Group prenatal care Mazzoni, Sara E., MD, MPH; Carter, Ebony B., MD, MPH
American journal of obstetrics and gynecology,
06/2017, Letnik:
216, Številka:
6
Journal Article
Recenzirano
Patients participating in group prenatal care gather together with women of similar gestational ages and 2 providers who cofacilitate an educational session after a brief medical assessment. The ...model was first described in the 1990s by a midwife for low-risk patients and is now practiced by midwives and physicians for both low-risk patients and some high-risk patients, such as those with diabetes. The majority of literature on group prenatal care uses CenteringPregnancy, the most popular model. The first randomized controlled trial of CenteringPregnancy showed that it reduced the risk of preterm birth in low-risk women. However, recent meta-analyses have shown similar rates of preterm birth, low birthweight, and neonatal intensive care unit admission between women participating in group prenatal care and individual prenatal care. There may be subgroups, such as African Americans, who benefit from this type of prenatal care with significantly lower rates of preterm birth. Group prenatal care seems to result in increased patient satisfaction and knowledge and use of postpartum family planning as well as improved weight gain parameters. The literature is inconclusive regarding breast-feeding, stress, depression, and positive health behaviors, although it is theorized that group prenatal care positively affects these outcomes. It is unclear whether group prenatal care results in cost savings, although it may in large-volume practices if each group consists of approximately 8–10 women. Group prenatal care requires a significant paradigm shift. It can be difficult to implement and sustain. More randomized trials are needed to ascertain the true benefits of the model, best practices for implementation, and subgroups who may benefit most from this innovative way to provide prenatal care. In short, group prenatal care is an innovative and promising model with comparable pregnancy outcomes to individual prenatal care in the general population and improved outcomes in some demographic groups.
The impact of chorionicity on maternal pregnancy outcomes Carter, Ebony B., MD, MPH; Bishop, Katherine C., BS; Goetzinger, Katherine R., MD, MSCI ...
American journal of obstetrics and gynecology,
09/2015, Letnik:
213, Številka:
3
Journal Article
Recenzirano
Objective Women carrying twin pregnancies often receive similar counseling, regardless of chorionicity, with the notable exception of twin-twin transfusion syndrome (TTTS); however, little is known ...about whether the presence of 1 vs 2 placentas confers dissimilar maternal risks. We sought to determine differences in maternal and neonatal outcomes based on chorionicity. Study Design This was a retrospective cohort study of all twin pregnancies at our institution undergoing routine second-trimester ultrasound for anatomic survey from 1990 through 2010. Secondary outcomes included other adverse maternal and neonatal outcomes. Relative risks and adjusted odds ratios (aORs) were calculated. Cluster analysis was used to account for nonindependence of twin pairs. Results Of 2301 pregnancies, 1747 (75.9%) were dichorionic and 554 (24.1%) were monochorionic. Rates of preeclampsia, gestational diabetes, placental abruption, placenta previa, preterm labor, and preterm premature rupture of membranes (PPROM) were not significantly different in dichorionic vs monochorionic pregnancies. Early preterm delivery less than 34 weeks (aOR, 1.47; 95% confidence interval CI, 1.17–1.86) and less than 28 weeks (aOR, 2.58; 95% CI, 1.58–4.20) were more likely in monochorionic twins, as was neonatal intensive care unit admission (aOR, 1.41; 95% CI, 1.12–1.78). Monochorionic twins delivered earlier at a mean gestational age of 34.2 weeks vs 35.0 weeks for dichorionic twins ( P < .001). Hospital length of stay was significantly longer for monochorionic twins with a mean of 13.7 days vs 10.8 days for dichorionic twins ( P = .01). Conclusion There are no significant differences in maternal outcomes by chorionicity; however, monochorionicity is associated with increased fetal risks. This information may be helpful in guiding more targeted counseling to expectant parents of twins that, although the presence of an additional placenta does not confer additional maternal risks, monochorionic infants tend to deliver earlier and require longer hospital stays.
Maternal marijuana use and neonatal morbidity Conner, Shayna N., MD, MSCI; Carter, Ebony B., MD, MPH; Tuuli, Methodius G., MD, MPH ...
American journal of obstetrics and gynecology,
09/2015, Letnik:
213, Številka:
3
Journal Article
Recenzirano
Objective Marijuana use is becoming increasingly common in the obstetric population; however, it is unknown whether it is associated with poor neonatal outcomes. We sought to determine the prevalence ...and risk factors for marijuana use in pregnancy and to evaluate whether marijuana use is independently associated with poor neonatal outcomes. Study Design This was a retrospective cohort study of all consecutive, nonanomalous, term deliveries at 1 institution over a 4-year study period. Women with marijuana use during pregnancy, either by self-report or positive urine drug screen, were compared with women who did not use marijuana. The primary outcome was a composite neonatal morbidity including birthweight less than 2500 g, neonatal intensive care unit admission, 5-minute Apgar score less than 7, and umbilical artery pH less than 7.10. Univariate, bivariate, and multiple logistic regression analyses were performed. Results Among the 8138 women in the cohort, 680 (8.4%) used marijuana during pregnancy. Women who used marijuana were younger; more likely to be of African American race; have inadequate prenatal care; and use tobacco, alcohol, and other drugs. Medical comorbidities did not differ between groups. After adjusting for smoking, other drug use, and African American race, the composite and all individual markers of poor neonatal outcome were not significantly higher among women who used marijuana during pregnancy. Conclusion Marijuana use is common in pregnancy but may not be an independent risk factor for poor neonatal outcomes in term pregnancies.
Abstract Background A number of evidence-based interventions have been proposed to reduce post cesarean wound complications. Examples of such interventions include appropriate timing of preoperative ...antibiotics, appropriate choice of skin antisepsis, closure of the subcutaneous layer if subcutaneous depth is ≥ 2 cm, and subcuticular skin closure with suture rather than staples. However, the collective impact of these measures is unclear. Objective We sought to estimate the impact of a group of evidence-based surgical measures (prophylactic antibiotics administered prior to skin incision, chlorhexidine-alcohol for skin antisepsis, closure of subcutaneous layer, and subcuticular skin closure with suture) on wound complications after cesarean, and to estimate residual risk factors for wound complications. Study Design We conducted a secondary analysis of data from a randomized controlled trial of chlorhexidine-alcohol versus iodine-alcohol for skin antisepsis at cesarean from 2011-2015. The primary outcome for this analysis was a composite of wound complications, including surgical site infection (SSI), cellulitis, seroma, hematoma, and separation within 30 days. Risk of wound complications in women who received all four evidence-based measures (prophylactic antibiotics within 60 minutes of cesarean and prior to skin incision, chlorhexidine-alcohol for skin antisepsis with three minutes of drying time prior to incision, closure of subcutaneous layer if ≥ 2 cm of depth and subcuticular skin closure with suture) were compared to those who did not. We performed logistic regression analysis limited to patients who received all the evidence-based measures to estimate residual risk factors for wound complications and SSI. Results Of 1082 patients with follow-up, 349 (32.3%) received all the evidence-based measures and 733 (67.7%) did not. The risk of wound complications was significantly lower in patients who received all the evidence-based measures compared to those who did not (20.3% vs 28.1%; aRR 0.75, 95% CI 0.58, 0.95). The impact appeared to be largely driven by a reduction in surgical site infections. Among patients who received all the evidence-based measures, unscheduled cesarean was the only significant risk factor for wound complications (27.5% vs. 16.1%, aRR 1.71, 95% CI 1.12, 2.47) and SSI (6.9% vs. 1.6%, RR 3.74, 95% CI 1.18, 11.92). Other risk factors, including obesity, smoking, diabetes, chorioamnionitis, surgical experience, and skin incision type were not significant among patients who received all of the four evidence-based measures. Conclusion Implementation of evidence-based measures significantly reduces wound complications, but the residual risk remains high. This suggests the need for additional interventions, especially in patients undergoing unscheduled cesareans, who are at risk for wound complications even after receiving current evidence-based measures.
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