Objective Multiple scoring systems exist to identify inpatients who are at risk for clinical deterioration. None of these systems have been evaluated in an obstetric population. We examined the ...Systemic Inflammatory Response syndrome (SIRS) and Modified Early Warning score (MEWS) criteria in pregnant women with chorioamnionitis. Study Design This was an 18-month retrospective analysis of patients with chorioamnionitis. SIRS and MEWS scores were calculated; clinical outcomes were ascertained, and test characteristics were calculated for the primary outcome of sepsis, intensive care unit transfer, or death. Results Nine hundred thirteen women with chorioamnionitis were identified. Five women experienced sepsis; there was 1 death. Five hundred seventy-five of the 913 women (63%) met SIRS criteria (95% confidence interval, 59.8–66.2%; positive predictive value, 0.9%). Ninety-two of the 913 women (10.3%) had a MEWS score of ≥5 (95% confidence interval, 8.3–12.2%; positive predictive value, 0.05%). Conclusion SIRS and MEWS criteria do not identify accurately patients who are at risk for intensive care unit transfer, sepsis, or death among pregnant women with intrauterine infection and should not be used in an obstetric setting.
The rise in maternal morbidity and mortality has resulted in national and international attention at optimally organizing systems and teams for pregnancy care. Given that maternal morbidity and ...mortality can occur unpredictably in any obstetric setting, specialists in general obstetrics and gynecology along with other primary maternal care providers should be integrally involved in efforts to improve the safety of obstetric care delivery. Quality improvement initiatives remain vital to meeting this goal. The evidence-based utilization of triggers, bundles, protocols, and checklists can aid in timely diagnosis and treatment to prevent or limit the severity of morbidity as well as facilitate interdisciplinary, patient-centered care. The purpose of this document is to summarize the pertinent elements from this forum to assist primary maternal care providers in their utilization and implementation of these safety tools.
Objective We sought to compare the predictive power of published modified obstetric early warning scoring systems (MOEWS) for the development of severe sepsis in women with chorioamnionitis. Study ...Design This was a retrospective cohort study using prospectively collected clinical observations at a single tertiary unit (Chicago, IL). Hospital databases and patient records were searched to identify and verify cases with clinically diagnosed chorioamnionitis during the study period (June 2006 through November 2007). Vital sign data (heart rate, respiratory rate, blood pressure, temperature, mental state) for these cases were extracted from an electronic database and the single worst composite recording was identified for analysis. Global literature databases were searched (2014) to identify examples of MOEWS. Scores for each identified MOEWS were derived from each set of vital sign recordings during the presentation with chorioamnionitis. The performance of these MOEWS (the primary outcome) was then analyzed and compared using their sensitivity, specificity, positive and negative predictive values, and receiver-operating characteristic curve for severe sepsis. Results Six MOEWS were identified. There was wide variation in design and pathophysiological thresholds used for clinical alerts. In all, 913 women with chorioamnionitis were identified from the clinical database. In all, 364 cases with complete data for all physiological indicators were included in analysis. Five women developed severe sepsis, including 1 woman who died. The sensitivities of the MOEWS in predicting the severe deterioration ranged from 40–100% and the specificities varied even more ranging from 4–97%. The positive predictive values were low for all MOEWS ranging from <2–15%. The MOEWS with simpler designs tended to be more sensitive, whereas the more complex MOEWS were more specific, but failed to identify some of the women who developed severe sepsis. Conclusion Currently used MOEWS vary widely in terms of alert thresholds, format, and accuracy. Most MOEWS have not been validated. The MOEWS generally performed poorly in predicting severe sepsis in obstetric patients; in general severe sepsis was overdetected. Simple MOEWS with high sensitivity followed with more specific secondary testing is likely to be the best way forward. Further research is required to develop early warning systems for use in this setting.
Fetal growth restriction (FGR) is associated with an increased risk of perinatal morbidity and mortality and has lifetime implications for the risk of chronic medical conditions. Antenatal diagnosis ...of FGR remains poor, with the majority of cases remaining undiagnosed. Although several factors contribute to the underdiagnosis of FGR, the error in ultrasound estimation of fetal weight (EFW) generally is not considered in clinical practice. In this commentary, we suggest that the intrinsic, or systematic, error in ultrasound EFW is a significant factor contributing to the underestimation of fetuses predicted to have FGR and should be incorporated into screening and surveillance recommendations. To illustrate this point, we present an analytic model of published data from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies characterizing and quantifying the impact of the systematic error in ultrasound EFW on the underdiagnosis of FGR. Independent of the centile at which the risk of adverse outcome related to FGR begins, whether the 10th, 5th or 3rd percentile, our analysis suggests the need to modify to the current paradigm for identifying and responding to fetuses estimated to be at risk.
Background By increasing intraabdominal pressure, pregnancy may increase the risk of abdominal hernia recurrence. Current data are limited to studies with small sample size and thus the impact of ...pregnancy on recurrence is unclear. Objective(s) The objective of this analysis was to evaluate the impact of pregnancy on clinically significant abdominal hernia recurrence in a large multicenter cohort. Study Design A multiinstitution deidentified electronic health record database, EPM: Explore (Explorys Inc, Cleveland, OH) was utilized to perform a retrospective cohort study of women aged 18–45 years with a history of an abdominal hernia repair from 1999 through 2013. Abdominal hernia was defined to include ventral and incisional hernias, and other types were excluded. The presence or absence of a pregnancy following primary hernia repair was elucidated from the database. Subjects were excluded if a hernia repair occurred during pregnancy. The rate of hernia recurrence, defined as reoperation, was calculated. The association between pregnancy and hernia recurrence was evaluated with logistic regression, both unadjusted and adjusted for diabetes, obesity (body mass index >30 kg/m2 ), tobacco abuse, and wound complication at the time of initial hernia repair. Results A total of 11,020 women with a history of hernia repair were identified, of whom 840 had a subsequent pregnancy. Overall, 915 women in the cohort had a hernia recurrence (8.3%). Women with a history of pregnancy following primary hernia repair were more likely to have a body mass index >30 kg/m2 , a history of tobacco abuse, and a wound complication at the time of primary repair. In an unadjusted analysis, pregnancy was associated with an increase in the risk of hernia recurrence (13.1% vs 7.1%, odds ratio, 1.96, 95% confidence interval, 1.60–2.42). The association between pregnancy and hernia recurrence was attenuated but persisted after adjusting for confounding factors (adjusted odds ratio, 1.73, 95% confidence interval, 1.40–2.14). Conclusion Pregnancy is associated with an increased risk of abdominal hernia recurrence after adjusting for confounding factors. The magnitude of this association is likely underestimated, given that the risk of recurrence was defined as reoperation, which captures only the most clinically significant group of recurrences. This information will facilitate counseling for reproductive-aged women planning elective ventral or incisional hernia repair. The risk of recurrence and subsequent reoperation should be balanced against the risk of incarceration and emergent surgery during pregnancy. As such, the desire for future pregnancy and/or contraception should be considered when planning asymptomatic hernia repair for women of reproductive age.
Background The prevailing obstetric practice of planned cesarean delivery for triplet gestations is largely empiric and data on the optimal route of delivery are limited. Objective The primary ...objectives of this study are to determine the likelihood of success in an attempted vaginal delivery and assess maternal and neonatal outcomes of attempted vaginal vs planned cesarean delivery of triplets using a multiinstitution obstetric cohort. Study Design We performed a retrospective cohort study using data from the Consortium on Safe Labor, identifying triplet pregnancies with delivery at a gestational age ≥28 weeks. Women with a history of cesarean delivery and pregnancies complicated by chromosomal or congenital anomalies, twin-twin transfusion syndrome, or a fetal demise were excluded. The attempted vaginal group included all women with spontaneous or induced labor and excluded all women delivering by prelabor cesarean delivery, including those coded as elective or for fetal malpresentation. Primary maternal outcomes included infection (composite of chorioamnionitis, endometritis, wound separation, and wound infection), blood transfusion, or transfer to the intensive care unit. Primary neonatal outcomes included neonatal asphyxia, mechanical ventilation, and composite neonatal morbidity, consisting of ≥1 of the following: birth injury, 5-minute Apgar <4, arterial pH <7.0 or base excess <–12.0, neonatal asphyxia, or neonatal death. For neonatal outcomes, Poisson regression was performed with clustering to account for correlation between neonates within a triplet pregnancy, controlling for confounders as outcome rates allowed. A sensitivity analysis was performed in the subcohort delivering at gestational age ≥34 weeks in which the attempted vaginal delivery group was restricted to include only women with evidence of induction or augmentation or labor. Results 188 triplet sets were identified of which 80 sets (240 neonates) met inclusion criteria and 24 sets (30%) had an attempted vaginal delivery. The rate of successful attempted vaginal delivery was 16.7% (4 triplet sets; 12 neonates). No women had a combined mode of delivery. Women attempting vaginal delivery were more likely to have preterm labor (45.8 vs 12.5%, P < .001) and receive antenatal corticosteroids (45.8 vs 21.4%, P = .03), however gestational age at delivery did not differ by mode of delivery. Attempted vaginal delivery was associated with a higher risk of maternal transfusion (20.8% vs 3.6%, P = .01) and neonatal mechanical ventilation (26.4% vs 7.7%; adjusted incidence rate ratio, 1.12; 95% confidence interval, 1.01–1.24). There was no significant difference in the risk of asphyxia or composite neonatal morbidity by mode of delivery. In the subcohort sensitivity analysis, attempted vaginal delivery was associated with an increased risk of composite neonatal morbidity (adjusted incidence rate ratio, 12.44; 95% confidence interval, 1.22–127.20) but not maternal transfusion (22.2% vs 3.5%, P = .06) or neonatal mechanical ventilation (adjusted incidence rate ratio, 1.02; 95% confidence interval, 0.89–1.17). Conclusion In a multicenter US cohort, attempted vaginal delivery of triplets is associated with higher risks of maternal transfusion and neonatal mechanical ventilation. Composite severe neonatal morbidity may be higher with attempted vaginal delivery although studies with greater power are required. The low probability of successful vaginal delivery raises questions regarding the utility of attempted vaginal delivery in triplet gestations. Our data support planned prelabor cesarean delivery as the preferred mode of delivery for triplet gestations.
Background Anecdotal evidence has suggested an association of intravenous drug abuse with alloimmunization, however published data are limited to case reports. Objective(s) To determine if women with ...a history of intravenous drug abuse have an increased risk of alloimmunization. Study Design A retrospective cohort study was performed using data from a single-center blood bank and perinatal database from 2008-2014. Blood bank data was used to identify women with alloimmunization, defined as a positive antibody screen in pregnancy not due to a naturally occurring antibodies, agglutinins, autoantibodies, or Rh immunoglobulin administration. Intravenous drug abuse was ascertained from a comprehensive database capturing all drug abuse in pregnancy since 2008. For women contributing more than one pregnancy to the database, only the most recent affected pregnancy was included. The rates of alloimmunization among women with a history of intravenous drug abuse and general obstetric populations were calculated and compared using chi-squared. The distribution of alloantibody types, proportion of Rh-group alloantibodies, and patient Rh status were assessed for intravenous drug abuse- and non-intravenous drug abuse-associated alloimmunization. Characteristics and outcomes between intravenous drug abuse- and non-intravenous drug abuse-associated alloimmunization were assessed for women with clinically significant alloantibodies. Results Alloimmunization was more common in women with a history of intravenous drug abuse (11 of 305, 3.6%) compared to women without a history of intravenous drug abuse (288 of 16,022, 1.8%, RR 2.00, 95% CI 1.11-3.62). Needle sharing was present in 7 and suspected in 4 women with an intravenous drug abuse history. Among women with a history of intravenous drug abuse, none had a history of transfusion or traditional risk factor for alloimmunization. The distribution of alloantibodies was different between intravenous drug abuse- and non-intravenous drug abuse-associated alloimmunization. Rh group alloantibodies and Rh negative status were more common in women with a history of intravenous drug abuse. Among Rh negative women with a history of intravenous drug abuse, 50% of RhD alloimmunization cases occurred in nulliparas. The rate of multiple alloantibodies was not different between intravenous drug abuse- and non-intravenous drug abuse-associated alloimmunization. Conclusion(s) Maternal history of intravenous drug abuse is associated with an increased risk of alloimmunization. Approximately 1 in 30 intravenous drug abuse women may be diagnosed with an alloantibody in pregnancy. Given the current US opioid epidemic, increased vigilance in screening is required. Needle sharing represents a possible mechanism for intravenous drug abuse-associated alloimmunization, however limited obstetric care, failure to obtain Rh immunoglobulin, or failure to identify early pregnancy loss cannot be excluded.
