Chaur-Dong Hsu

Reduction and sustainability of cesarean section surgical site infection: An evidence-based, innovative, and multidisciplinary quality improvement intervention bundle program

BACKGROUND We found cesarean section (C-section) surgical site infection (SSI) at our institution was significantly higher than the national benchmark. METHODS A retrospective cohort study was conducted under 4 phases from January 2008-December 2014. The hospital infection control (IC) policies and a presurgical checklist were bundled and implemented. The study was conducted with 3,334 cesarean deliveries: phase A (January 1, 2008-January 31,2010): 1,250 patients without intervention (baseline SSI rate), phase B (February 1, 2010-July 31, 2011): 682 patients were intervened with IC policies, phase C (August 1, 2011-December 31, 2012): 591 patients with an SSI reduction bundle, and phase D (January 1, 2013-December 31, 2014): 811 patients were monitored for C-section SSI sustainability. Patients not following strict protocols because of emergency C-section deliveries were excluded. The χ2 test, Fisher exact test, and standard Z test were used for statistical analyses. RESULTS C-section SSI rates were 6.2% (77/1,250) in phase A, 3.7% (25/682) in phase B, 1.7% (10/591) in phase C, and 0.1% (1/811) in phase D, respectively. By implementing the IC policies and bundle, the C-section SSI rate was reduced 40.3% (phase B vs phase A), 72.6% (phase C vs phase A), and 98.4% (phase D vs phase A). All statistics were significantly different. CONCLUSIONS We conclude that implementing a C-section SSI reduction bundle was associated with reduced C-section SSI rate down toward zero. A future prospectively randomized controlled trial is warranted.

Are placental Fas and Fas ligand gene polymorphisms associated with preeclampsia

INTRODUCTION Increased placental trophoblastic apoptosis has been reported in pregnancies complicated by preeclampsia. Fas-Fas ligand is one of the major signal transduction pathways of apoptosis. OBJECTIVES To determine if placental Fas and Fas ligand gene polymorphisms differ between patients with and without preeclampsia. METHODS Forty-five singleton placentas were studied. Twenty-three placentas were from preeclamptic pregnancies and 22 were from normotensive controls. The study was approved by IRB. Genotyping was performed for Fas-1377, Fas-691, Fas-670, Fas ligand-844, Fas ligand-1174, Fas ligand-2777. Chi-square and Fishers exact tests were used for statistical analysis. RESULTS There were no significant differences in maternal age, parity or race between the two groups. There were no significant differences in genotypes or allele frequencies for the placental Fas-1377, Fas-691, Fas-670, Fas ligand-844, Fas ligand-1174 and Fas ligand-2777. CONCLUSION Immune intolerance of maternal and placental interaction plays an important role in the pathogenesis of preeclampsia. Our findings do not support the role of placental Fas and Fas ligand gene polymorphisms in the pathogenesis of preeclampsia. The heterogeneous and complex etiology of preeclampsia makes it unrealistic to expect a single nucleotide polymorphism to explain the pathogenesis of this pregnancy complication. This relatively understudied area warrants further investigation.

PP128. Placental Caspase-3 gene polymorphisms is associated with preeclampsia

INTRODUCTION Increased placental trophoblastic apoptosis (programmed cell death) was previously reported in pregnancies complicated by preeclampsia. Caspase-3 is one of the key executioners of apoptosis. Caspase are expressed in many tissues including human placental trophoblast and other tissues. Variations in the promoter area of the Caspase genes may modulate apoptotic signaling, contributing to an increased risk of preeclampsia OBJECTIVES To determine if gene polymorphisms of Caspase 3 proteins differ between patient with and without preeclampsia. METHODS Forty-three singleton placentas were studied. Twenty-two placentas were with preeclampsia and 21 were normotensive controls. DNA was extracted from placentas using QIAAmp DNA Minikit. Genotyping of Caspase 3 +567 was determined by real-time PCR using the Applied Biosystems Prism 7900 HT SDS machine. Chi-square and Fishers exact tests were used for statistical analysis. RESULTS There were no significant differences in maternal age, parity or race between the two groups. Preeclamptic placentas had higher frequency of wild type TT of Caspase-3 SNP (+567) as compared with normotensive controls (59% versus 28.5%). Preeclamptic placentas expressed significantly more genotype of TT of Caspase-3 SNP (+567) than normotensive patients when compared to CC (p=0.02). The alle frequencies of the Caspase SNP (+567) in preeclampstic placentas were 0.77 and 0.23 for T and C, respectively, as compared to 0.52 and 0.48, respectively, in placentas from normotensive pregnancies. CONCLUSION Immune intolerance of maternal and placental interaction plays an important role in the pathogenesis of preeclampsia. Increased of placental apoptosis was reported in pregnancy complicated with preeclamsia. Our findings indicate placental Caspase 3 (+567) gene polymorphisms is associated with preeclampsia. Altered placental alle frequencies and caspase-3 SNP (+567) in preeclampsia further suggests preeclampsia is a trophoblastic disorder.

Prenatal Diagnosis using Fetal Genetic Material in Maternal Circulation

Summary In this paper, we review the major highlights in the development of clinical noninvasive prenatal diagnostic approaches analyzing fetal genetic material recovered from maternal circulation.

Evidence-Based Approach to Reduce Surgical Site Infections After Cesarean Delivery

INTRODUCTION: The objective of this study was to determine if implementing infection control policies and an evidence-based checklist would reduce surgical site infection rate after cesarean delivery and identify which surgical site infection Centers for Disease Control and Prevention (CDC) classification will improve the most. METHODS: Infection control policies and a presurgical checklist of seven different evidence-based practices (ie, chlorhexidine, etc) were bundled and implemented at our institution. This is a retrospective chart review of 2,436 patients who had cesarean deliveries from January 2008 to September 2012. Patients were allocated into: group A (January 1, 2008, to January 31, 2010): 1,250 patients without intervention, group B (February 1, 2010, to September 31, 2012): intervention with checklist including 1,186 patients. Patients with surgical site infections were identified and then subdivided into CDC classifications: superficial incisional (SSI-1), deep incisional (SSI-2), and organ or space (SSI-3). Groups and surgical site infection subgroups were compared with &khgr;2 test, Fishers exact test, and standard Z test for statistical analyses. RESULTS: Our baseline surgical site infection rate after cesarean delivery was 6.2% with most infections being SSI-1 (84%) followed by SSI-3 (10.4%) and SSI-2 (5.2%). By implementing the checklist, the surgical site infection rate was 3.0%, a 51.61% reduction. If broken down into surgical site infection CDC classifications, we observed a 61.54% decrease in SSI-1 and 34.68% in SSI-3; SSI-2 had no reduction (Table 1). Implementation of our checklist can potentially reduce 95.92% of surgical site infections. Table 1 Surgical Site Infections After Cesarean Delivery: Incidence and Reduction Percentages CONCLUSIONS: Our evidence-based checklist effectively reduces the incidence of surgical site infections after cesarean deliveries. Most SSIs are SSI-1, primarily decreased with the checklist. The checklist did not affect deep incisional infections (SSI-2). Research geared toward identifying risk factors may be useful in establishing best practices to further decrease SSI-2.

Characteristics associated with postoperative diagnosis of adenomyosis or combined adenomyosis with fibroids

To identify clinical characteristics associated with combined adenomyosis and fibroids and to determine whether preoperative diagnosis by ultrasonography correlates with postoperative diagnosis by pathology.

Comparing transabdominal and transvaginal ultrasound-guided follicular aspiration: A risk assessment formula

OBJECTIVE We sought to identify patients at risk of incomplete transvaginal oocyte retrieval, develop a risk assessment formula to identify patients who would benefit from a transabdominal approach, and compare complication and pregnancy rates between these two approaches. MATERIALS AND METHODS In this retrospective case control study in a private in vitro fertilization center, 95 cases of women undergoing transabdominal follicular aspiration for oocyte retrieval (15 transabdominal only and 80 transabdominal and vaginal combined) were compared with 278 controls of women undergoing the transvaginal aspiration only. Transabdominal oocyte retrieval was performed when one or more ovaries could not be retrieved via the transvaginal approach. Main study outcomes included need for transabdominal retrieval, pregnancy rates, and complications. RESULTS A risk assessment scoring system was developed as follows: difficulty seeing ovaries on ultrasound (+4), history of pelvic surgery (+3), and body mass index of 30 kg/m(2) or greater (+2). With a cutoff score of 4 or greater, the overall sensitivity is 75%, specificity is 80%, positive predictive value is 57%, and negative predictive value is 90%. No statistically significant differences were found for pregnancy rates or complications. CONCLUSION The transabdominal approach is an alternative option that would increase the total number of oocytes retrieved with no statistical difference in complication or pregnancy rates. We also developed a scoring system that can serve as a useful screening tool for identifying women at increased risk of transabdominal oocyte retrieval.

PP079. Evidence of placental and vascular endothelial apotosis and dysfunction by elevated serum human chorionic gonadotropin, soluble selectin and soluble Fas in HELLP syndrome.

INTRODUCTION The etiology of Hemolysis, Elevated Liver enzyme, and Low Platelets (HELLP) syndrome remains unknown. We hypothesized that placental and vascular endothelial apoptosis and dysfunction might be the pathogenesis of HELLP syndrome. OBJECTIVES To determine maternal serum levels and association among human chorionic gonadotropin (hCG), soluble Fas (sFas), and E-selectin (sE-selectin) in HELLP syndrome. METHODS Forty-two singleton pregnant women were studied. Fourteen patients were with HELLP syndrome and 28 patients were healthy gravidas. The serum levels of total beta-hCG, sFas, and sE-selectin were measured by enzyme-linked immunoassays. Mann-Whitney test and Spearman rank correlation were used for statistical analyses. Data were expressed as median and ranges. P value less than 0.05 is considered statistically significant. RESULTS There were no significant differences in maternal age, gestational age, parity or race in patients with and without HELLP syndrome. The median levels of serum total beta-hCG, sFas, and sE-selectin were significantly higher in women with HELLP syndrome than in healthy gravidas {total beta-hCG: 52,168 (14,936-213,445)mIU/mL vs. 17,942 (966-176,600)mIU/mL, p=0.016; sFas: 8.20 (3.0-22.6)U/ml vs. 5.8 (1.2-18.5)U/ml, p=0.001; sE-selectin: 107.7 (26.2-194.7)ng/mL vs. 23.0 (11.1-107.7)ng/mL, p<0.0001}. Moreover, serum total beta-hCG levels were significantly correlated with serum sFas (r=0.32, p=0.039) and sE-selectin levels (r=0.32, p=0.038). Serum sFas levels were also significantly correlated with serum sE-slectin (r=0.47, p=0.003) CONCLUSION: Our data suggest that placental and vascular endothelial apoptosis in preeclampsia may further lead to placental and endothelial dysfunction as the possible pathogenesis in HELLP syndrome.