Collin Miller

Tension compared to no tension on a Foley transcervical catheter for cervical ripening: a randomized controlled trial

BACKGROUND: Cervical ripening of an unfavorable cervix can be achieved by placement of a transcervical catheter. Advantages of this method include both lower cost and lower risk of tachysystole than other methods. Despite widespread use with varying degrees of applied tension, an unanswered question is whether there is an advantage to placing the transcervical catheter to tension compared with placement without tension. OBJECTIVE: The purpose of this study was to determine whether tension placed on a transcervical balloon catheter that is inserted for cervical ripening results in a faster time to delivery. STUDY DESIGN: This was a prospective, randomized controlled trial; 140 women who underwent cervical ripening (Bishop score, ≤6) were assigned randomly to a balloon catheter with applied tension vs no tension. Tension was created when the catheter was taped to the patients thigh and tension was reapplied in 30‐minute increments. There were 67 patients in the tension group and 73 patients in the no tension group. Low‐dose oxytocin (maximum, 6 mU/min) was administered after catheter placement. The primary outcome was time from catheter insertion to delivery. A secondary outcome was time from insertion to catheter expulsion. The Kolmogorov‐Smirnov test was used to determine whether the data were distributed normally. Survival curves that used lifetables were constructed from time of catheter insertion to delivery and from time of catheter insertion to catheter expulsion and were compared with the use of the Wilcoxon (Gehan) Breslow statistic. A probability value of <.05 was set to denote statistical significance. RESULTS: Baseline characteristics were similar between groups. The median time from catheter insertion to delivery was not significantly different between the tension group and the no tension group (16.2 vs 16.9 hours; P=.814). The median time from catheter insertion to expulsion, however, was significantly less in the tension group vs the no tension group (2.6 vs 4.6 hours; P<.001), respectively. Vaginal delivery within 24 hours was not significantly different between the tension and no tension groups (41/52 [79%] vs 37/52 [71%]; P=.365) nor were there significant differences in cesarean delivery rates between the tension and no tension groups (17/67 [25%] vs 27/73 [37%]; P=.139). CONCLUSION: Application of tension did not result in faster delivery times but did result in faster times to catheter expulsion.

Obstetricians' views on the ethics of cardiac surgery for newborns with common aneuploidies

To examine whether obstetricians think that cardiac surgery is ethical in babies with common aneuploidies and whether insurance companies should be required to pay for these surgeries.

Impact of Clinical Pharmacy on Asthma in Pregnancy in a Maternal-Fetal Care Clinic A Pilot Study

Background: Asthma complicates 4% to 8% of pregnancies. The impact of clinical pharmacists providing asthma management and education to obstetric patients is unknown. Objective: Evaluate the impact of and patient satisfaction with clinical pharmacy services on asthma in pregnancy. Methods: This prospective quasi-experimental study enrolled 30 pregnant patients with asthma and assessed perceived asthma understanding, control, and inhaler technique before and after a clinical pharmacist visit and education. The primary outcome was change in pre- and postsurvey scores. Items were rated on a 5-point Likert-type scale; higher scores represented higher perceived knowledge or satisfaction. Secondary outcomes included inhaler technique scores, asthma control, correlating patient-specific factors with the primary outcome, and level of patient satisfaction with clinical pharmacy services. Results: Perceived knowledge of asthma in pregnancy median score (maximum score 50) significantly increased with clinical pharmacy education (37.5 pre vs 49 post, P = .001). Prior to clinical pharmacy services, patients highly rated their perceived knowledge of asthma in pregnancy with median scores on 7 of 10 items between 4 and 5. Despite this, significant changes were observed on 9 items. The proportion of patients with controlled asthma significantly increased after the pharmacist visit (33.3% vs 90%, P < .001). Satisfaction with clinical pharmacy services was overwhelmingly positive with average scores on all items 4.5 to 5. Inhaler technique scores significantly increased from baseline to follow-up (4 vs 7, P = .001). Conclusions: Pharmacists significantly improved patient perceived knowledge about asthma, asthma control, and inhaler technique. Patients were overwhelmingly satisfied with the care provided by the pharmacist.

Smoking Cessation Following Text Message Intervention in Pregnant Women

Background: Smoking during pregnancy has detrimental effects on mother and fetus. Text messaging has been utilized to improve patient care. Objective: To evaluate the impact of text messaging on smoking cessation rates among pregnant women in addition to standard of care (SOC) smoking cessation services. Our SOC includes pharmacist-driven education with or without nicotine patch or bupropion. Methods: This randomized, open-label, prospective trial was conducted at a maternal fetal care center from May 2014 to January 2016. Pregnant patients in the preparation stage of change were randomized to text messaging or SOC. The primary outcome was smoking cessation verified with exhaled carbon monoxide levels (eCO) 2 weeks from quit date. All received clinical pharmacist weekly calls for 3 weeks and biweekly visits until pharmacotherapy completion. The text messaging group also received predetermined motivational messages. Results: Of 49 randomized patients, 13 withdrew, and 6 were lost to follow-up. The remaining included 14 texting and 16 SOC patients. eCO-verified cessation was achieved by 57.1% in the texting group versus 31.3% in the control (P = 0.153). Overall, 64.3% of the texting group achieved an eCO below 8 ppm at ≥1 visit versus 37.5% in the control group (P = 0.143). No difference was found in birth outcomes. The study was underpowered because of slow enrollment and high drop-out rates. Conclusions and Relevance: Text messaging had minimal impact on improving smoking cessation rates in the obstetric population. However, further research is warranted because of the underpowered nature of this trial. Given the detrimental effects of smoking in pregnancy, more comprehensive cessation strategies are warranted.

Administration Rates of the Tdap Vaccine in Obstetric Patients

Background: Infants younger than 6 months of age are at high risk for contracting pertussis because of not being fully vaccinated. The Advisory Committee on Immunization Practices (ACIP) recommends vaccinating all pregnant women with tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) between 27 and 36 weeks to offer passive immunity to the infant to help protect them until they are able to receive the full pertussis series. Objective: To assess and compare compliance with the 2013 ACIP recommendation of vaccinating pregnant women with Tdap at 27 to 36 weeks’ gestation in 2 obstetric clinics. Methods: This cross-sectional, retrospective chart review evaluated Tdap vaccine compliance in a random sample of obstetric patients from October 2013 to September 2014. The primary outcome evaluated the proportion of patients who received Tdap between 27 and 36 weeks’ gestation. Secondary outcomes included the proportion of patients who received Tdap at any point in pregnancy and within 30 days postpartum. Results: The charts of 573 patients were reviewed, and 237 met inclusion criteria. For the primary outcome, 142 patients (59.9%) received the Tdap vaccine. Overall, 156 patients (65.8%) received Tdap at some point during the pregnancy. Factors associated with receiving the Tdap vaccination were insurance status, prenatal care risk level and site of prenatal care, receipt of the influenza vaccine, and preterm labor in the current pregnancy. Conclusion: The Tdap vaccine rate was 65.8%, with 59.9% of patients receiving the vaccine within the recommended ACIP timeframe. Further education, improvements in documentation, and chart reminders are needed to enhance administration.

Physician Satisfaction With Clinical Pharmacist Services in an Obstetrics and Gynecology Teaching Clinic

Objective: To evaluate physician satisfaction with clinical pharmacy services in an obstetrics teaching clinic. Study Design: A 35-question survey was created to evaluate demographics and provider satisfaction with clinical pharmacy services using 5-point Likert scale and open response questions. Surveys were administered to all clinic attendings, maternal fetal medicine fellows, and OB/Gyn residents in June 2014 via Survey Monkey. Results: Thirty-one physicians (83.8%) completed the survey. The first set of questions utilized a 5-point Likert-type scale ranging from “poor” (1) to “excellent” (5) and evaluated respondents’ impressions of the clinical pharmacists’ clinical knowledge and professional behavior. The median score was 5 (“excellent”) on all items in the survey, and many demonstrated an average response of 4.81 to 4.9 or higher, demonstrating that almost all respondents chose “excellent.” The next set of questions assessed the clinical pharmacist’s role with the clinic’s multidisciplinary team and asked respondents to answer questions based on a 5-point Likert-type scale ranging from “strongly disagree” (1) to “strongly agree” (5). The majority of responses to questions in this section were between 4.19 and 4.84. Reasons for referring patients to the clinical pharmacist were smoking cessation, asthma management, psych medication use/issues, adherence/polypharmacy, medication reconciliation, counseling on medication safety in pregnancy, insulin/heparin administration, and substance abuse. Conclusions: Overall, the survey identified a positive response and high level of physician satisfaction with clinical pharmacy services. Clinical pharmacy has the capacity to enhance pregnancy care and should be more routinely integrated into the prenatal care team.

Low Versus High Transverse Skin Incisions for Obese Patients Undergoing Cesarean Delivery [14K]

INTRODUCTION: Surgical outcomes of obese patients receiving high (infraumbilical) versus low (Pfannensteil) transverse skin incisions at the time of Cesarean delivery (CD) were compared. While Pfannensteil and vertical skin incisions have been compared in the literature, few studies have examined outcomes of high versus low transverse incisions in the obese population. METHODS: A retrospective cohort of 274 obese women underwent CD by either low or high transverse skin incision. Demographics in addition to surgical and postoperative outcomes were collected. The primary outcome was wound complications. Additional outcomes included blood loss and operative time. Chi-square, Fischers Exact test and Mann-Whitney U tests were used for statistical analysis. RESULTS: Women in the high incision group had a significantly larger BMI (51 versus 45) and a trend of increased gestational diabetes (32.5% versus 19.2%). There was no difference in other baseline demographics. The high incision group had a significantly increased estimated blood loss compared to the low incision group (800 versus 700 mL). There was no difference in the primary outcome of wound complications. These findings remained when only analyzing the class III obesity group. CONCLUSION: Although Pfannensteil incisions were most commonly chosen, providers were more likely to select a high transverse skin incision in patients with increasing BMIs. While blood loss was found to be increased with high transverse incisions, no difference was noted in wound complications despite the higher median BMI in this group. Further prospective trials are needed to study the effects of high versus low transverse skin incisions in the obese population.