Society For Maternal-Fetal Medicine Research Articles

AIUM-ACR-ACOG-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations.

AIUM-ACR-ACOG-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetric Ultrasound Examinations.

Framework for Critical Care in Obstetrics.

In 2015, The American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine issued a joint care consensus document intended to develop standards for designations of levels of maternal care that are complimentary to, but distinct from, neonatal levels of care. Level III and Level IV centers must be prepared to provide obstetric intensive care services. Developing a critical care obstetric program is a resource-intensive process that requires a carefully planned strategic effort essential for successful program implementation and sustainability. In this article, a framework utilizing key components of program development is discussed including environment, scope, model, education and training, maternal transport, and unique aspects of care for women who become critically ill during pregnancy or the postpartum period.

Mode of Delivery in Previable Births.

Preterm birth before 23 weeks of gestation typically results in neonatal death (5% survival). Society for Maternal-Fetal Medicine and American College of Obstetricians and Gynecologists published consensus guidelines recommending cesarean delivery (CD) not be performed for fetal indications between 20 and 226/7 weeks given the lack of proven benefit. We sought to quantify the previable CD rate and identify characteristics associated with previable CD. We performed a population-based retrospective cohort study of all live births in Ohio (2006-2015). Frequency of previable CD was stratified by week of gestation, defined as delivery between 16 and < 23 weeks of gestation. Maternal, obstetric, and neonatal characteristics were compared between women who underwent vaginal delivery versus CD. Multivariable logistic regression estimated the relative influence of maternal and fetal factors on the outcome of CD among previable live births. Of 1,463,506 live births in Ohio during the 10-year study period, 2,865 births (0.2%) occurred during the previable period of 16 to 22 weeks. Nearly 1 in 10 live births at less than 23 weeks was delivered by cesarean (n = 273/2,865), CD rate 9.5% (95% confidence interval, 8.5-10.7). At 16 to 22 weeks of gestation, the CD rates were 0, 5.5, 7.6, 3.5, 5.4, 10.1, and 15.1%, respectively. Factors associated with CD included increasing parity, increasing birth weight, maternal corticosteroid administration, and fetal malpresentation. Previable neonates born by CD were more likely to be admitted to the NICU, receive ventilator support, and more likely to be living at the time of birth certificate filing. Nearly 1 out of 10 births during the previable period was delivered via cesarean. Factors associated with previable CD suggest intent for neonatal interventions, such as NICU admission and supportive therapies. Our findings support that education and adherence with guidelines for care of previable births are a potential area of focus for perinatal quality improvement efforts.

Maternal Death Due to Amniotic Fluid Embolism: A National Study in France

(Anesth Analg. 2018;126(1):175–182) Signs and symptoms of amniotic fluid embolism (AFE) vary greatly and are not specific to AFE, making it a difficult condition to diagnose and treat. Recently, the Society for Maternal-Fetal Medicine (SMFM) and the AFE Foundation proposed 4 uniform diagnostic criteria to help identify cases of AFE for research purposes. These criteria have not been tested on a specific population. The authors of the present study applied these criteria to maternal deaths attributed to AFE between 2007 and 2011, as identified by a national experts committee from the French Confidential Enquiry into Maternal Deaths, to evaluate its potential as a diagnostic tool. Furthermore, they described the epidemiology, clinical characteristics, and management of AFE by the presence or absence of all 4 diagnostic criteria.

Committee Opinion No. 726: Hospital Disaster Preparedness for Obstetricians and Facilities Providing Maternity Care

(Obstet Gynecol. 2017;130(6):e291–e297) Large-scale catastrophic events or disasters cause evacuation of as many as 20 hospitals per year. In general, health care institutions play an important role in effective disaster mitigation planning. However, the obstetric population is unique and particularly vulnerable to patient volume surge, unpredictable resource use, infectious disease, and trauma. Obstetric units and their associated patient populations thereby warrant special consideration in the event of a disaster. New publications from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) have highlighted the importance of disaster preparedness through the definition of specific levels of maternity care and protocols specific to obstetric triage.

Reassessing the Duration of the Second Stage of Labor in Relation to Maternal and Neonatal Morbidity

(Obstet Gynecol. 2018;131(2):345–353) Prolonged second stage of labor is associated with an increased risk of postpartum hemorrhage, maternal febrile morbidity, infection, perineal trauma, and neonatal morbidities. Previously, the Society for Maternal-Fetal Medicine and American College of Obstetricians and Gynecologists in an effort to reduce an initial cesarean section in patients receiving epidural analgesia, recommended that second-stage arrest be redefined by the addition of 1 hour: 4 versus 3 hours for nulliparous women with an epidural, and 3 versus 2 hours for multiparous women with an epidural. In the present study, the authors calculated the likelihood of vaginal birth without serious maternal or neonatal morbidity or mortality compared with birth with morbidity or mortality, so as to better inform clinical decision-making.

Female Physicians in Maternal-Fetal Medicine: A 32-Year Perspective.

To examine trends of female physicians either pursuing fellowships or in active practice in maternal-fetal medicine (MFM). This observational study examined complete sets of MFM fellows and active members of the Society for Maternal-Fetal Medicine (SMFM) between 1985 and 2016. Databases from SMFM, American College of Obstetricians and Gynecologists (ACOG), and Accreditation Council for Graduate Medical Education were used. Analysis of covariance testing was used to assess interactions over time between groups. The proportion of female MFM fellows increased steadily from 17.1% in 1985 to 72.5% in 2016. The proportion of females grew more rapidly among the MFM fellows than obstetrics and gynecology (ob-gyn) residents (2.1 vs. 1.4% per year; p = 0.001) and among those who were active SMFM members than ACOG Fellows (1.4 vs. 1.2% per year; p = 0.013). Slightly more than half (52.4%) of all SMFM members are now female and will approach two-thirds (64.4%) by 2025 (compared with 53.4% in 2016 and 65.3% in 2025 of ACOG fellows). The rising proportion of female MFM fellows is directly related to the high number of female ob-gyn residents. Females comprise slightly more than half of all active SMFM members now and projected to approach two-thirds by 2025.

Attitudes and Perceptions of Healthcare Providers Regarding the Safe Reduction of the Cesarean Section [7C

INTRODUCTION: The American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) identified risk factors that increase the likelihood for a cesarean section (C/S). Analysis of these factors can aid in the safe reduction of the C/S rate within an institution. METHODS: Surveys comprised of clinical scenarios regarding the ACOG/SMFM C/S risk factors were sent to all providers within a hospital system. 250 surveys were analyzed using profession, experience, multiple hospital system exposure, and malpractice influence as outcome variables. Analysis was performed using Pearson correlation, Student's T-test, Chi-square Analysis, and Levene’s test. RESULTS: Baseline results showed that most C/S are done for category 2 fetal heart rate, about 40% of providers practice defensively, and that more providers are willing to speak up to a nurse, as compared to an attending. Significant findings showed that providers with a previous lawsuit are more likely to practice defensively (66.4% vs 47.8%, P-.002) and to speak up when they disagree with a care plan (80% vs 63%, P-.002). Nurses, as opposed to physicians, are more willing to wait during labor rather than support a C/S (91.6% vs 70%, P-.000), but are less likely to speak up (64.1% vs 79.6%, P-.006). More experienced providers are more likely to speak up (85.3% vs 57%, P-.000) and less likely to induce at 41 weeks (19.9% vs 31.5%, P-.021). CONCLUSION: These results suggest local risk factors that may be associated with increased C/S rates; this knowledge can be utilized to develop appropriate interventions to safely reduce the C/S rate.

The effect of hospital acuity on severe maternal morbidity in high-risk patients

In 2015, the Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists published guidelines that established levels of maternal care. These guidelines outlined the nursing, provider, and facility requirements for hospitals to be designated a birthing center or 1 of 4 levels of care. To date, these levels of maternal care have not been adopted widely; currently, no data exist on how these designations may affect maternal or neonatal outcomes. Because the levels of maternal care attempt to reflect a hospital's ability to treat patients with certain conditions that are associated with increased risk of complications, our objective was to compare outcomes among high- and low-risk patients between high- and low-acuity hospitals. We hypothesized that hospitals that cared for a high rate of high-risk patients, which we considered "high-acuity" centers, would have a lower risk of severe maternal morbidity among high-risk patients compared with low-acuity centers. Deliveries were identified in the 2013 Nationwide Readmission Database. A patient's comorbidity index was assigned based on diagnosis and procedure codes with the use of previously validated methods; a comorbidity index of ≥3 has been associated with increased odds of severe maternal morbidity. Patients were classified as low, intermediate, or high risk by their comorbidity index for analysis. Patients at hospitals with <100 deliveries per year and transferred patients were excluded. A hospital was defined as low or high-acuity if it was in the bottom or top quartile, respectively, based on its percent of patients with a comorbidity index of ≥3. Log-binomial regression models were constructed to assess the effects of a patient's comorbidity index group on the risk of severe morbidity in high- and low-acuity hospitals. The models controlled for available patient and hospital factors. The regression used patient-level data with robust standard errors that were clustered at the level of the hospital. The Wald test was used to assess for the effect modification between comorbidity index group and hospital acuity. From 1203 hospitals, 1,656,659 delivering patients met the inclusion criteria. There were 58.7% low-risk, 39.0% intermediate-risk, and 2.3% high-risk patients in the overall sample, and the overall rate of severe maternal morbidity was 1.2%. Less than 3.7% of delivering patients in low-acuity hospitals had a high-risk condition. In comparison, >7.1% patients in high-acuity centers had a high-risk condition. In the adjusted analysis, intermediate-risk patients had a slightly increased risk of morbidity in both low-acuity and high-acuity centers compared with low-risk patients (adjusted risk ratios, 1.53 [95% confidence interval, 1.33-1.77] vs 1.57 [95% confidence interval, 1.49-1.65]). However, there was a notable difference in the adjusted risk ratios for severe maternal morbidity in the high-risk population: the adjusted risk ratio was 9.55 (95% confidence interval, 6.83-13.35) in low-acuity hospitals compared with 6.50 (95% confidence interval, 5.94-7.09) in high-acuity hospitals. High-risk patients have a higher risk of severe maternal morbidity at low-acuity hospitals compared with high-acuity centers. These findings support the concept of regionalization of maternity care to improve outcomes for high-risk patients.

Maternal-Fetal Medicine Workforce Survey: Are We Ready for Regionalized Levels of Maternal Care?

To conduct a survey of the members of the Society for Maternal-Fetal Medicine (SMFM) to determine the practice patterns of maternal-fetal medicine (MFM) subspecialists in the United States and to estimate the likelihood that our work force is sufficient to support the proposed MFM staffing requirements for level III and IV maternity centers. All regular SMFM members in the United States were invited to answer a 26 question survey by email. The survey queried demographic characteristics, practice type, night call arrangements, and whether the respondent's hospital was currently equipped with the services and personnel described in the requirements for level III or IV centers. Of the MFM specialists working full time in what would be considered a level III or IV maternity center, only 47.5% took in-house call. Of those taking only call from home or back-up call, the majority reported that during call hours, MFM antepartum and laboring patients are cared for by generalist obstetrician gynecologists; only 6.4% work with MFM hospitalists. Respondents from level III or IV centers also reported that many of their centers did not meet the criteria for nursing support, anesthesia support, or intensive care services. These data, if confirmed, indicate that work needs to be done to upgrade services and achieve appropriate staffing to meet the proposed level III and IV criteria for maternity care.

Chromosomal microarray analysis as the first-tier clinical diagnostic test for miscarriage analysis

Despite the high failure rate and inherent limitations of conventional cytogenetic/karyotype analysis for products of conception samples (POCs) and high success rate and diagnostic benefits of chromosomal microarray analysis (CMA), testing of this sample type by CMA remains low. This underutilization may be due to a lack of awareness of the technology's diagnostic power, and more importantly, lack of clear opinions or recommendations in support of this testing by professional committees, such as The American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM). We undertook a retrospective analysis of over 13 thousand consecutive POCs evaluated by CMA with the purpose of determining analytical success, failure rates, and frequency/rates of causative and non-causative abnormalities. In addition, potential challenges, either sample-related or test-related, were cataloged. Materials and Methods Of the 13,711 cases received for evaluation by CMA, 12,324 were successfully analyzed and reported (90%); 83% of samples were ascertained for recurrent pregnancy loss (RPL) or spontaneous abortion (SAB). About 78% of samples were fresh and 21% of samples were FFPE. The majority of samples (88%) were analyzed by whole-genome SNP-based CMA allowing detection of whole chromosome or segmental copy number changes (greater than 20kb; and greater than 5% mosaicism), triploidy, whole-genome uniparental isodisomy (molar pregnancy), and maternal cell contamination. In 54% (6665/12324) of cases, a clinically significant abnormality was identified, and over 96% of those abnormalities were deemed causative of the pregnancy loss. Normal results were obtained in 44% of cases, and variants of uncertain significance (VOUS) were detected in the remaining2% of cases. The most common abnormalities detected were autosomal trisomies (single trisomy, 62%; multiple trisomies, 4%), triploidy (12%), molar pregnancy (1%) and monosomy X (11%). Autosomal monosomies were rare (<1% of cases). Clinically significant segmental deletions and duplications were detected in 4.6% cases. This data shows the continued diagnostic value of CMA for the evaluation of POCs and further supports its use for miscarriage analysis. The success rates and diagnostic power in providing a high resolution genome-wide evaluation of POCs for causative abnormalities should be the primary determining factors for the establishment of recommendations or guidelines for routine genetic evaluation of RPL and SAB. Unfortunately, recommendations for miscarriage analysis by CMA remain unclear. As seen in this large, retrospective study, the high success rate (90%) and the ability to provide a causative genetic diagnosis for over 50% of samples make CMA the best testing option for POCs and support its use as the first-tier diagnostic test for evaluation of all miscarriages.

ACOG and SMFM guidelines for prenatal diagnosis: Is karyotyping really sufficient?

What's already known about this topic? Current professional guidelines regarding the use of chromosomal microarray analysis (CMA) versus karyotyping in prenatal diagnosis support CMA over karyotype only when fetal structural abnormalities are present.Examination of the clinical utility of these guidelines, given advances in microarray technology and prenatal screening, is largely unaddressed. What does this study add? This study demonstrates the diagnostic superiority of CMA by SNP microarray compared with karyotyping for prenatal diagnosis, regardless of the clinical indication for testing.

Conflict of interest related to clinical practice is underreported: The case of noninvasive prenatal testing.

Authors of policy statements from the American College of Obstetricians and Gynecologists and from the Society for Maternal-Fetal Medicine do not acknowledge the potential for their clinical income to influence their opinions, or the positions of the societies they represent. These policy statements were published in Obstetrics and Gynecology and the American Journal of Obstetrics and Gynecology, again, without acknowledgment of the potential for conflict of interest. The case of noninvasive prenatal testing, which has threatened the role of maternal-fetal medicine in the practice of prenatal screening and diagnosis, and has significantly reduced the demand for invasive prenatal diagnosis, illustrates the importance of identifying this potential conflict.

Maternal Death Due to Amniotic Fluid Embolism: A National Study in France.

A structured definition of amniotic fluid embolism (AFE) based on 4 criteria was recently proposed for use in research by the Society for Maternal-Fetal Medicine (SMFM) and the Amniotic Fluid Embolism Foundation. The main objective of this study was to review all AFE-related maternal deaths in France during 2007-2011 according to the presence or not of all these 4 diagnostic criteria. Maternal deaths due to AFE were identified by the national experts committee of the French Confidential Enquiry into Maternal Deaths during 2007-2011 (n = 39). The maternal mortality ratio for AFE was calculated. We applied the structured definition proposed by the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation to AFE-related maternal deaths identified by the national experts committee. Characteristics of women, pregnancies and deliveries; clinical and biological features of AFE; and specific laboratory tests used were described by the presence or not of all 4 diagnostic criteria. Management of obstetric hemorrhage and quality of care according to the experts were also described. The maternal mortality ratio from AFE was 0.95/100,000 live births (95% confidence interval, 0.67-1.3). Detailed clinical data were collected for 36 women who died from AFE: 21 (58%) had all 4 proposed diagnostic criteria and 15 (42%) had 1 or more missing criterion. Documented early disseminated intravascular coagulopathy was missing for 14 women, and 2 women exhibited more than 1 missing criterion. Ten of the 15 women with missing criteria had clinical coagulopathy, with standard hemostasis tests performed in only 3. Specific diagnostic examinations for AFE were performed in similar proportions by the presence or not of all diagnostic criteria. Opportunities to improve care included timely performance of indicated hysterectomy (n = 13) and improved transfusion practices (n = 9). In the context of maternal cardiac arrest, for 5 of 13 women, fetal extraction was performed within 5 minutes. The structured definition of AFE for research studies would exclude more than one-third of AFE-related maternal deaths identified by the national experts committee. Inclusion of clinical coagulopathy as a diagnostic criterion for AFE would reduce this proportion to 14%. There is still room for improvement in the management of obstetric hemorrhage and timely fetal extraction in the context of maternal cardiac arrest, frequently observed in AFE-related maternal death.

645: Females in maternal-fetal Medicine: A 32 year perspective

The proportions of residents and practitioners in obstetrics and gynecology (ob-gyn) who are female have increased in the past 30 years. The objective of this study was to examine trends in gender representation in maternal-fetal medicine (MFM) fellowships and in active practice for this time period. This observational study involved an examination of complete sets of MFM fellows and active members in the Society for Maternal-Fetal Medicine (SMFM) between 1985 (when accurate record keeping began) and the most recent year, 2016. Databases from SMFM, American College of Obstetricians and Gynecologists (ACOG), and Accreditation Council for Graduate Medical Education (ACGME) were utilized. ANCOVA testing was used to assess the relationship between groups over time. The proportion of MFM fellows who were female increased steadily from 17.1% in 1985 to 72.5% in 2016. This graduak progression was similar for ob-gyn residents, with a time-lag reflecting the length of residency training. The proportion of females rose more among the MFM fellows than residents (2.1% vs. 1.4% per year; p < .001). More than half of all MFM fellows who were female began in 2003. The proportion of females also grew slightly more among those who were SMFM members than ACOG Fellows (1.4% vs. 1.2% per year; p = .013). More than half of all SMFM members and ACOG Fellows are now female (52.4% and 53.5%, respectively). The rising proportion of MFM fellows who are female is directly related to the increasing number of female ob-gyn residents over the past 32 years. Females now comprise more than half of all SMFM members and ACOG Fellows. These findings have implications for career development of MFM subspecialists in the future.

Joint Position Statement from the International Society for Prenatal Diagnosis (ISPD), the Society for Maternal Fetal Medicine (SMFM), and the Perinatal Quality Foundation (PQF) on the use of genome-wide sequencing for fetal diagnosis.

Joint Position Statement from the International Society for Prenatal Diagnosis (ISPD), the Society for Maternal Fetal Medicine (SMFM), and the Perinatal Quality Foundation (PQF) on the use of genome-wide sequencing for fetal diagnosis.

Bilateral salpingectomy to reduce the risk of ovarian/fallopian/peritoneal cancer in women at average risk: a position statement of the Korean Society of Obstetrics and Gynecology (KSOG).

Based on the current understanding of a preventive effect of bilateral salpingectomy on ovarian/fallopian/peritoneal cancers, the Korean Society of Obstetrics and Gynecology, Korean Society of Gynecologic Endocrinology, Korean Society of Gynecologic Oncology, Korean Society of Maternal Fetal Medicine, and Korean Society for Reproductive Medicine support the following recommendations:• Women scheduled for hysterectomy for benign gynecologic disease should be informed that bilateral salpingectomy reduces the risk of ovarian/fallopian/peritoneal cancer, and they should be counseled regarding this procedure at the time of hysterectomy.• Although salpingectomy is generally considered as a safe procedure in terms of preserving ovarian reserve, there is a lack of evidences representing its long-term outcomes. Therefore, patients should be informed about the minimal potential of this procedure for decreasing ovarian reserve.• Prophylactic salpingectomy during vaginal hysterectomy is favorable in terms of prevention of ovarian/fallopian/peritoneal cancer, although operation-related complications minimally increase with this procedure, compared to the complications associated with vaginal hysterectomy alone. Conversion to open or laparoscopic approach from vaginal approach to perform prophylactic salpingectomy is not recommended.• Women who desire permanent sterilization at the time of cesarean delivery could be counseled for prophylactic salpingectomy before surgery on an individual basis.

SMFM 2018 Pregnancy Meeting: Looking Ahead to the Scientific Program (Podcast)

In this supplemental episode, Dr. William Goodnight talks to Dr. Cynthia Gyamfi-Bannerman, Scientific Forum Chair, to discuss the upcoming Society for Maternal Fetal Medicine 2018 Annual Pregnancy Meeting.

Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes: Executive Summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Maternal-Fetal Medicine, Centers for Disease Control and Prevention, and the March of Dimes Foundation.

Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes: Executive Summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Maternal-Fetal Medicine, Centers for Disease Control and Prevention, and the March of Dimes Foundation.

643: Readability of online patient materials from major obstetrics organizations

To assess the readability of obstetrics-related patient education materials from major obstetric organizations and adherence with national recommendations. All online obstetrics-related patient education materials from the websites of the American Academy of Family Physicians, American College of Nurse-Midwives, American Congress of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, and UpToDate were reviewed. Educational materials were excluded if they were not written in English or were not free, the material was only presented in a pictorial, table, video, or hyperlink format, if the content had insufficient text to analyze, or they were not intended for women in the United States. Patient readability was determined using the Flesch-Kincaid Grade Level. To assess adherence with the readability recommendations put forth by the American Medical Association and the National institutes of Health, the percentage of articles written below sixth-grade level was calculated for each organization. The percent of educational materials written below eighth-grade level was also determined given this is the average reading level in the United States. Two hundred and thirty-two obstetrics-related patient education materials from five organizations were reviewed. The median number of patient education materials per organization was 55 (range 12-60). The median reading level was 8.1 (range 2.2-17.2) with 3% and 45% of patient educational materials written below the sixth- and eighth-grade reading level, respectively. Online obstetric patient education materials from most national organizations are written at a level above what is expected for the average patient. These medical organizations provide reliable and accessible information for providers and patients but often deliver content above the recommended level of readability. Ongoing efforts to improve delivery of understandable patient educational materials are needed.