Society for Maternal-Fetal Medicine Special Statement: Checklist for initial management of amniotic fluid embolism.

Amniotic fluid embolism is a rare syndrome characterized by sudden cardiorespiratory collapse during labor or soon after delivery. Because of its rarity, many obstetrical providers have no experience in managing amniotic fluid embolism and may therefore benefit from a cognitive aid such as a checklist. We present a sample checklist for the initial management of amniotic fluid embolism based on standard management guidelines. We also suggest steps that each facility can take to implement the checklist effectively.

Maternal and Fetal Death on Weekends.

BACKGROUND: Higher mortality rates have been reported in patients admitted to the hospital on weekends. This study aimed to compare maternal mortality ratio (MMR), fetal mortality ratio, and other maternal and neonatal outcomes by day of death or delivery in the United States. METHODS: Our database consisted of a population-level analysis of live births and maternal and fetal deaths between 2004 and 2014 in the United States from the Centers for Disease Control and Prevention's National Center for Health Statistics. We also examined the relationship between these deaths and various documented maternal and fetal clinical conditions. RESULTS: A total of 2,061 maternal deaths occurred on weekends and 5,510 deaths on weekdays. During the same period of time, 65,063 and 210,851 cases of fetal demise were delivered on weekends and on weekdays, respectively. Maternal mortality was significantly higher on weekends than weekdays (22.9 vs. 15.3/100,000 live births, p < 0.001) as was fetal mortality (7.21 vs. 5.85/100,000, p < 0.001), despite a lower frequency of serious comorbidities among women delivering on weekends. CONCLUSION: Our data demonstrate a significant increase in the U.S. MMR and stillbirth delivery on weekends. Relative representation of antepartum, intrapartum, and postpartum deaths cannot be ascertained from these data.

Reducing Maternal Mortality and Severe Maternal Morbidity: The Role of Critical Care.

Throughout most of the 20th century, the risk of maternal mortality in high resource countries decreased dramatically; however, this trend recently has stalled in the United States and appears to have reversed. Equally alarming is that for every reported maternal death, there are numerous severe maternal morbidities or near misses. Shifting maternal demographics (eg, obesity, advanced maternal age, multifetal pregnancies), with attendant significant medical comorbidities (eg, hypertension, diabetes, cardiac disease) and the increase in cesarean deliveries significantly contribute to increased maternal morbidity and mortality. This chapter focuses on the role of critical care in reducing maternal mortality and morbidity.

Multidisciplinary team learning in the management of the morbidly adherent placenta: outcome improvements over time.

BACKGROUND: Morbidly adherent placenta (MAP) is a serious obstetric complication causing mortality and morbidity. OBJECTIVE: To evaluate whether outcomes of patients with MAP improve with increasing experience within a well-established multidisciplinary team at a single referral center. STUDY DESIGN: All singleton pregnancies with pathology-confirmed MAP (including placenta accreta, increta, or percreta) managed by a multidisciplinary team between January 2011 and August 2016 were included in this retrospective study. Turnover of team members was minimal, and cases were divided into 2 time periods so as to compare 2 similarly sized groups: T1 = January 2011 to April 2014 and T2 = May 2014 to August 2016. Outcome variables were estimated blood loss, units of red blood cell transfused, volume of crystalloid transfused, massive transfusion protocol activation, ureter and bowel injury, and neonatal birth weight. Comparisons and adjustments were made by use of the Student t test, Mann-Whitney U test, χ2 test, analysis of covariance, and multinomial logistic regression. RESULTS: A total of 118 singleton pregnancies, 59 in T1 and 59 in T2, were managed during the study period. Baseline patient characteristics were not statistically significant. Forty-eight of 59 (81.4%) patients in T1 and 42 of 59 (71.2%) patients in T2 were diagnosed with placenta increta/percreta. The median [interquartile range] estimated blood loss (T1: 2000 [1475-3000] vs T2: 1500 [1000-2700], P = .04), median red blood cell transfusion units (T1: 2.5 [0-7] vs T2: 1 [0-4], P = .02), and median crystalloid transfusion volume (T1: 4200 [3600-5000] vs T2: 3400 [3000-4000], P < .01) were significantly less in T2. Also, a massive transfusion protocol was instituted more frequently in T1: 15/59 (25.4%) vs 3/59 (5.1%); P < .01. Neonatal outcomes and surgical complications were similar between the 2 groups. CONCLUSION: Our study shows that patient outcomes are improved over time with increasing experience within a well-established multidisciplinary team performing 2-3 cases per month. This suggests that small, collective changes in team dynamics lead to continuous improvement of clinical outcomes. These findings support the development of centers of excellence for MAP staffed by stable, core multidisciplinary teams, which should perform a significant number of these procedures on an ongoing basis.

Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies.

Amniotic fluid embolism is a leading cause of maternal mortality in developed countries. Our understanding of risk factors, diagnosis, treatment, and prognosis is hampered by a lack of uniform clinical case definition; neither histologic nor laboratory findings have been identified unique to this condition. Amniotic fluid embolism is often overdiagnosed in critically ill peripartum women, particularly when an element of coagulopathy is involved. Previously proposed case definitions for amniotic fluid embolism are nonspecific, and when viewed through the eyes of individuals with experience in critical care obstetrics, would include women with a number of medical conditions much more common than amniotic fluid embolism. We convened a working group under the auspices of a committee of the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation whose task was to develop uniform diagnostic criteria for the research reporting of amniotic fluid embolism. These criteria rely on the presence of the classic triad of hemodynamic and respiratory compromise accompanied by strictly defined disseminated intravascular coagulopathy. It is anticipated that limiting research reports involving amniotic fluid embolism to women who meet these criteria will enhance the validity of published data and assist in the identification of risk factors, effective treatments, and possibly useful biomarkers for this condition. A registry has been established in conjunction with the Perinatal Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to collect both clinical information and laboratory specimens of women with suspected amniotic fluid embolism in the hopes of identifying unique biomarkers of this condition.

Geospatial analysis of food environment demonstrates associations with gestational diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM) is one of most common complications of pregnancy, with incidence rates varying by maternal age, race/ethnicity, obesity, parity, and family history. Given its increasing prevalence in recent decades, covariant environmental and sociodemographic factors may be additional determinants of GDM occurrence. OBJECTIVE: We hypothesized that environmental risk factors, in particular measures of the food environment, may be a diabetes contributor. We employed geospatial modeling in a populous US county to characterize the association of the relative availability of fast food restaurants and supermarkets to GDM. STUDY DESIGN: Utilizing a perinatal database with >4900 encoded antenatal and outcome variables inclusive of ZIP code data, 8912 consecutive pregnancies were analyzed for correlations between GDM and food environment based on countywide food permit registration data. Linkage between pregnancies and food environment was achieved on the basis of validated 5-digit ZIP code data. The prevalence of supermarkets and fast food restaurants per 100,000 inhabitants for each ZIP code were gathered from publicly available food permit sources. To independently authenticate our findings with objective data, we measured hemoglobin A1c levels as a function of geospatial distribution of food environment in a matched subset (n = 80). RESULTS: Residence in neighborhoods with a high prevalence of fast food restaurants (fourth quartile) was significantly associated with an increased risk of developing GDM (relative to first quartile: adjusted odds ratio, 1.63; 95% confidence interval, 1.21-2.19). In multivariate analysis, this association held true after controlling for potential confounders (P = .002). Measurement of hemoglobin A1c levels in a matched subset were significantly increased in association with residence in a ZIP code with a higher fast food/supermarket ratio (n = 80, r = 0.251 P < .05). CONCLUSION: As demonstrated by geospatial analysis, a relationship of food environment and risk for gestational diabetes was identified.

Birth Rates Among Hispanics and Non-Hispanics and their Representation in Contemporary Obstetric Clinical Trials.

Objective Our study aims were to establish whether subjects enrolled in current obstetric clinical trials proportionately reflects the contemporary representation of Hispanic ethnicities and their birth rates in the United States. Methods Using comprehensive source data over a defined interval (January 2011-September 2015) on birth rates by ethnicity from the Centers for Disease Control and Prevention (CDC), we evaluated the proportional rate by ethnicity, then analyzed the observed to expected relative ratio of enrolled subjects. Results Hispanic women comprise a significant contribution to births in the United States (23% of all births). Systematic analysis of 90 published obstetric clinical trials showed a correlation between inclusion of Hispanic gravidae and the corresponding state's birth rates (r = 0.501, p < 0.001). While the mean was strongly correlated, individual clinical trials may have relatively over-enrolled (n = 31, or 34%) or under-enrolled (n = 33, or 37%) relative to their regional population. In 48% of obstetric clinical trials the Hispanic proportion of the study population was not reported. Conclusion Hispanic gravidae represent a significant number of contemporary U.S. births, and are generally adequately represented as obstetric subjects in clinical trials. However, this is trial-dependent, with significant trial-specific under- and over-enrollment of Hispanic subjects relative to the regional birth population.

Initial experience with a dual-balloon catheter for the management of postpartum hemorrhage.

OBJECTIVE: When uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after delivery, tamponade of the uterus can be effective in decreasing hemorrhage secondary to uterine atony. STUDY DESIGN: These data are from a postmarketing surveillance study of a novel dual-balloon catheter tamponade device, the Belfort-Dildy Obstetrical Tamponade System (ebb). RESULTS: A total of 57 women were enrolled: 55 women had the diagnosis of postpartum hemorrhage, and 51 women had uterine balloon placement within the uterine cavity. This study reports the outcomes in the 51 women who had uterine balloon placement within the uterine cavity for treatment of postpartum hemorrhage, as defined by the "Instructions for Use." We further assessed 4 subgroups: uterine atony only (n = 28 women), placentation abnormalities (n = 8 women), both uterine atony and placentation abnormalities (n = 9 women), and neither uterine atony nor placentation abnormalities (n = 6 women). The median (range) time interval between delivery and balloon placement was 2.2 hours (0.3-210 hours) for the entire cohort (n = 51 women) and 1.3 hours (0.5-7.0 hours) for the uterine atony only group (n = 28 women). Bleeding decreased in 22/51 of cases (43%), stopped in 28/51 of cases (55%), thus decreased or stopped in 50/51 of the cases (98%) after balloon placement. Nearly one-half (23/51) of all women required uterine balloon volumes of >500 mL to control bleeding. CONCLUSION: We conclude that uterine/vaginal balloon tamponade is very useful in the management of postpartum hemorrhage because of uterine atony and abnormal placentation.

Intrapartum management of category II fetal heart rate tracings: towards standardization of care.

There is currently no standard national approach to the management of category II fetal heart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Under such circumstances, it would be difficult to demonstrate the clinical efficacy of FHR monitoring even if this technique had immense intrinsic value, since there has never been a standard hypothesis to test dealing with interpretation and management of these abnormal patterns. We present an algorithm for the management of category II FHR patterns that reflects a synthesis of available evidence and current scientific thought. Use of this algorithm represents one way for the clinician to comply with the standard of care, and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.

Fetal pulse oximetry.

The original expectation of fetal pulse oximetry (FPO) for the field of obstetrics was predicated on the tremendous positive impact pulse oximetry had upon the fields of anesthesiology, critical care medicine, and many other disciplines of medicine. With the general acceptance that many, if not most, concerning fetal heart rate patterns are not associated with significant fetal hypoxemia and acidemia, the additional physiologic information FPO offers (ie, actual arterial blood oxygenation) was believed and hoped by many to be the reassurance that would allow safe avoidance of unnecessary interventions such as cesarean delivery. To date, FPO has not met that expectation, not because of its inability to measure fetal arterial oxygen saturation, but because of its inability to do so with a reduction in overall cesarean deliveries.

Intraluminal pressure in a uterine tamponade balloon is curvilinearly related to the volume of fluid infused.

We studied the effect of incremental infusion of fluid volume in a tamponade balloon on intraluminal pressure and uterine blood flow. Following placental delivery, a tamponade balloon was inserted into the uterus and incrementally inflated. Intraluminal pressure was measured at incremental volumes. Ultrasound was used to determine positioning of the catheter, uterine wall thickness, and uterine artery velocity waveforms in eight patients. Pressure-volume relationship was estimated by regression analysis. Significance was p < 0.05. There was a significant exponential curvilinear relationship between balloon pressure and infused volume at the maximum volume for each subject ( R = 0.64, p = 0.01). Doppler ultrasound showed that at or above 1000 mL inflation volume, 5/6 patients (83%) showed reversal of uterine artery diastolic flow. At maximal inflation volume, all of the patients with reversed diastolic flow had intraluminal pressure less than systolic blood pressure. Intraluminal pressure increases curvilinearly as volume of an intrauterine tamponade balloon is increased. The mechanism of action of tamponade balloons is likely related to a reduction in uterine artery perfusion pressure. Whether this is the result of direct compression of the artery in the lower segment or due to wall conformational changes is not clear.

Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth.

OBJECTIVE: No studies exist that have examined the effectiveness of different approaches to a reduction in elective early term deliveries or the effect of such policies on newborn intensive care admissions and stillbirth rates. STUDY DESIGN: We conducted a retrospective cohort study of prospectively collected data and examined outcomes in 27 hospitals before and after implementation of 1 of 3 strategies for the reduction of elective early term deliveries. RESULTS: Elective early term delivery was reduced from 9.6-4.3% of deliveries, and the rate of term neonatal intensive care admissions fell by 16%. We observed no increase in still births. The greatest improvement was seen when elective deliveries at <39 weeks were not allowed by hospital personnel. CONCLUSION: Physician education and the adoption of policies backed only by peer review are less effective than "hard stop" hospital policies to prevent this practice. A 5% rate of elective early term delivery would be reasonable as a national quality benchmark.

Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period.

OBJECTIVE: The purpose of this study was to analyze reasons for postpartum readmission. STUDY DESIGN: We conducted a database analysis of readmissions within 6 weeks after delivery during 2007, with extended (180 day) analysis for pneumonia, appendicitis, and cholecystitis. Linear regression analysis, survival curve fitting, and Gehan-Breslow statistic with Holm-Sidak all-pairwise analysis for multiple comparisons were used. Probability values of < .05 were considered significant. RESULTS: Of 222,751 women delivered, 2655 women (1.2%) were readmitted within 6 weeks (0.83% vaginal delivery and 1.8% cesarean section delivery; P < .001). A high percentage of these readmittances occurred within the first 6 weeks: pneumonia (84%), appendicitis (43%), or cholecystitis (46%). Cumulative readmission rates were higher in the first 6 weeks after delivery than in the next 20 weeks (pneumonia curve gradient, 3.7 vs 0.11; appendicitis curve gradient, 1.1 vs 0.36; cholecystitis curve gradient, 6.6 vs 1.7). CONCLUSION: The cause of postpartum readmission is primarily infectious in origin. A recent pregnancy appears to increase the risk of pneumonia, appendicitis, and cholecystitis.

Emergency department use during the postpartum period: implications for current management of the puerperium.

OBJECTIVE: The purpose of this study was to define patterns of morbidity that are experienced by women in the postpartum period who seek care in the emergency department within 42 and 100 days of discharge. STUDY DESIGN: We conducted a retrospective examination of discharge diagnosis codes and descriptions for emergency department visits and analyzed temporal patterns of both emergency department visits and hospital readmissions. RESULTS: During 2007, 222,084 patients delivered in Hospital Corporation of America facilities in the United States. Among these women, there were 10,751 emergency department visits within 42 days of delivery (4.8%). Fifty-eight percent of the patients were seen for conditions that were related to pregnancy; 42% of the patients were seen for conditions unrelated to pregnancy. Fifty percent of patients in the postpartum period who were seen either in the emergency department (21,833 patients) or readmitted (5190 patients) during both 2007 and 2008 had this encounter within 10 days of discharge. CONCLUSION: The scheduling and content of traditional postpartum education and clinical visits appear poorly suited to the prevention of puerperal morbidity.

Mixoploidy: perinatal diagnosis and pregnancy outcome.

Mixoploidy is rare chromosomal disorder characterized by multiple cell lines, usually including triploidy, within tissues. Pregnancy outcome has generally been considered poor with congenital anomalies and developmental delay reported in postnatally diagnosed cases. We report on two cases of abnormal midtrimester ultrasound showing placental abnormalities. Karyotype assessment showed mixoploidy, and both cases had satisfactory pregnancy outcome.