Catherine M. Albright

The Sepsis in Obstetrics Score: a model to identify risk of morbidity from sepsis in pregnancy

OBJECTIVE We sought to design an emergency department sepsis scoring system to identify risk of intensive care unit (ICU) admission in pregnant and postpartum women. STUDY DESIGN The Sepsis in Obstetrics Score (S.O.S.) was created by modifying validated scoring systems in accordance with recognized physiologic changes of pregnancy. The S.O.S. was applied to a retrospective cohort of pregnant and postpartum patients from February 2009 through May 2011 with clinical suspicion of sepsis. The primary outcome was ICU admission. Secondary outcomes were telemetry unit admission, length of stay, positive blood cultures, positive influenza swabs, perinatal outcome, and maternal mortality. Receiver operating characteristic curves were constructed to estimate the optimal score for identification of risk of ICU admission. RESULTS In all, 850 eligible women were included. There were 9 ICU (1.1%) and 32 telemetry (3.8%) admissions, and no maternal deaths. The S.O.S. had an area under the curve of 0.97 for ICU admission. An S.O.S. ≥6 (maximum score 28) had an area under the curve of 0.92 with sensitivity of 88.9%, specificity of 95.2%, positive predictive value of 16.7%, and negative predictive value of 99.9% for ICU admission, with an adjusted odds ratio of 109 (95% confidence interval, 18-661). An S.O.S. ≥6 was independently associated with increased ICU or telemetry unit admissions, positive blood cultures, and fetal tachycardia. CONCLUSION A sepsis scoring system designed specifically for an obstetric population appears to reliably identify patients at high risk for admission to the ICU. Prospective validation is warranted.

Surgical aspects of removal of Essure microinsert

Essure is designed as a hysteroscopically placed permanent birth control. Removal of the Essure microinsert can be a technically challenging procedure. Requests for removal are uncommon but do occur. Although hysteroscopic and laparoscopic removal has been reported, there is limited information available describing appropriate surgical technique. There have been six patients requesting Essure removal at our institution (one approximately 2 years after placement). Based on this experience, we have developed specific counseling points and surgical principles for laparoscopic removal: avoid injection of a hemostatic solution into the fallopian tube; avoid excessive traction on the coils; avoid cauterization of the outer coil; follow the Essure coil into the interstitial end of the fallopian tube to ensure complete removal of the insert; perform a salpingectomy rather than a salpingostomy. By taking into account these principles, key preoperative counseling points can be discussed, and laparoscopic Essure removal years after placement can be accomplished in a safe and deliberate fashion.

Adhesion barriers at cesarean delivery: advertising compared with the evidence.

Cesarean delivery, the most common surgery performed in the United States, is complicated by adhesion formation in 24-73% of cases. Because adhesions have potential sequelae, different synthetic adhesion barriers are currently heavily marketed as a means of reducing adhesion formation resultant from cesarean delivery. However, their use for this purpose has been studied in only two small, nonblinded and nonrandomized trials, both of which were underpowered and subject to bias. Neither demonstrated improvement in meaningful clinical outcomes. In the only cost-effectiveness analysis of adhesion barriers to date, the use of synthetic adhesion barriers was cost-effective only when the subsequent rate of small bowel obstruction was at least 2.4%, a rate far higher than that associated with cesarean delivery. In fact, intra-abdominal adhesions from prior cesarean delivery rarely cause maternal harm and have not been demonstrated to adversely affect perinatal outcome. Based on our review of the available literature, we think the use of adhesion barriers at the time of cesarean delivery would be ill-advised at the present time.

Cost savings of red cell salvage during cesarean delivery.

OBJECTIVE: To use decision analysis to evaluate whether and under what conditions routine setup of intraoperative cell salvage during cesarean delivery is cost-saving. METHODS: We developed a decision model to compare costs associated with two strategies for cesarean delivery: 1) routine setup of intraoperative cell salvage; or 2) standard care without intraoperative cell salvage. One-, two-, and three-way sensitivity analyses as well as Monte Carlo simulation were used to assess the robustness of our findings. RESULTS: Among nonselected women undergoing cesarean delivery, our base case estimate was that 3.2% would require red blood cell transfusion. Under this assumption, cell salvage is cost-saving only if each woman requires at least 60 units. Conversely, if only two units on average are required, the probability of transfusion needs to be at least 58% for cell salvage to be cost-saving. In our base case analysis, setup of intraoperative cell salvage during routine cesarean deliveries is not cost-saving, increasing the cost per cesarean delivery by

Malignancies in pregnancy

223.80. We found that cell salvage would be cost-saving only in very high-risk scenarios. For example, severe maternal anemia or abnormal placentation, in which 54% and 75% of women are transfused three and two units per case, respectively, would make cell salvage cost-saving. CONCLUSION: Setup of intraoperative cell salvage during cesarean delivery is cost-saving and should be considered only when there is a predictably high probability of transfusion or when a massive transfusion is reasonably likely.

Third-Trimester Prenatal Syphilis Screening: A Cost-Effectiveness Analysis.

Malignancy complicating pregnancy is fortunately rare, affecting one in 1000 to one in 1500 pregnancies. Optimal treatment involves balancing the benefit of treatment for the mother while minimizing harm to the fetus. This balance is dependent on the extent of the disease, the recommended course of treatment, and the gestational age at which treatment is considered. Both surgery and chemotherapy are generally safe in pregnancy, whereas radiation therapy is relatively contraindicated. Iatrogenic prematurity is the most common pregnancy complication, as infants are often delivered for maternal benefit. In general, however, survival does not differ from the nonpregnant population. These patients require a multidisciplinary approach for management with providers having experience in caring for these complex patients. The aim of this review was to provide an overview for obstetricians of the diagnosis and management of malignancy in pregnancy.

Perinatal outcomes with normal compared with elevated umbilical artery systolic-to-diastolic ratios in fetal growth restriction.

OBJECTIVE: To estimate the cost to prevent one case of congenital syphilis or fetal or neonatal death with universal third-trimester syphilis rescreening in the United States and to estimate the incidence of syphilis seroconversion at which rescreening becomes cost-effective. METHODS: We created a decision model comparing universal third-trimester syphilis rescreening in women who screened negative in the first trimester with no rescreening. The assumed base case incidence of seroconversion was 0.012%. The primary outcome was the cost to prevent one case of congenital syphilis. Secondary outcomes included the cost to prevent one fetal or neonatal death and the number needed to rescreen to prevent one adverse outcome. A strategy was considered cost-effective if it cost less than

Use of Cefazolin for Group B Streptococci Prophylaxis in Women Reporting a Penicillin Allergy Without Anaphylaxis

285,000 to prevent one case of congenital syphilis (the estimated long-term care cost). RESULTS: Under our assumptions, universal third-trimester rescreening would cost an additional

Lactic acid measurement to identify risk of morbidity from sepsis in pregnancy.

419,842 for each case of congenital syphilis prevented and

Relation of QRS shortening to cardiac output during temporary resynchronization therapy after cardiac surgery.

3,621,144 and