twice weekly [n = 117]). Randomization of Bishop's score was different between groups (P = 0.019), with 67%, 71%, and 83% of control, once-, and twice-weekly groups, respectively, having scores of 3-4. There was no difference in the unadjusted rate of labor induction between the groups (35% versus 27% versus 23%, P = 0.149), and after the adjustment for the randomization of Bishop's score (adjusted odds ratio [OR] = 0.73, 95% confidence interval [CI] 0.41-1.29 and OR = 0.65, 95% CI 0.36-1.18 for once- and twice-weekly groups, respectively). A Bishop's score of 3-4 at randomization was the only statistically significant factor that decreased the likelihood of induction at 41 weeks (OR = 0.42, 95% CI 0.25-0.69). CONCLUSION: Frequency of membrane sweeping does not influence the likelihood of remaining undelivered at 41 weeks of pregnancy. The Bishop's score at around 39 weeks is the important factor as a predictor of the duration of pregnancy, and further studies would be required to determine whether membrane sweeping influences pregnancy duration.

Abnormal 1 hour glucose challenge test followed by a normal 3 hour glucose tolerance test: does it identify adverse pregnancy outcome?

OBJECTIVE: To determine if pregnancies with an abnormal glucose challenge test (GCT) but a normal (GTT) are at increased risk for fetal macrosomia or an adverse pregnancy outcome. STUDY DESIGN: This prospective observational study matched women with an abnormal glucose challenge test and a normal GTT with the next patient with a normal GCT. RESULTS: Over 12 months, 107 women with abnormal GCT were matched with 107 women with normal GCT. Women with an abnormal GCT were older (27.3 vs. 24.7, p = 0.001) and less likely to be African-American (OR = 2.2, 95% CI 1.06-4.49) but no more likely to have an adverse pregnancy outcome. ROC curves could not differentiate between macrosomic vs non-macrosomic newborns using GCT values. CONCLUSION: Women with an abnormal GCT but a normal GTT are more likely to be older, less likely to be African-American, but no more likely to have an adverse pregnancy outcome or a macrosomic fetus.