High-risk Obstetrics Research Articles

Retrieval medicine and pre-hospital care in remote Australia.

Retrieval medicine and pre-hospital care in remote Australia are challenging, requiring competencies in major trauma, high-risk obstetrics, critical care in adults and children, severe mental health-related agitation and envenomation. They keep a city-based retrieval and pre-hospital care doctor on their toes. Cultural fluencies to enhance care for Aboriginal and remote communities are critical during the long hours taken for the patient journey from the accident scene or clinic to definitive care.

Breaking Bad News: A Study on Formal Training in a High-Risk Obstetrics Setting.

Background: Breaking bad news is a frequent task in high-risk obstetrics clinics. Few studies have examined the role of training in improving such a difficult medical task.Aim: To evaluate the influence of a training program on the participants' perceptions of bad news communication at a high-risk obstetrics center.Design: This prospective study was conducted at the Department of Obstetrics/Gynecology, Hospital das Clinicas, from March 2016 to May 2017.Setting/Participants: Maternal-fetal health specialists were invited to complete an institutional questionnaire based on the SPIKES protocol for communicating bad news before and after training. The training consisted of theoretical lectures and small group practice using role play. The questionnaire responses were compared using nonparametric tests to evaluate the differences in physicians' perceptions at the two timepoints. The questionnaire items were evaluated individually and in groups following the communication steps of the SPIKES protocol.Results: In total, 110 physicians were invited to participate. Ninety completed the pretraining questionnaire and 40 answered the post-training questionnaire. After training, there were significant improvements in knowing how to prepare the environment before delivering bad news (p = 0.010), feeling able to transmit bad news (p < 0.001), and to discuss the prognosis (p = 0.026), feeling capable of discussing ending the pregnancy (p = 0.003), and end-of-life issues (p = 0.007) and feeling confident about answering difficult questions (p = 0.004). The comparison of the grouped responses following the steps of the SPIKES protocol showed significant differences for “knowledge” (p < 0.001), “emotions,” (p = 0.004) and “strategy and summary” (p = 0.002).Conclusion: The implementation of institutional training in breaking bad news changed the perception of the physicians in the communication setting.

A Pilot Study on the Prevalence of Marijuana Use in the High Risk Obstetrics Population at the University of Florida [02E

INTRODUCTION: Marijuana is the most commonly used illicit drug in pregnancy and prevalence rates are reported to be 5–7%. With legalization of marijuana, there is concern that more women believe marijuana use is safe in pregnancy. The purpose of this pilot study was to determine prevalence of marijuana use in our high-risk obstetrics population. METHODS: An IRB approval was obtained. Pregnant women seen in the high-risk obstetrics clinic at University of Florida were invited to participate in an anonymous survey related to marijuana exposure. A total of 106 women were included in the study. RESULTS: More than a half (52.3%) of the women reported having used marijuana in the lifetime, 34.6% reported using marijuana prior to pregnancy, and 16.8% reported use after becoming pregnant. The prevalence rates of marijuana use varied by duration of pregnancy. Higher prevalence rates were noted for pregnancy of 12 weeks or less (18.2%) and 25 weeks or longer (19.4%); however, this was not statistically significant. Among the 7 women who reported using marijuana for recreational purposes, 6 used marijuana during pregnancy. Among all women who used marijuana prior to pregnancy, 48.7% continue to use after becoming pregnant and 51.3% quit. CONCLUSION: The prevalence of marijuana use in our high-risk obstetrics population was self-reported to be 16.8%, this is significantly higher than national self-reported data. Self-reported marijuana use did decrease when comparing use before and after identification of pregnancy. This pilot data illustrates the importance of continued research to determine adverse pregnancy outcomes related to marijuana exposure.

Stroke in Pregnancy: A Focused Update.

Ischemic stroke (IS) and hemorrhagic stroke (HS) can be devastating complications during pregnancy and the puerperium that are thought to occur in approximately 30 in 100,000 pregnancies. In high-risk groups, such as women with preeclampsia, the incidence of both stroke subtypes, combined, is up to 6-fold higher than in pregnant women without these disorders. IS or HS may present in young women with atypical symptoms including headache, seizure, extremity weakness, dizziness, nausea, behavioral changes, and visual symptoms. Obstetric anesthesiologists who recognize these signs and symptoms of pregnancy-related stroke are well positioned to facilitate timely care. Acute stroke of any type is an emergency that should prompt immediate coordination of care between obstetric anesthesiologists, stroke neurologists, high-risk obstetricians, nurses, and neonatologists. Historically, guidelines have not addressed the unique situation of maternal stroke, and pregnant women have been excluded from the large stroke trials. More recently, several publications and professional societies have highlighted that pregnant women suspected of having IS or HS should be evaluated for the same therapies as nonpregnant women. Vaginal delivery is generally preferred unless there are obstetric indications for cesarean delivery. Neuraxial analgesia and anesthesia are frequently safer than general anesthesia for cesarean delivery in the patient with a recent stroke. Potential exceptions include therapeutic anticoagulation or intracranial hypertension with risk of herniation. General anesthesia may be appropriate when cesarean delivery will be combined with intracranial neurosurgery.

Life as a physician in obstetrics and gynaecology.

A career in obstetrics and gynaecology is flexible, exciting, and fulfilling. There is a great variety of work within the specialty, with most doctors working in both obstetrics and gynaecology. Many consultants have an interest in a particular area, such as fertility care or high risk obstetrics, and some work solely in a specific area of practice. The specialty combines medical and surgical activity and involves close cooperation with other specialties such as colorectal surgery, oncology, and urology. Most hospitals have a team of consultants who are responsible for providing obstetric or gynaecological care. Clinical activities are diverse, depending on your area of specialisation. Emergencies may arise at any time, so 24 hour cover is always necessary. In obstetrics, most women, although pregnant, are otherwise fit and healthy. However, some will have acute or …

Telehealth Interventions to Improve Obstetric and Gynecologic Health Outcomes: A Systematic Review.

To systematically review the effectiveness of telehealth interventions for improving obstetric and gynecologic health outcomes. We conducted a comprehensive search for primary literature in ClinicalTrials.gov, Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Qualifying primary studies had a comparison group, were conducted in countries ranked very high on the United Nations Human Development Index, published in English, and evaluated obstetric and gynecologic health outcomes. Cochrane Collaboration's tool and ROBINS-I tool were used for assessing risk of bias. Summary of evidence tables were created using the United States Preventive Services Task Force Summary of Evidence Table for Evidence Reviews. Of the 3,926 published abstracts identified, 47 met criteria for inclusion and included 31,967 participants. Telehealth interventions overall improved obstetric outcomes related to smoking cessation and breastfeeding. Telehealth interventions decreased the need for high-risk obstetric monitoring office visits while maintaining maternal and fetal outcomes. One study found reductions in diagnosed preeclampsia among women with gestational hypertension. Telehealth interventions were effective for continuation of oral and injectable contraception; one text-based study found increased oral contraception rates at 6 months. Telehealth provision of medication abortion services had similar clinical outcomes compared with in-person care and improved access to early abortion. Few studies suggested utility for telehealth to improve notification of sexually transmitted infection test results and app-based intervention to improve urinary incontinence symptoms. Telehealth interventions were associated with improvements in obstetric outcomes, perinatal smoking cessation, breastfeeding, early access to medical abortion services, and schedule optimization for high-risk obstetrics. Further well-designed studies are needed to examine these interventions and others to generate evidence that can inform decisions about implementation of newer telehealth technologies into obstetrics and gynecology practice.

Prior authorization and its impact on access to obstetric ultrasound

Prior authorization is a process requiring health care providers to obtain advance approval from a payer before a patient undergoes a procedure for the study to be covered. Prior authorization was introduced to decrease overutilization of ultrasound procedures. However, it has led to unanticipated consequences such as impeding access to obstetric imaging, increased administrative overhead without reimbursement, and contribution to physician frustration and burnout. Payers often use intermediary radiology benefit management companies without providing specialty-specific review in a timely manner as is requisite when practicing high-risk obstetrics. This article proposes a number of potential solutions to this problem: (1) consider alternative means to monitor overutilization; (2) create and evaluate data regarding providers in the highest utilization; (3) continue to support and grow the educational efforts of speciality societies to publish clinical guidelines; and (4) emphasize the importance of practicing evidence-based medicine. Understanding that not all health plans may be willing or able to collaborate with health care providers, we encourage physicians to advocate for policies and legislation to limit the implementation of prior authorization within their own states.

212: Medication events leading to patient harm in an inpatient obstetrics unit

According to a report by the Institute of Medicine the average hospitalized patient in the U.S. experiences one medication error every day. Many medications used frequently in obstetrics are classified as high-alert by the Institute for Safe Medication Practices (ISMP) however evaluation of their safe use in practice is largely unknown. The objective of this quality improvement study was to describe errors resulting in patient harm and determine the frequency of patient harm from high-alert medications in our high-risk inpatient obstetrics unit. We performed a retrospective analysis of all medication errors from January 1, 2014 to July 1, 2019 using our institution’s centralized risk management event reporting system. Utilizing the error severity classification system (A–unsafe condition no event, B–Near miss, C-No harm, reached patient no monitoring, D–No harm, reached patient monitoring required, E–Harm, temporary intervention needed & F–Harm, temporary hospitalization/higher level of care needed) we assessed all medication errors with harm events (E & F). All errors were evaluated by event and medication type. During the time analyzed there were 18 medication errors resulting in patient harm. Figure 1 depicts the number of harm events by medication and event type. Magnesium sulfate had the most harm events (n=5) followed by regular insulin (n=2), bupivacaine with sufentanil epidurals (n=2), and gentamicin (n=2). A variety of process steps lead to harm events. Administering an IV infusion medication at the wrong rate was the cause of most errors (n=5) followed by inappropriate doses (n=4) and missed doses (n=3). The 3 most frequent medications leading to harm are listed as high-alert by ISMP. High-alert medications represented 10 of the 18 harm events (Figure 2). Our analysis demonstrates that, although infrequent, medication events leading to patient harm occur in our obstetrics unit. ISMP high-alert drugs were involved in 55% of harm events. These high-alert medications should be prioritized by quality improvement initiatives to reduce errors.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Enfermedades hepáticas y embarazo

La prevalencia de las enfermedades hepáticas en el embarazo no es despreciable, ya que estas se presentan en 3%-5% de todas las gestaciones. Entre las múltiples causas se encuentran cambios fisiológicos del embarazo; enfermedad hepática preexistente, siendo las más comunes las enfermedades colestásicas (colangitis biliar primaria y colangitis esclerosante primaria), hepatitis autoinmune, enfermedad de Wilson, hepatitis virales crónicas, cirrosis establecida de cualquier etiología y paciente con historia de trasplante hepático; enfermedad hepática adquirida durante el embarazo, siendo las principales las hepatitis virales, la toxicidad inducida por medicamentos y la hepatolitiasis; hepatopatía relacionada con el embarazo, en la cual se encuentran 5 entidades principales: hiperémesis gravídica, colestasis intrahepática del embarazo, preeclampsia, síndrome HELLP e hígado graso del embarazo.&#x0D; La severidad de estas entidades tiene una amplia gama de presentaciones, desde la paciente que es completamente asintomática, hasta la falla hepática aguda e incluso la muerte. La gravedad del cuadro se asocia con una morbilidad y mortalidad significativas tanto para la madre como para el feto, lo cual hace que una evaluación rápida, diagnóstico certero y manejo apropiado por un equipo multidisciplinario (incluida obstetricia de alto riesgo, hepatología, gastroenterología y radiología intervencionista), en un servicio que tenga la posibilidad de ofrecer trasplante hepático, sean fundamentales para obtener buenos desenlaces.

Consultation, Surveillance, Monitoring, and Intensive Care (COSMIC): A Novel 4-Tier Program to Identify and Monitor High-Risk Obstetric Patients From the Clinic to Critical Care

(Anesth Analg. 2019;128(6):1354–1360) The majority of obstetric patients experience good outcomes from the birthing process. However, a small group of women develop serious morbidity or even die during pregnancy, labor, or delivery. This article described the consultation, surveillance, monitoring, and intensive care (COSMIC) program that has been implemented in the authors’ institution to escalate serious obstetric patient issues to the appropriate level of medical care. The goal of the COSMIC program is to optimize available resources for high-risk obstetrical patients in the most cost effective and efficient manner.

The impact of the Medicaid high-risk ob care management program in New York State.

To examine the effect of high-risk obstetrics (HROB) care management on infant health and Medicaid expenditures. Medicaid administrative data and vital statistics from 2011 to 2013. In New York State, all Medicaid managed care plans provide HROB care management to their members. We conducted a retrospective cohort study with a nonequivalent control group. Selection bias was addressed by using probit and OLS models with the Heckman correction and inverse probability weight with regression adjustment. While program enrollment was associated with poor infant health outcomes (low birthweight, very low birthweight, preterm delivery, and gestational age), correcting for sample selection substantially improved most of these outcomes. All infant health outcomes significantly improved as the number of weeks in the program increased. We found that a 1-week increase in program duration is associated with a 0.01 percentage point decrease in low birthweight and a 0.03 percentage point decrease in very low birthweight. Further, a 1-week increase in program duration decreases the probability of preterm delivery by 0.01 percentage points and increases gestational age by 0.14days. Medicaid expenditures for maternity care and newborn delivery were not significantly or materially affected by program enrollment or program duration. High-risk obstetrics care management appears to successfully identify individuals with high-risk pregnancies and improve health without substantially increasing medical expenses.

Treatment of Pregnancy-Associated Breast Cancer.

KS is a 33-year-old Caucasian married woman who works full time as an accountant and has one daughter who is 2 years old. She enjoys reading and exercising in her spare time. She initially presented in July 2015 at the age of 31 years with a 1-cm breast mass in the left inner breast, which prompted a mammogram to be obtained. The mammogram revealed diffuse and occasionally grouped left breast calcifications. Additionally, there was focal edema at the site of the mass.A follow-up mammogram was recommended to document stability in 6 months, which demonstrated an interval increase in number and size of segmental pleomorphic calcifications in the lower inner breast spanning 6 cm in size. A stereotactic core needle biopsy was completed and revealed high-grade ductal carcinoma in situ (DCIS) that was estrogen receptor (ER) and progesterone receptor (PR) positive.Surgical TreatmentKS underwent genetic testing due to her young age at diagnosis of noninvasive breast cancer. She was tested with the breast/ovarian cancer panel, which was negative for mutation.She preceded to bilateral nipple-sparing mastectomy with left sentinel node biopsy and immediate implant reconstruction in February 2016. The operative pathology revealed 3.3 cm of high-grade DCIS. The surgical margins were negative (less than 1 mm posteriorly and less than 2 mm anteriorly). There was 1 sentinel node and 2 nonsentinel nodes negative for malignancy. The right breast was negative for cancer and both retro areolar margins were negative.KS did well during the ensuing routine follow-up every 6 to 12 months in surgical oncology at an academic medical center. She was not recommended to take adjuvant endocrine therapy given the benefit of bilateral mastectomy.In 2017, at a routine oncology follow-up visit, she expressed a desire to have more children. After a negative clinical exam, she and her husband were advised that future contraception may be pursued.Pregnancy-Associated Breast Cancer DiagnosisKS was in her usual state of good health when she noticed a left breast mass in the inferior reconstructed breast in June 2017. She presented to the nurse practitioner (NP) in the surgical oncology clinic for evaluation. At that time, she was 17 weeks pregnant and being seen in the same facility for high-risk obstetrics and gynecology care. KS had no other concerning symptoms for recurrent cancer, and her pregnancy had been progressing smoothly.The surgical oncology NP noted a 1-cm firm superficial mass in the breast at 6 o’clock. She had no other bilateral breast findings or adenopathy. Upon review of systems, she denied new persistent headache, shortness of breath, abdominal pain, weight loss, night sweats, or fatigue.Due to her pregnancy and the superficial presentation of the breast mass, a left breast ultrasound was ordered. It revealed an 8-mm irregular hypoechoic mass 7 cm from the nipple at the 6 o’clock position in the reconstructed breast.A diagnostic workup ensued with a left breast ultrasound-guided core needle biopsy. KS was given a diagnosis of clinical stage T1b, N0, grade 2 invasive micropapillary carcinoma: ER positive (Allred 6), PR positive (Allred 8), HER2/neu, immunohistochemistry 3+, and fluorescence in situ hybridization amplified.After discussion of this recurrent cancer diagnosis, her team opted for a bilateral diagnostic mammogram (with abdominal shielding) and bilateral axillary and breast ultrasound to evaluate the contralateral breast and lymph nodes. There was no adenopathy, a small amount of accessory breast tissue in the right axillary tail region, and a biopsy clip was noted in the left inferior breast at 6 o’clock. The new cancer was not seen on mammogram, likely due to the proximity to the implant.

The inception of a group psychotherapeutic intervention in infertile women – difficulties and obstacles through the constitution of a group setting in a maternity hospital

Several cases of infertility without the presence of a known medical cause and with a spontaneous remission have been studied from the psychological point of view. A look at infertility, in a psychodynamic way, suggests that it is the result of a defensive activation, aimed at promoting emotional protection, seen in pregnant women in high-risk obstetrics, in infertile couples waiting for infertility appointments and in pregnant women waiting for amniocentesis examination outcome. Thus, a spontaneous remission may be seen as a translation that the psychological impasse would have been overcome. This article intends to present a research project that has been held at the Maternity Hospital Dr. Alfredo da Costa (MAC), in Lisbon, and which participants are women followed in the MAC infertility consultation, unable to conceive or lead to good fruition a pregnancy after at least one year of regular sexual intercourse without resorting to contraceptive methods. In this article we intend to reflect the hindrances, difficulties and obstacles felt through the inception of a group psychotherapeutic setting in a Maternity Hospital. After all the bureaucratic issues have been solved out, the psychological resistance of the participants emerged, revealing to be a pattern.

Variation in outcome reporting across studies evaluating interventions for selective fetal growth restriction.

Variation in outcome reporting across studies evaluating interventions for selective fetal growth restriction.

Consultation, Surveillance, Monitoring, and Intensive Care (COSMIC): A Novel 4-Tier Program to Identify and Monitor High-Risk Obstetric Patients From the Clinic to Critical Care.

Consultation, Surveillance, Monitoring, and Intensive Care (COSMIC): A Novel 4-Tier Program to Identify and Monitor High-Risk Obstetric Patients From the Clinic to Critical Care.

Expectant Mothers’ Experiences After a Diagnosis of Fetal Anomaly

To explore expectant mothers’ perceptions of uncertainty and waiting from prenatal diagnosis of fetal anomaly through postpartum. Fetal anomaly diagnosis complicates pregnancy and is a multidimensional complex phenomenon that differs from uncomplicated pregnancies. Early in 2nd trimester, women may receive a fetal diagnosis and must live with this knowledge for months before birth. A descriptive phenomenological approach was used to explore mothers’ perceptions of fetal anomaly diagnosis over time. The study was conducted in a high-risk obstetrics clinic in a pediatric hospital. In-depth interviews were conducted with 10 mothers prenatally and 8 at postpartum. Data were analyzed using Giorgi method of phenomenological analysis. Institutional review board approval was obtained. Semistructured interviews revealed an overarching theme of Pregnancy Forever Changed. Three prenatal subthemes emerged: (a) News of a Diagnosis—No Going Back; (b) A Mother’s Response—Managing Information; and (c) Words From Others Matter. Postpartum was reflected by two subthemes: (a) The Journey Continues—Echoing Past Concerns; and (b) Not the Journey We Planned. Women described their experiences as complicated by uncertainty, disclosure, anxiety, information needs, loss and grief, decision dilemmas, fragmented health care, isolation, foreknowledge, waiting, and adaptation. Information needs pervaded all aspects of the experience. The women revealed that these issues experienced during pregnancy continued into the postpartum period (information needs, disclosure, and uncertainty). Women’s distress related to disclosure was a surprise finding. Understanding the unique journey and distress related to fetal anomaly diagnosis can guide practice for maternal–child nurses. Learning what mothers value can inform care by providing information, anticipatory guidance, and support. Implications for future research include studies evaluating the effectiveness of interventions that meet the mothers’ increased information needs and anticipatory guidance for managing information from multiple clinicians. Implications for education include teaching clinicians about women’s experiences associated with prenatal diagnosis of fetal anomaly as well as evidence-based interventions. Understanding the influence of the prenatal diagnosis on the postpartum experience is vital, as maternal–child nurses provide care across the continuum, from the initial diagnosis, through pregnancy, and into infancy.

Upstream Obstetrics: Assessing the Prevalence of Food Insecurity in a High-Risk Obstetrics Population [26D

Upstream Obstetrics: Assessing the Prevalence of Food Insecurity in a High-Risk Obstetrics Population [26D

Stroke recurrence in pregnancy: Experience at a regional referral center

BackgroundAlthough stroke is more common with advancing age, especially in the elderly, women of reproductive age may still suffer from stroke, and from its deleterious consequences. Women of reproductive age who suffer a stroke may do so either due to a specific predisposition, or due to pregnancy-related hypertensive emergencies. ObjectiveTo assess the risk of stroke recurrence in pregnancy and the postpartum period in women who have suffered a stroke before pregnancy. Study designThis was a retrospective cohort study conducted at Thomas Jefferson University Hospital from January 2005 to December 2015. This is a tertiary referral center for high-risk obstetrics and one of the largest stroke referral centers for neurosurgery. All consecutive pregnant women that had a viable pregnancy (≥24 weeks of gestation) and a history of stroke prior to pregnancy were identified. The primary outcome of this study was stroke recurrence in pregnancy or the postpartum period defined as 6 weeks after delivery. ResultsForty-eight pregnancies with a history of stroke before pregnancy were identified in 24 women. Thirty-one pregnancies (64.6%) had a history of an ischemic stroke, 11 (22.9%) had a history of transient ischemic attack, and 6 (12.5%) had a history of a hemorrhagic stroke. There was no stroke recurrence during pregnancy or the postpartum period for the three groups of stroke. In the ischemic stroke group, 8 (25.8%) had recurrence in the non-pregnant state compared to none in the TIA and the hemorrhagic stroke group. ConclusionThere was no stroke recurrence during pregnancy or the postpartum period for the three groups of stroke.

High Risk Obstetrics in Developing Countries: Root Cause Analysis and Viable Mitigation Strategies

High Risk Obstetrics in Developing Countries: Root Cause Analysis and Viable Mitigation Strategies

Pregnancy after renal transplantation.

A well-functioning renal transplant usually reverses ESRD-related infertility and allows the reproductive function to improve. In this study, we wanted to emphasize that women who have renal transplantation can live healthy pregnancies with a careful follow-up. 204 patients underwent renal transplantation in our center and 84 of them were female. Five of our patients (one of them had two births) gave birth to a total of 6 pregnancies. All of these patients were evaluated according to the criteria by the organ transplant team and perinatologist before the pregnancy planning and during the pregnancy processes. The mean age of the patients was 22.5 ± 4.5 (18-29) years. The creatinine level was below in 1.5 mg/dl in all patients in the pre-pregnancy period, and 1 + proteinuria was found in only two of them. Pregnancy periods varied between 31 weeks and 38 weeks. All births were performed by cesarean section and birth weight in babies ranged between 1650 and 3190 gram. Pregnancy in the renal transplant recipient is high-risk and should be managed by a multidisciplinary team of high-risk obstetricians, perinatalogists and transplant nephrologists. It should be closely monitored in terms of complications during pregnancy (Tab. 5, Ref. 16).