Maternal-fetal Medicine Physicians Research Articles

What Is Culture Made of? An Exploratory Study of Ethical Cultures and Provider Perspectives on the Care of Periviable Neonates

Objective Studies examining intercenter variation in neonatal intensive care unit practices at the limits of fetal viability have hypothesized that institutional “culture” can be one of many factors that impact patient care. This study aimed to describe institutional culture at a single, large academic center with regard to the antenatal consultation, resuscitation, and postnatal management of periviable neonates. Study Design Members of six clinical groups—attending and fellow maternal–fetal medicine physicians, attending and fellow neonatal–perinatal medicine physicians, neonatal nurses, advanced practiced neonatal nurses, pediatric hospitalist physicians, and neonatal respiratory therapists—were invited to complete qualitative, semi-structured interviews. All audio recordings were transcribed. Dedoose software was used to complete team-based coding and thematic analysis. Results Twenty-two interviews were completed. Thematic analysis revealed three central themes described by participants as contributory to institutional culture: Perception, referring to factors based on individual attitudes and insights, Statements of Information, referring to factors anchored in more objective concepts such as outcomes data and institutional policy, and Dynamic Factors, referring to the relatively fluid factors of institutional culture that interact with both Perception and Statements of Information. Participants were more likely to mention factors in the Perception category (n = 430) compared with factors in the Information category (n = 225), and although the latter were described as critical components of antenatal counseling and perinatal management, the philosophy of our unit appeared to be more heavily rooted in institutional memory and individual belief systems. Conclusion Our data demonstrate a personal undertone to institutional culture at the limits of viability, with an emphasis on individual attitudes and subjective interpretations of fact rather than empirical data. As the landscape of neonatology continues to change, understanding those factors that contribute to culture remains a necessary step toward deconstructing institutional belief systems and optimizing clinical care. Key Points

Adherence to Labor Arrest and Failed Induction of Labor Guidelines: The Impact of a Quality-Improvement Educational Intervention.

Background/Objective: To evaluate adherence to labor arrest and failed induction of labor (IOL) criteria in nulliparous, term, singleton, and vertex (NTSV) cesarean deliveries at an academic medical center and to measure the impact of a quality-improvement educational initiative that focused on obstetric provider education of modern labor arrest and failed IOL criteria. Methods: This is a retrospective cohort study using electronic health record (EHR) data with a pre- (1 September 2018-30 September 2019) and post-intervention (1 October 2019-31 March 2020) study design of all NTSV cesarean deliveries for labor arrest or failed IOL performed at an academic medical center in the northeastern United States. The quality-improvement educational intervention consisted of the distribution of educational pocket cards outlining modern labor arrest and failed IOL criteria to obstetric providers. Outcomes included adherence to labor arrest and failed IOL criteria pre- and post-intervention with secondary outcomes evaluating adherence by provider type (Maternal-Fetal Medicine (MFM) or generalist obstetrician). Descriptive and bivariate statistics were used in the analysis. Results: Pre-intervention, 272 NTSV cesarean deliveries were performed for labor arrest or failed IOL versus 92 post-intervention. Adherence improved post-intervention amongst failed IOL (OR 6.5, CI 1.8-23.8), first-stage arrest (OR 4.5, CI 2.2-10.8) and second-stage arrest (OR 3.7, CI 1.5-9.4). When comparing provider type, MFM physicians were more likely to be adherent to labor arrest and failed IOL criteria compared to generalist obstetricians pre-intervention (OR 3.1, CI 1.7-5.5); however, post-intervention, there was no longer a difference in adherence (OR 3.3, CI 0.9-12.3). Conclusions: Adherence to labor arrest criteria was suboptimal in the pre-intervention period; however, a targeted quality-improvement educational intervention improved adherence rates to labor arrest and failed IOL criteria among obstetric providers.

Impact of post-Dobbs abortion restrictions on maternal-fetal medicine physicians in the Southeast: a qualitative study

BackgroundThe US Supreme Court overturned federal abortion protections in Dobbs v. Jackson Women's Health Organization. Many states in the Southeastern US responded with restrictive policies that limit and criminalize abortion care. ObjectiveTo characterize the impacts of abortion restrictions on maternal fetal medicine physicians (MFMs) in the Southeastern US post Dobbs. Study DesignWe conducted qualitative, semi-structured interviews with 35 MFMs in 10 Southeastern states between February and June 2023. Our recruitment strategy relied on convenience and snowball sampling. Audio-recorded interviews were analyzed using Dedoose software and a descriptive qualitative approach that incorporated deductive and inductive approaches. ResultsEmergent themes were identified, and a conceptual framework was developed based on overarching themes. We found that abortion laws and external constraints following Dobbs resulted in ethical, professional, and legal challenges for MFMs that led to changes in clinical practice and deviations from patient-centered care. These forced changes resulted in negative impacts on MFMs such as increased fear, hypervigilance, and increased workload for MFMs. The changes also prompted concerns about health risks and negative emotional impacts for patients. Supportive colleagues, hospital systems, and policies were associated with decreased stress, emotional distress, and disruption of healthcare delivery. ConclusionsAbortion restrictions in the Southeastern US limit the ability of MFMs to provide or facilitate abortions in the setting of fetal anomalies and maternal health risk. MFMs perceived these restrictions to have negative professional and emotional repercussions for themselves, as well as negative impacts on patients. Supportive colleagues and clear guidance from hospital systems and departments on how to interpret laws were protective. Our findings have implications for the MFM workforce and patient care in the region.

Characteristics Associated with Trial of Labor among Patients with Twin Pregnancies.

This study aimed to identify patient and provider factors associated with undergoing trial of labor (TOL) among eligible patients with twin gestations. This retrospective cohort study of patients with twin gestations who received care at a large tertiary care center from 2000 to 2016 included individuals with live pregnancies greater than 23 weeks of gestation and cephalic-presenting twin. Patients with a prior uterine scar or contraindication to vaginal delivery were excluded from analyses. Maternal and clinical characteristics were compared among patients who did and did not undergo TOL. Multivariable logistic regression models included characteristics chosen a priori and those with bivariable associations with p < 0.1. Interactions between parity and other significant variables in the primary models were also investigated. Among 1,888 eligible patients, 80.7% (N = 1,524) underwent TOL. Those undergoing TOL were more likely to be younger, multiparous, and have a maternal-fetal medicine physician as the delivering provider (p < 0.01). Hypertensive disorders of pregnancy were less prevalent among patients undergoing TOL (20.2 vs. 27.8%, p < 0.01). In multivariable analysis, advanced maternal age (adjusted odds ratio [aOR]: 0.55, 95% confidence interval [CI]: 0.40-0.74) and nulliparity (aOR: 0.36, 95% CI: 0.25-0.52) conferred a lower odds of TOL, while having a maternal-fetal medicine provider (aOR: 2.74, 95% CI: 1.55-4.83) was associated with higher odds. Interaction analyses demonstrated no significant interaction effects between parity and other characteristics. Among those undergoing a TOL, 76.0% (1,158/1,524) had a successful vaginal delivery of both twins, with 48.1% (557/1,158) having breech extraction of the second twin. In this cohort of twin gestations with a high frequency of TOL, patient and provider characteristics are associated with attempting vaginal delivery. Variation in provider practices suggests differing skills and comfort with twin vaginal delivery may influence route of delivery decision-making in patients with twins. · Most patients with twin pregnancies undergoing TOL had successful vaginal deliveries.. · Having an MFM delivering provider was associated with higher odds of attempting twin TOL.. · Nulliparity and advanced maternal age were associated with lower odds of twin TOL..

A Crossover Trial Evaluating Coconut Oil as an Alternative to Commercial Ultrasound Gel in Obstetrical Ultrasounds.

Our objective was to evaluate the quality of obstetrical ultrasound images obtained with coconut oil compared with commercial ultrasound gel and to assess patient acceptability. This was a randomized two-period crossover study in which 40 pregnant patients had standard biometry images obtained with both coconut oil and commercial ultrasound gel during their growth or anatomy ultrasound. All images were then rated by two blinded maternal-fetal medicine physicians on quality, resolution, and detail using a 0 to 100 scale. Contrasts obtained from linear mixed models were used to estimate the differences in image parameters between the agents. Participant experience was evaluated with an acceptability survey which included five items measured on a five-point Likert scale. Image quality, as rated by physicians, was found to be equivalent between commercial ultrasound gel and coconut oil. Additionally, there was not a statistically significant difference in image resolution or detail between the two coupling agents. The overall patient experience was significantly lower for commercial ultrasound gel when compared with coconut oil (mean difference = - 5.48, 95% confidence interval = [-6.89, -4.06]). Ultrasound images collected with coconut oil as the coupling agent are equivalent in quality to those collected using commercial ultrasound gel. Patients also preferred the use of coconut oil during their ultrasound, making its use a possible way to improve the patient ultrasound experience. Coconut oil has the potential as an alternative coupling agent that could significantly increase access to ultrasound use in resource-limited settings. · Coconut oil produces quality images during obstetrical ultrasounds.. · Patients prefer the use of coconut oil to standard ultrasound gel during obstetrical ultrasounds.. · Coconut oil is a coupling agent that could increase ultrasound use in resource-limited settings..

An Overview of Arrhythmias in Pregnancy.

Cardiovascular disease significantly jeopardizes pregnancies in the United States, impacting 1% to 4% of pregnancies annually. Among complications, cardiac arrhythmias are prevalent, posing concerns for maternal and fetal health. The incidence of arrhythmias during pregnancy is rising, partly due to advances in congenital heart surgery and a growing population of women with structural heart disease. While most arrhythmias are benign, the increasing prevalence of more serious arrhythmias warrants a proactive approach. Guidance and reassurance suffice in many cases, but persistent symptoms require cautious use of antiarrhythmic drugs or other therapies for a safe outcome. Managing more serious arrhythmias requires a comprehensive, multidisciplinary approach involving specialists, including maternal-fetal medicine physicians, cardiologists, electrophysiologists, and anesthesiologists.

Examining Postpartum Anticoagulation Practices: An International Survey of Healthcare Providers

Background Prophylactic anticoagulation is usually recommended for six weeks postpartum (PPM) for individuals at high risk of developing venous thromboembolism (VTE). However, there are no randomized controlled trials (RCTs) assessing optimal duration of prophylactic anticoagulation post-partum. Moreover, the risk is not equivalent throughout the six weeks as evidenced by a sharp decline in VTE risk following the third week PPM. These observations call into question the optimal duration of PPM thromboprophylaxis and whether a full six weeks is needed. Objective This study sought to determine postpartum anticoagulation practices and to explore practitioners' willingness to consider reduction of the duration of PPM prophylactic anticoagulation. Methods We conducted a cross-sectional study between December 2022 and April 2023 using a self-administered electronic questionnaire on the ‘SurveyMonkey’ platform to gauge international preferences for the use, dose and duration of postpartum anticoagulation . The survey was validated for face and content validity and explored expert preferences across complex PPM scenarios. Physician characteristics, years in practice, specialty and continent of practice were also collected. We employed various methods of dissemination including email, scientific conferences, expert groups, and social media. Results Of the 113 participants that responded to the initial invitation, 78 completed the survey with the following regional distribution: 53.9% from Europe, 23.1% from North America, and 19.0% from Australia and New Zealand. Among the respondents, 60% were haematologists, 20% were general obstetric physicians, and 13% were maternal-fetal medicine (MFM) experts. For prior unprovoked or hormone-associated deep venous thrombosis (DVT) or pulmonary embolism (PE), non-hormone associated provoked DVT/PE, cerebral venous sinus thrombosis (CVST) and splanchnic vein thrombosis, 97.4%, 93.5%, 91.0% and 88.5% of experts selected six weeks of prophylactic anticoagulation with LMWH postpartum compared to 3 weeks or prophylaxis with unfractionated heparin. This practice was also supported by 70.5%, 78.2% and 87.2% of experts in individuals with sickle cell disease (SCD), obstetric antiphospholipid syndrome (APS) and high-risk thrombophilia, respectively. For individuals with a history of unprovoked PE/DVT or history of thrombosis at atypical sites (splanchnic thrombosis or CVST) approximately half of the experts (48.7% and 47.4 %) were willing to offer thromboprophylaxis with 3 weeks of LMWH followed by 3 weeks of aspirin, while approximately one-third (34.6% and 32.1%) would consider 3 weeks of LMWH only (Table 1). Respondents managing more than 10 patients per year (p=0.0001), with over 5 years of practice experience (p=0.0004) and specialization in Haematology or MFM demonstrated a greater willingness to explore shorter durations. For scenarios of individuals with SCD, obstetric APS and myeloproliferative neoplasms (MPNs), with no history of VTE, a higher percentage of respondents (69.2%, 60.3%, 67.9%) would support 3 weeks of LMWH followed by 3 weeks of aspirin or no anticoagulation PPM (Table 1). For SCD, Haematologists were slightly less supportive (68.1%) than MFM (80%) and obstetric medicine physicians (75%) of shorter durations, although the difference was not statistically significant (p=0.45). For MPNs, Haematologists were more supportive of shorter durations (76.6%) than MFMs (60%) and obstetric medicine physicians (50%) (p=0.047). For obstetric APS, there was no significant difference amongst the specialties with respect to explore shorter anticoagulation durations. Conclusion The majority of experts (90%) prescribe a 6 week LMWH regimen for patients with a background of DVT/PE, thrombosis in atypical sites, or high-risk thrombophilias, while fewer adopt this approach for SCD, obstetric APS. Half of the specialists would consider shorter durations of prophylactic anticoagulation PPM for individuals with prior DVT/PE, thrombosis in atypical sites and even more (60-70%) for SCD, obstetric APS and MPNs. Experience and caseload influence acceptance of shorter durations. There is an urgent need for prospective studies addressing peripartum management of anticoagulation such as appropriate type, dosage, initiation timing and duration in different diseases, to provide evidence regarding optimal strategies.

Society for Maternal-Fetal Medicine Statement: Clinical considerations for the prevention of respiratory syncytial virus disease in infants

Respiratory syncytial virus is a leading cause of lower respiratory tract illness globally in children under 5 years. Each year, approximately 58,000 hospitalizations in the United States are attributed to respiratory syncytial virus. Infants aged 6 months and younger experience the most severe morbidity and mortality. Until recently, prevention with the monoclonal antibody, palivizumab, was only offered to infants with high-risk conditions, and treatment primarily consisted of supportive care. Currently, two products are approved for the prevention of respiratory syncytial virus in infants. These include the Pfizer bivalent recombinant respiratory syncytial virus prefusion F protein subunit vaccine, administered seasonally to the pregnant person between 32 0/7 and 36 6/7 weeks of gestation, and the monoclonal antibody, nirsevimab, administered to infants up to 8 months entering their first respiratory syncytial virus season. With few exceptions, administering both the vaccine to the pregnant person and monoclonal antibody to the infant is not recommended. All infants should be protected against respiratory syncytial virus using one of these strategies. Key considerations for pregnant individuals include examining available safety and efficacy data, weighing accessibility and availability, and patient preferences for maternal vaccination versus infant monoclonal antibody treatment. It will be critical for maternal-fetal medicine physicians to provide effective and balanced counseling to aid patients in deciding on a personalized approach to the prevention of respiratory syncytial virus in their infants.

A survey evaluating practice pattern in management of obstetric hemorrhage.

Hemorrhage anticipation and management has shifted significantly over the past decade due to evolution of data surrounding management of obstetric hemorrhage. Limited data exists which describe the practical use and clinical application of hemorrhage management. Our goal was to identify obstetric hemorrhage management patterns in a cohort of practicing Maternal Fetal Medicine physicians. We administered a survey to Maternal Fetal Medicine (MFM) fellows and faculty that addressed the management of hemorrhage including risk assessment, uterotonic use, antifibrinolytic use, cell saver use, and abnormal placentation management. An email was sent out regarding the survey to a listserv of all Maternal Fetal Medicine fellow program coordinators to disseminate to their faculty and fellows. Eighty responses were obtained. A total of 78 surveys were analyzed. Participants preferred methylergonovine as a first line agent (n = 57; 73%, n = 62; 80%). Most participants would consider using cell salvage when also activating MTP (28, 48%) or during scheduled deliveries who are high risk of hemorrhage (40, 69%). Approximately a third of providers would use TXA (tranexamic acid) prophylactically (n = 21; 28%). Only 26% of MFM fellows felt comfortable performing cesarean hysterectomy without Gynecologic Oncology. In comparison to prior reports, TXA use has increased substantially. Further, when looking at the management of abnormal placentation, the use of magnetic resonance imaging and embolization have both increased. Possibly due to the rise in centers of excellence for treatment of accreta spectrum disorders, Maternal Fetal Medicine fellows still feel largely unprepared to perform a cesarean hysterectomy without Gynecologic Oncology.

Discovering harmony as a maternal-fetal medicine physician

Discovering harmony as a maternal-fetal medicine physician

Effect of initial anesthetic technique on fetal cord blood gas pH for cesarean deliveries performed for the indication of fetal heart rate abnormalities

Background We hypothesized that parturients who had general anesthesia as the initial anesthetic technique for cesarean deliveries performed for fetal heart rate abnormalities would have a lower fetal cord blood gas pH compared to parturients who had regional anesthesia as the initial anesthetic technique. Methods We searched our electronic medical record for patients who had cesarean deliveries for the indication of fetal heart rate abnormalities from July 1, 2019, to June 30, 2021, at our hospital. An obstetrics resident and a maternal fetal medicine physician determined if the fetal heart tracing was category 2 or 3. Results A total of 130 and 29 patients with category 2 and 3 fetal heart tracing had regional and general anesthesia as the initial anesthetic technique, respectively. Fourteen and 20 patients with a category 3 fetal heart tracing had regional and general anesthesia as the initial anesthetic techniques, respectively. There were no differences in fetal cord blood gas pH between patients who had regional or general anesthesia as the first attempted anesthetic technique when patients with category 2 and 3 tracings were evaluated separately. Conclusion The initial anesthetic technique attempted for cesarean delivery was not associated with a worse fetal cord blood gas pH.

A cross-sectional analysis of compassion fatigue, burnout, and compassion satisfaction in maternal–fetal medicine physicians in the United States

Compassion fatigue is secondary traumatic distress experienced by providers from ongoing contact with patients who are suffering. Compassion satisfaction is emotional fulfillment from caring for others. Burnout is distress related to dissonance between job demands and available resources. Although burnout is well-studied, compassion satisfaction and compassion fatigue are neglected components of physician well-being. Because of recurrent exposure to adverse outcomes, maternal-fetal medicine providers may be at particular risk for compassion fatigue. This study aimed to better characterize both clinical and nonclinical drivers of work-related distress vs satisfaction. The modified Compassion Fatigue and Satisfaction Self-Test and a questionnaire of professional and personal characteristics were distributed electronically to maternal-fetal medicine providers nationally. Multivariable regression models were constructed for compassion fatigue, burnout, and compassion satisfaction as a function of potential predictors. The survey response rate was 24% (n=366), primarily consisting of White physicians working in academic medical centers. Significant predictors of lower burnout scores included employment at 1 institution for >20 years, discussing work-related distress with friends, and having one's most recent involvement in decision-making for a periviable fetus >6 months ago; distress because of coworkers and personal factors predicted higher scores. Female sex, self-report of significant emotional depletion, use of mental health services, and having other maternal-fetal medicine physicians as part of the care team for a fetus with severe anomalies were significant predictors of higher compassion fatigue scores, whereas White race and having social work as part of the care team for a maternal mortality predicted lower scores. Personal spiritual practice was a significant predictor of higher compassion satisfaction score, whereas employment at current institution for <5 years predicted lower scores. Compassion fatigue, compassion satisfaction, and burnout are associated with several modifiable risk factors, such as practice type, having a multidisciplinary team, and emotional support outside of the workplace; these are potential targets for intervention.

Provider willingness towards periviable cervical cerclage placement in singleton gestations: a survey of providers nationwide

Cervical cerclage placement up to 24 weeks may prolong pregnancy and reduce preterm birth rates and associated neonatal morbidity. In certain settings, neonatal viability now extends as early as 22 weeks’ gestational age (GA). This periviability overlap leads to great variability among providers’ willingness to perform an ultrasound-indicated (UC) or physical exam-indicated (PEC) cerclage at 22- and 23-weeks GA. We aimed to elucidate current periviable cerclage placement practices among Maternal-Fetal Medicine (MFM) physicians. A survey was available to all MFM members of the Society for Maternal-Fetal Medicine from February-May 2022. Participants were asked about their practice for UC and PEC between 22 0/7 – 22 6/7 weeks (22 weeks) and between 23 0/7 – 23 6/7 weeks (23 weeks). UC and PEC were defined in the instructions. This abstract specifically addresses provider willingness to provide UC and PEC at each GA in singletons. Rates of cerclage placement were calculated. Chi-square analysis and Fisher’s exact test assessed response differences according to physician characteristics (number of years in practice, practice model, and region of practice in the country). Separate logistic regression models were used on adjusted analysis to estimate the association between the odds of offering cerclage and each characteristic above. 406 responses (response rate 18.1%) revealed that at 22 weeks, 92.1% would offer UC and 95.8% would offer PEC. At 23 weeks, 62.6% would offer UC and 66.3% would offer PEC, with differences noted according to the number of years in practice and the region of the country of practice (Table 1). On adjusted analysis these differences remained, with the odds of UC and PEC being significantly lower at 23 weeks for those in practice > 10 years and providers in the South (Table 2). Periviable cerclage management varies greatly, with willingness to perform UC and PEC being significantly different according to region of the country and the number of years in practice. These differences reflect the need for evidence-based guidelines in these scenarios.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Quality Improvement Through Nurse-initiated Kaiser Sepsis Calculator at a County Hospital.

Suspected early onset sepsis drives most antibiotic use in the newborn nursery. The Kaiser Sepsis Calculator (KSC) is a validated tool that safely decreases laboratory evaluation and antibiotic administration in infants aged ≥34 weeks. Our quality improvement aim was a nurse-initiated, KSC-based program to decrease blood cultures (BCx) and complete blood counts (CBC) by 10% from March 2021 to October 2021 among chorioamnionitis-exposed infants born ≥35 weeks' gestation. A secondary aim was to decrease antibiotic administration by 10%. The KSC was implemented for infants at University Health, a county hospital affiliate of the University of Texas Health Science Center San Antonio, with a level I nursery and level IV NICU. The multidisciplinary project included pediatric hospitalists, neonatologists, family practitioners, maternal-fetal medicine physicians, fellows, residents, and nurses. All infants born 6 months before (August 2020-January 2021) and 7 months after protocol implementation (March 2021-September 2021) were analyzed. A total of 53 chorioamnionitis-exposed infants were included from the preintervention period and 51 from the postintervention period. CBC utilization decreased from 96% to 27%, BCx utilization decreased from 98% to 37%, and antibiotic utilization fell from 25% to 16%. In no cases were antibiotics prescribed against the KSC, and to our knowledge, no early onset sepsis diagnoses or infection-related hospital readmissions were missed. The multidisciplinary implementation of the KSC led to a reduction in testing, exceeding our initial goal. A nurse-initiated protocol reduced BCx, CBC, and antibiotic utilization among chorioamnionitis-exposed infants.

Incidentally Found Midtrimester Shortened Cervical Length: Practice Patterns among American Maternal-Fetal Medicine Specialists.

The management of incidentally found short cervical length (CL) without prior spontaneous preterm birth (PTB) can vary. While most agree on starting vaginal progesterone, management after CL shortens <10 mm varies. The purpose of this study was to elucidate current practice patterns amongst maternal-fetal medicine (MFM) specialists. We conducted an online survey of MFM attending physicians and fellows in the United States from May 2019 to April 2020. The primary outcome was management of varying CL based on gestational age. Variations in management were assessed descriptively. There were 236 respondents out of 400 eligible surveyed, with a response rate of 59.2%. Universal CL screening was reported by 93.6% (49.6% abdominal and 44.1% transvaginal). Management of short CL varied based on CL measurement, rather than gestational age at presentation. At CL <10 mm, management included cerclage (17.4-18.7%), vaginal progesterone (41.3-41.7%), or cerclage plus vaginal progesterone (43.4%). Between CL of 10 to 20 mm, the majority (77.4-91.9%) would start vaginal progesterone. At CL 21 to 25 mm, management varied between expectant management (45.5-48.5%) or vaginal progesterone (51.1-52.8%). Suture material used was ethylene terephthalate (47.4%) or polypropelene (31.2). Preoperative antibiotic use was reported by 22.3%, while 45.5% used them only if the amniotic membranes were exposed, and 32.2% reported no antibiotic use. Postoperative tocolytic use varied with 19.3% reporting no use, 32.6% using it always, 8.2% only after significant cervical manipulation, 22.7% after the patient is experiencing symptoms, and 17.6% using it only if the cervix is dilated on exam. After cerclage placement, 44.5% continued CL surveillance. Substantial differences of opinion exist among MFM physicians regarding management of incidentally found short CL in patients without history of PTB. The differences in responses obtained highlight the need for evidence-based guidelines for managing this clinical scenario. · There is lack of consensus on the management of incidentally found shortened CL.. · The purpose of this study was to elucidate current trends in CL screening and management.. · Substantial differences of opinion exist regarding management of incidentally found short CL..

How Medical Societies Can Collaborate with Vendors to Improve EHR Utilization

Summary The electronic health record (EHR) is a key component of patient interactions, quality improvement efforts, patient safety, and research endeavors. Yet medical societies have not focused on collaborative efforts with EHR vendors to improve their systems. In October 2018, the Society for Maternal-Fetal Medicine (SMFM) formed a Clinical Informatics Committee to investigate the possibility of collaborating with EHR vendors to optimize systems. This committee surveyed the 2,718 clinical maternal-fetal medicine physician members to investigate EHR use, system problems, and future needs. The committee received 312 responses from 43 states. Practice patterns were diverse and generally represented the society membership. Responses from maternal-fetal medicine physicians revealed broad frustration with system usage, interfaces, and design provided by the EHR systems they used. In response to survey results, SMFM’s Clinical Informatics Committee formed subcommittees that collaborated with vendors’ EHR specialists to consider how to optimize EHR systems. Considerable progress was made: pushing society guidelines into the main EHR systems, adopting common term definitions to improve data quality, forming standardized clinical text statements for members and vendors to create common and consistent input for providers, and defining data within ultrasound systems to facilitate future interfaces involving information transfer from ultrasound equipment to ultrasound reporting systems and EHR systems. The success of the society’s efforts to improve EHR systems should encourage other societies to work with EHR vendors to enhance and optimize strategies to improve patient care, safety, and research.

Prenatal Considerations and Outcomes for Girls Aged 14 and Under: Development of a Multidisciplinary Team in a Large Tertiary Care Facility.

Adolescent girls account for 11% of all births that occur globally every year. Among developing countries, the United States continues to have one of the highest adolescent birth rates, despite a decreasing trend between 1990 and 2010. Pregnant adolescents are a vulnerable population who are at increased risk for maternal morbidity and mortality. Additional risks are noted within the early adolescent population, usually defined as age 10 to 14. At Parkland hospital, a large tertiary care facility in Dallas, Texas, a multidisciplinary team was created in 2017 to care for this vulnerable population. The team consisted of a certified nurse-midwife (CNM), a Certified Child Life Specialist, a maternal fetal medicine physician, a social worker, and a Spanish interpreter, with additional services consulted as needed. Between 2017 and 2020, this team grew to include 8 CNMs and provided care to 76young adolescents ages 14 and younger. Of the young adolescents who attendedprenatalvisits with theAdolescent Prenatal Care Team at Parkland, 87%presented toParkland for birth.Eighteen percent had pregnancy-induced hypertension or eclampsia. Only7% of adolescents in the program gave birthprior to 37 weeks. Seventy-four percent had vaginal births. Sixty percentof the adolescents attendedknown postpartum visits. In contrast to most studies, this Adolescent Care Team did not find a high rate of premature birth in early adolescents. Further work by this team is needed to compare the data obtained during this period with data on similar adolescents who have given birth at Parkland in prior years. In addition, comparing outcomes of early adolescents with those aged 15 to 19, who were not included in the Adolescent Care Team, will help to understand the impact that such a team or similar intervention might have on this vulnerable population.

Evaluation of classic and novel ultrasound signs of placenta accreta spectrum

ABSTRACTObjectivesImprovement in the antenatal diagnosis of placenta accreta spectrum (PAS) would allow preparation for delivery in a referral center, leading to decreased maternal morbidity and mortality. Our objectives were to assess the performance of classic ultrasound signs and to determine the value of novel ultrasound signs in the detection of PAS.MethodsThis was a retrospective cohort study of women with second‐trimester placenta previa who underwent third‐trimester transvaginal ultrasound and all women with PAS in seven medical centers. A retrospective image review for signs of PAS was conducted by three maternal–fetal medicine physicians. Classic signs of PAS were defined as placental lacunae, bladder‐wall interruption, myometrial thinning and subplacental hypervascularity. Novel signs were defined as small placental lacunae, irregular placenta–myometrium interface (PMI), vascular PMI, non‐tapered placental edge and placental bulge towards the bladder. PAS was diagnosed based on difficulty in removing the placenta or pathological examination of the placenta. Multivariate regression analysis was performed and receiver‐operating‐characteristics (ROC) curves were generated to assess the performance of combined novel signs, combined classic signs and a model combining classic and novel signs.ResultsA total of 385 cases with placenta previa were included, of which 55 had PAS (28 had placenta accreta, 11 had placenta increta and 16 had placenta percreta). The areas under the ROC curves for classic markers, novel markers and a model combining classic and novel markers for the detection of PAS were 0.81 (95% CI, 0.75–0.88), 0.84 (95% CI, 0.77–0.90) and 0.88 (95% CI, 0.82–0.94), respectively. A model combining classic and novel signs performed better than did the classic or novel markers individually (P = 0.03). An increasing number of signs was associated with a greater likelihood of PAS. With the presence of 0, 1, 2 and ≥ 3 classic ultrasound signs, PAS was present in 5%, 24%, 57% and 94% of cases, respectively.ConclusionsWe have confirmed the value of classic ultrasound signs of PAS. The use of novel ultrasound signs in combination with classic signs improved the detection of PAS. These findings have clinical implications for the detection of PAS and may help guide the obstetric management of patients diagnosed with these placental disorders. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Twin Reversed Arterial Perfusion Sequence.

Twin Reversed Arterial Perfusion Sequence.

Examining the association between preterm birth and geographic disparities in the Maternal-Fetal Medicine physician workforce

Maternal-Fetal Medicine (MFM) specialists disproportionately practice in metropolitan areas of the most populous states of the US. Prior regional data have suggested an improvement in preterm birth (PTB) rates with presence of MFM services within a community. We hypothesize that geographic disparity in the MFM physician workforce distribution nationally is associated with a higher rate of PTB in counties without MFM presence. Utilizing workforce data provided by the Society for Maternal-Fetal Medicine and county-level prematurity data from The March of Dimes, we mapped physician location in all 50 US states and Puerto Rico using R Studio software. Logistic regression analysis was utilized to estimate the odds of county PTB rates higher than the national average (10.2%, 2019 national data) by MFM physician location. The University of Iowa Institutional Review Board determined this study to be exempt and application was not required. Urban areas had the highest density of MFM physicians (purple circles in the figure) whereas less populous areas in the Midwest and western US had the lowest density. Out of the 2981 counties with PTB rates available, 9.7% (n = 289) had a practicing MFM physician. US counties without an MFM physician are more likely to have a PTB rate higher than the national average, OR 1.56 (1.22-1.99), when compared to a county with at least 1 MFM physician. In counties with no practicing MFM physician, those counties have a 56% increase in the odds of having PTB rates higher than the national average. Lack of proximate high-risk obstetric care is one of many disparities associated with PTB. The location of the MFM workforce has implications for both clinical care and health policy for maternal and neonatal care. These data suggest that attention should be directed toward where physicians practice and to increase access to care for at-risk pregnant people (i.e. outreach programs, telehealth).