Maternal Fetal Medicine Service Research Articles

Population adjustment of the definition of the vaginal birth after cesarean rate

Objective: The vaginal birth after cesarean delivery rate is calculated with a denominator equal to the number of all women who give birth after a previous cesarean delivery, including those who are not candidates for a trial of labor. We evaluated the impact of adjustment for noncandidates for a trial of labor on vaginal birth after cesarean delivery rates. Study Design: All women with a previous cesarean delivery who were delivered during 1998 were classified as either candidates or noncandidates for a trial of labor. An adjusted vaginal birth after cesarean delivery rate was calculated by eliminating noncandidates for a trial of labor from the denominator. The percentage of noncandidates for a trial of labor, the vaginal birth after cesarean delivery rate, and the adjusted vaginal birth after cesarean delivery rate were compared among 3 clinical services. Results: The maternal-fetal medicine service had a significantly higher percentage of noncandidates for a trial of labor than did either the low-risk resident clinic or the low-risk private service. The maternal-fetal medicine service had a significantly lower vaginal birth after cesarean delivery rate than did the private service, but this difference was no longer present after application of an adjusted vaginal birth after cesarean delivery definition. Conclusion: For accurate comparison of vaginal birth after cesarean delivery rates among providers it is essential to account for patient risk status in the vaginal birth after cesarean delivery definition through the elimination of noncandidates for a trial of labor. (Am J Obstet Gynecol 2000;183:1166-9.)

Twin gestations at a community hospital: comparing management styles of private versus resident and maternal–fetal medicine services

Objective: In 1990, we developed fixed criteria for transfer of multiple gestations to the maternal–fetal medicine (MFM) service. To evaluate these criteria and analyze outcome and quality of care for multiple gestations, a retrospective review of low-risk twin gestations was conducted.Methods: All low-risk twin pregnancies delivered by private and MFM/resident services in 1990–1997 were identified, pertinent data obtained from chart review, and results summarized.Results: Of the low-risk twin pregnancies (n = 491), 73% were seen by private services, 8.5% by MFM, and 18% by resident. Resident patients had a lower average maternal age and less infertility and were higher in parity and gravidity. A greater proportion of MFM patients had significant past medical histories, and more had undergone selective reduction. There was an increased use of oral tocolytics, a higher birth weight, and a higher mean gestational age in the private group. Total rate of cesarean deliveries for private patients was higher when compared with resident/MFM (52%–37%). The rate of combined procedures (vaginal followed by cesarean delivery) was significantly different with 4/90 resident/MFM and 33/151 private services second twins delivered abdominally (P = 0.02). A greater proportion of breeches were delivered vaginally, and there were more instrumental vaginal deliveries in the resident/MFM group (P = 0.02). Perinatal morbidity was not different among the groups.Conclusions: Outcome results are similar among private, MFM, and resident services. Differences in practice patterns result in a higher private services cesarean delivery rate. Good outcomes for both groups reflect adherence to management protocols. Use of version and inexperience with breech extraction were major contributors to the higher private cesarean delivery rate.

Use of Greenfield Filters in Pregnant Women at Risk for Pulmonary Embolism

A 3-year retrospective study (1992 to 1995) was done to identify all cases of Greenfield filter use in pregnant patients cared for by the Maternal-Fetal Medicine Service of our institution. The patient selection criteria included placement of a Greenfield filter in the index pregnancy or placement of a Greenfield filter before conception and in a patient who subsequently became pregnant. A series of eight pregnant patients with Greenfield filters was identified, the largest to date in a single institution. Management of the pregnant patient at risk for pulmonary embolism or its recurrence is problematic. Hypercoagulability occurs during pregnancy and predisposes the at-risk patient to thromboembolic phenomena such as deep venous thrombosis and pulmonary embolism. This study, though limited, indicates that Greenfield filters may be used safely in pregnant women and are effective in preventing pulmonary embolism or its recurrence.

Use of Greenfield filters in pregnant women at risk for pulmonary embolism.

A 3-year retrospective study (1992 to 1995) was done to identify all cases of Greenfield filter use in pregnant patients cared for by the Maternal-Fetal Medicine Service of our institution. The patient selection criteria included placement of a Greenfield filter in the index pregnancy or placement of a Greenfield filter before conception and in a patient who subsequently became pregnant. A series of eight pregnant patients with Greenfield filters was identified, the largest to date in a single institution. Management of the pregnant patient at risk for pulmonary embolism or its recurrence is problematic. Hypercoagulability occurs during pregnancy and predisposes the at-risk patient to thromboembolic phenomena such as deep venous thrombosis and pulmonary embolism. This study, though limited, indicates that Greenfield filters may be used safely in pregnant women and are effective in preventing pulmonary embolism or its recurrence.