Sequential Compression Device Adherence is Low in Hospitalized Antepartum Patients.

OBJECTIVE: This study was aimed to describe sequential compression device (SCD) adherence and its associations with SCD education in hospitalized antepartum women. STUDY DESIGN: This study included antepartum, nonlaboring women admitted from 2016 to 2018, 1 year before and after an SCD education intervention. SCD use was assessed through the Kendall SCD 700 series compliance meter, which tracks the time the SCD machine takes within the monitoring interval. Recruitment occurred after 60 to 80 hours of monitoring, at which time a patient survey was completed. SCD use was the percentage of time the machine was on during monitoring. Mann-Whitney U and Chi-square tests were used to compare associations between SCD use, education, and pharmacologic prophylaxis. RESULTS: Among 125 recruited women, 123 provided adherence data, 69 before and 54 after the education. Median SCD use was 17.3% before and 20.7% after (p = 0.71). Pharmacologic prophylaxis use was similar between the two periods and was not associated with SCD use. Among 121 surveys, the most common reason as to why SCDs were not worn was prevention of walking (52/121 [43.0%]). CONCLUSION: Using a novel monitoring technique, we found low-SCD use among antepartum inpatients, which was neither affected by education nor concurrent pharmacologic prophylaxis. Improving mobility with SCDs may improve use in this population. KEY POINTS: · SCD use was low in this cohort of hospitalized antepartum patients.. · A patient/nursing education intervention was not associated with SCD adherence.. · Concurrent pharmacologic VTE prophylaxis was not associated with SCD adherence..

Management of Hepatitis B Infection in Pregnancy.

In many parts of the world, perinatal transmission is the most common route of infection for hepatitis B virus. In the United States, sexual contact is the most common source of hepatitis B virus infection. As a result, it is essential that women's health care providers become aware of the recommended strategies used to identify women infected with hepatitis B and to subsequently reduce perinatal transmission, particularly now that immigration and globalization is more common and reproductive science makes pregnancy more possible for women with liver disease. This article reviews evidence-based strategies for management of hepatitis B infection during pregnancy.

Induction rates and delivery outcomes after a policy limiting elective inductions.

The purpose of this study was to assess induction rates, maternal, and neonatal outcomes following adoption of a policy prohibiting elective inductions at less than 39 weeks gestation and inductions between 39 and 41 weeks with an unfavorable cervix. A retrospective cohort study of all deliveries greater than or equal to 37 weeks gestation was conducted 1 year prior to through 1 year after implementation of the induction policy. Induction rates before and after the policy were calculated as the primary outcome while maternal and neonatal conditions were assessed as secondary outcomes. Elective inductions (p = 0.016), elective inductions less than 39 weeks gestation (p = 0.020), and elective inductions 39-40 weeks and 6 days gestation with an unfavorable cervix (p = 0.031) decreased significantly following adoption of the policy. Maternal and neonatal outcomes, including rates of cesarean deliveries, postpartum hemorrhage, chorioamnionitis, and neonatal intensive care unit admissions remained unchanged, though this study was not adequately powered to detect differences in these outcomes. An institutional induction policy was associated with a reduction in elective inductions prior to 39 weeks and up to 40 weeks and 6 days with an unfavorable cervix. These reductions were not accompanied by change in maternal or neonatal outcomes at our institution.

Managing Diabetes in Pregnancy Using Cell Phone/Internet Technology.

In Brief For pregnant women with diabetes, using cell phone/Internet technology to track and report self-monitoring of blood glucose results improves compliance and satisfaction compared to using the more traditional methods of log books, telephone calls, and voicemail messages.

Use of tenofovir disoproxil fumarate in highly viremic, hepatitis B mono-infected pregnant women.

BACKGROUND: Antiviral therapy in addition to immunoprophylaxis at birth has been shown to further reduce perinatal transmission of hepatitis B virus (HBV) in highly viremic women. AIMS: The aim of this study was to describe the use of tenofovir disoproxil fumarate (TDF) prophylaxis to reduce maternal HBV DNA levels and potentially vertical transmission in highly viremic women. METHODS: After receiving IRB approval, we performed a retrospective chart review of mothers positive for hepatitis B surface antigen (HBsAg) who delivered between 2009 and 2012. We identified women with HBV DNA levels ≥6 log copies/mL who were treated with TDF in pregnancy. RESULTS: There were 22 women identified. The majority were of Micronesian ethnicity. All were negative for hepatitis C antibody and HIV infection. The median gestational age of TDF initiation was 31 weeks with a median duration of treatment of 45 days. There was a reduction in median HBV DNA levels from baseline 9.0 ± 2.0 to 5.4 ± 1.1 log copies/mL after treatment. There were five (22.7 %) preterm deliveries and five (22.7 %) cesarean deliveries. All infants received immunoprophylaxis at birth. Postnatal HBsAg testing at 9-12 months was available for 13 infants, 12 of which were negative. There was one case of perinatal transmission. CONCLUSIONS: This is the second published case series to date on the use of TDF prophylaxis in HBV mono-infected, highly viremic mothers. This series suggests the use of TDF in pregnancy reduces maternal HBV DNA levels and is well tolerated.

Rates of bacteriuria in laboring women with epidural analgesia: continuous vs intermittent bladder catheterization.

OBJECTIVE: The purpose of this study was to compare the rates of bacteriuria in laboring women with epidural analgesia with the use of intermittent bladder catheterization (IC) vs continuous indwelling Foley catheterization (CIF). STUDY DESIGN: We conducted a randomized, nonblinded trial in which 160 laboring women received IC or CIF. An initial catheterized urine culture was taken at the time of epidural placement. A second catheterized or voided culture was taken at discharge. Results were analyzed to compare bacteriuria rates between CIF and IC with the use of the Center for Disease Control (CDC) and Infectious Disease Society of America (IDSA) definitions. RESULTS: Samples from 146 women were analyzed. Randomization, demographics, and labor characteristics were not significantly different between groups; 5.48% of the samples met CDC criteria for bacteriuria, and 17.8% of the samples met IDSA criteria. In the IC group, 7 samples (8.9%) met CDC criteria for bacteriuria, and 18 samples (22.8%) met IDSA criteria for bacteriuria. In the CIF group, 1 sample (1.5%) met CDC criteria, and 8 samples (12.1%) met IDSA criteria. There was a significantly higher rate of bacteriuria by both criteria in the IC group among all deliveries, all vaginal deliveries, and spontaneous vaginal deliveries (P < .05). CONCLUSION: Compared with CIF, IC was associated with significantly higher rates of bacteriuria.

Transvaginal ovarian cystectomy for adnexal torsion during pregnancy.

Ovarian torsion requiring surgical intervention in pregnancy is rare. Herein is reported a case of ovarian torsion that was managed by transvaginal ovarian cystectomy in a 27 week gravid patient.

Urine drug screening on labor and delivery.

BACKGROUND: Substance use including opioids, methamphetamines, benzodiazepines, and barbiturates during pregnancy is harmful for the pregnant person and the fetus. Routine screening using validated questionnaires is recommended, but often biologic sampling is done instead. There is often bias in urine drug screening on labor and delivery units. OBJECTIVE: This study aimed to compare characteristics of people who did and did not receive urine drug screening during labor and delivery and to examine the relationship of maternal results to neonatal results. STUDY DESIGN: This was a retrospective chart review examining all people in 2017 who delivered in the labor and delivery unit at our institution. We collected urine drug screening result information, maternal demographic data, follow-up after positive maternal tests, and neonatal test results. Individual characteristics and obstetrical outcomes were analyzed. RESULTS: Of 6265 deliveries, 297 urine drug screening tests were ordered. People who were tested identified most commonly as Native Hawaiian or Pacific Islander (P<.0001). The most common indications for ordering tests were a history of substance use and insufficient prenatal care (P<.0001). People who tested positive were more likely to self-identify as White (P=.03) and have history of substance use (P<.0001). Among the positive test results, 24 (24%) were caused by a provider-ordered medication. Self-identification as Native Hawaiian or Pacific Islander was not predictive of a positive result. Of the tested people, 36% (108/297) had a positive result on preliminary testing, and 33% (98/295) on confirmatory testing. CONCLUSION: Native Hawaiians and Pacific Islanders were more likely to undergo testing, whereas White people were more likely to have a positive result. Maternal results were not reliable for predicting neonatal drug test results and vice versa. With rising rates of substance use disorders in the pregnant and reproductive-age population, standardized unbiased race-neutral guidelines for urine drug screening should be implemented using laboratory test results that include preliminary and reflex confirmatory results.

Placental mesenchymal dysplasia.

Placental mesenchymal dysplasia is a benign condition that can be confused with a molar pregnancy by ultrasound scanning and gross examination. Conservative management should be considered with a normal-appearing singleton fetus and a cystic-appearing placenta. We present a case of placental mesenchymal dysplasia with a favorable outcome.

Aortic aneurysm and dissection in pregnancy: A case report.

We describe a 24-year-old pregnant woman at 34 weeks of gestation who presented to a community hospital with sharp chest pain radiating to her back. She was found to have a 6 cm ascending aortic aneurysm despite not having any established risk factors. She was transported by air ambulance to a tertiary-care hospital. She delivered a live female neonate via cesarean delivery. Her postpartum course was notable for multiple episodes of chest pain and multiple imaging studies that were read as negative for aortic dissection. Definitive valve surgery was postponed by the cardiothoracic surgeons to allow for recovery from severe preeclampsia, treatment of endometritis, and due to concerns for uterine bleeding while on anticoagulation during cardiopulmonary bypass. She was eventually transferred to another hospital in another state for valve-sparing surgery. During transport, she developed a pulmonary embolism, and after arrival an aortic dissection was confirmed. She received a mechanical aortic valve replacement and the aneurysm was repaired. She returned home and recovered without complication. A gene panel revealed a heterozygous pathogenic variant of the Filamin A gene. Aortic aneurysms during pregnancy are rare, and aortic dissections are more rare. We recommend expeditious surgical treatment, a heightened index of suspicion, and testing for a genetic cause of aneurysm when diagnosed in a pregnant or postpartum woman with no known risk factors.

Methamphetamine Use in Pregnant Women in Hawai'i: A Case Series.

Methamphetamine use is widespread among pregnant and reproductive-aged women in Hawai'i. Women who use methamphetamine require comprehensive care that is gender specific and tailored to their needs. In Hawai'i, more services are needed to solve this serious public health problem. The authors present three cases of methamphetamine use with negative maternal and fetal outcomes. The first case describes a pregnant woman with daily methamphetamine use who experienced cardiac arrest with subsequent preterm delivery and maternal death due to global anoxic brain injury. The second case describes a pregnant woman with daily methamphetamine use which exacerbated her chronic hypertension and led to intrauterine fetal demise. The third case describes a pregnant woman with current methamphetamine use who experienced preeclampsia and a cerebrovascular accident necessitating preterm delivery. Methamphetamine remains a serious public health concern for the United States and especially in the state of Hawai'i.

Chorionic villus sampling and risk for hypertensive disorders of pregnancy.

OBJECTIVE: This study was undertaken to evaluate the relationship between chorionic villus sampling at 10-13 weeks' gestational age and hypertensive disorders of pregnancy. STUDY DESIGN: The prevalence of hypertensive disorders of pregnancy in women with singleton gestations, undergoing transcervical or transabdominal chorionic villus sampling between 10 weeks 0 days' and 13 weeks 6 days' gestational age was compared with that of control women with singleton gestations having first-trimester screening with nuchal translucency and biochemistry between 11 weeks 0 days' and 13 weeks 6 days' gestational age. Patients having invasive prenatal diagnosis (chorionic villus sampling or amniocentesis) were excluded from the control group. All patients delivered at Cedars-Sinai Medical Center. RESULTS: There were 1540 women who had chorionic villus sampling and 840 controls. Hypertensive disorders of pregnancy were diagnosed in 76 (4.9%) patients in the chorionic villus sampling group and in 37 (4.4%) of the controls (chi2 = 0.34, P = .31). CONCLUSION: Chorionic villus sampling at 10 to 13 weeks' gestational age does not appear to increase the overall risk for hypertensive disorders of pregnancy. However, there appears to be an association between chorionic villus sampling and severe hypertensive disorders including severe preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome.

Discrepancy Between Identification of Early-Term Elective Deliveries by Manual Chart Review and Data Vendor.

Elective delivery from 37 to 39 weeks gestation (early-term deliveries) is a Joint Commission National Quality Measure, and hospitals report on early-term elective delivery rates through Outcome Research Yields Excellence (ORYX) vendors. The objective of this study was to compare early-term elective deliveries, identified through ORYX vendors with those identified through manual chart review, the traditional method of medical record review. We reviewed early-term labor inductions and cesarean deliveries at a single hospital from June 1, 2010 to May 31, 2012. Rates of early-term elective deliveries identified by the data vendor were compared to physician chart review. Overall, the rate of elective deliveries by ORYX was 3% compared to 2% by physician chart review (RR 1.51 [95% CI 1.12-2.03], P < .001). Of the 116 elective early-term deliveries identified by vendor and/or chart review, vendors classified significantly more inductions and cesareans as elective (P < .001) and missed nine elective deliveries. Of the 107 deliveries identified as elective by ORYX, 62 (57.9%) were verified by chart review, including 69.0% of cesareans and 36.1% of inductions. Findings from this study suggest substantial discrepancy between identification of early-term elective deliveries by data vendors and physician chart review, and indicate that vendor-derived data may overestimate the number of electively delivered patients.