Cynthia Shellhaas

The Frequency and Complication Rates of Hysterectomy Accompanying Cesarean Delivery

OBJECTIVE: To estimate the frequency, indications, and complications of cesarean hysterectomy. METHODS: This was a prospective, 2-year observational study at 13 academic medical centers conducted between January 1, 1999, and December 31, 2000, on all women who underwent a hysterectomy at the time of cesarean delivery. Data were abstracted from the medical record by study nurses. The outcomes included procedure frequency, indications, and complications. RESULTS: A total of 186 cesarean hysterectomies (0.5%) were performed from a cohort of 39,244 women who underwent cesarean delivery. The leading indications for hysterectomy were placenta accreta (38%) and uterine atony (34%). Of the hysterectomy cases with a diagnosis recorded as accreta, 18% accompanied a primary cesarean delivery, and 82% had a prior procedure (P<.001). Of the hysterectomy cases with atony recorded as a diagnosis, 59% complicated primary cesarean delivery, whereas 41% had a prior cesarean (P<.001). Major maternal complications of cesarean hysterectomy included transfusion of red blood cells (84%) and other blood products (34%), fever (11%), subsequent laparotomy (4%), ureteral injury (3%), and death (1.6%). Accreta hysterectomy cases were more likely than atony hysterectomy cases to require ureteral stents (14% compared with 3%, P=.03) and to instill sterile milk into the bladder (23% compared with 8%, P=.02). CONCLUSION: The rate of cesarean hysterectomy has declined modestly in the past decade. Despite the use of effective therapies and procedures to control hemorrhage at cesarean delivery, a small proportion of women continue to require hysterectomy to control hemorrhage from both uterine atony and placenta accreta. LEVEL OF EVIDENCE: II

The clinical content of preconception care: nutrition and dietary supplements.

Women of child-bearing age should achieve and maintain good nutritional status prior to conception to help minimize health risks to both mothers and infants. Many women may not be aware of the importance of preconception nutrition and supplementation or have access to nutrition information. Health care providers should be knowledgeable about preconception/pregnancy-related nutrition and take the initiative to discuss this information during preconception counseling. Women of reproductive age should be counseled to consume a well-balanced diet including fruits and vegetables, iron and calcium-rich foods, and protein-containing foods as well as 400 microg of folic acid daily. More research is critically needed on the efficacy and safety of dietary supplements and the role of obesity in birth outcomes. Preconception counseling is the perfect opportunity for the health care provider to discuss a healthy eating guideline, dietary supplement intake, and maintaining a healthy weight status.

Provider and patient perceptions about dental care during pregnancy

Objective. To compare the opinions of dentists, obstetricians, and patients on dental care in pregnancy: its necessity, accessibility, and safety. Methods. A 35-item questionnaire was distributed within Ohio, to 400 patients and 1000 providers between October 2004 and July 2005. Univariate comparisons between dentists and obstetricians were made by Fishers exact test. Adjustments for confounding were made through logistic regression models. Results. Most providers rated prenatal dental screening as important, agreeing that poor dental hygiene related to adverse pregnancy outcomes. Although 84% of patients reported dental visits as safe only 44% received care; the main limitation was financial. Providers agreed that pregnant patients could undergo dental cleanings, caries treatments, and abscess drainage but disagreed regarding the safety of X-rays, periodontal surgery, amalgam, and narcotic usage. In general, obstetricians were more comfortable than dentists with procedures and medication usage but less often reported recommending routine prenatal dental care. Conclusions. Different respondent perceptions exist regarding the safety, accessibility, and necessity of prenatal dental treatments. Professional guidelines about oral health screening in pregnancy and the safety of dental procedures would benefit our patients and colleagues.

The clinical content of preconception care: women with chronic medical conditions.

This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.

The clinical content of preconception care: the use of medications and supplements among women of reproductive age

The use of prescription and over-the-counter medications and dietary supplements are common among women of reproductive age. For medications, little information about the teratogenic risks or safety is available, as pregnant women are traditionally excluded from clinical trials, and premarketing animal studies do not necessarily predict the effects of treatment in human pregnancy. Even less is typically known about the effects of dietary supplements on pregnancy outcomes, as they are not held to the same rigorous safety and efficacy standards as prescription medications. Congenital anomalies associated with medication use are potentially preventable, because they are linked with modifiable maternal exposures during the period of organogenesis. However, as women of reproductive age experience acute and chronic conditions that can result in adverse outcomes for the woman and her offspring, the benefits of use of a particular medication before or early in pregnancy may outweigh the risks. Resources and principles outlined in this article will aid healthcare providers in selecting appropriate medication regimens for women of reproductive age, particularly those with chronic health conditions, those who are planning a pregnancy, and those who may become pregnant.

Strategies Associated with Higher Postpartum Glucose Tolerance Screening Rates for Gestational Diabetes Mellitus Patients

BACKGROUND Most women with histories of gestational diabetes mellitus do not receive a postpartum screening test for type 2 diabetes, even though they are at increased risk. The objective of this study was to identify factors associated with high rates of postpartum glucose screening. METHODS This cross-sectional analysis assessed characteristics associated with postpartum diabetes screening for patients with gestational diabetes mellitus (GDM)-affected pregnancies self-reported by randomly sampled licensed obstetricians/gynecologists (OBs/GYNs) in Ohio in 2010. RESULTS Responses were received from 306 OBs/GYNs (56.5% response rate), among whom 69.9% reported frequently (always/most of the time) screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Compared to infrequent screeners, OBs/GYNs who frequently screen for postpartum glucose tolerance were statistically (p<0.05) more likely to have a clinical protocol addressing postpartum testing (67.2% vs. 26.7%), an electronic reminder system for providers (10.8% vs. 2.2%) and provide reminders to patients (16.4% vs. 4.4%). Frequent screeners were more likely to use recommended fasting blood glucose or 2-hour oral glucose tolerance test (61.8% vs. 34.6%, p<0.001) than infrequent screeners. CONCLUSIONS Strategies associated with higher postpartum glucose screening for GDM patients included clinical protocols for postpartum testing, electronic medical records to alert providers of the need for testing, and reminders to patients.

Gestational Diabetes Mellitus and Postpartum Care Practices of Nurse-Midwives

INTRODUCTION Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement. METHODS From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening. RESULTS Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight/obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care. DISCUSSION CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies.

Ultrasound prediction of growth abnormalities in fetuses with gastroschisis.

Objective. We seek to determine whether (1) mean abdominal circumference (AC) of fetuses with gastroschisis is smaller than published normative values, (2) diagnosis of AC ≤2.5th percentile is supported by postnatal diagnosis of small-for-gestational age (SGA) and (3) adverse neonatal outcomes are more common in fetuses affected by gastroschisis with a sonographically measured small AC. Methods. Retrospective review of pregnancies complicated with gastroschisis between 2000 and 2008. Patient demographics, method of closure, length of stay, use of ventilator support and gastrointestinal complications were compared. Results. Seventy-four fetuses were identified with 368 ultrasound observations. Mean AC of fetuses with gastroschisis fell between the 2.5th and 50th percentile for gestational age. Thirty patients had AC measurements ≤2.5th of which 50% were SGA at delivery. Eleven of the 74 fetuses were diagnosed with intrauterine growth restriction (IUGR) and all were SGA. Birth weight was lower in those with a small AC (2104 g vs. 2665 g, p < 0.001). There were no other differences in outcomes. Conclusion. AC values fell within the normal range of normative curves. Fifty percent of fetuses with small AC were SGA at birth. Neonatal outcomes in patients with small AC are similar to those with a normal AC.

Ambulatory management of preterm labor.

The care of women with preterm labor has focused predominantly on inpatient therapy: tocolysis, antibiotics, and steroid administration. The emphasis is slowly but surely shifting to secondary prevention and outpatient therapy. Our goal should be toward primary prevention of preterm labor in all women. Then and only then will a true reduction in spontaneous prematurity rates be seen.

The Ohio Gestational Diabetes Postpartum Care Learning Collaborative: Development of a Quality Improvement Initiative to Improve Systems of Care for Women.

Objectives To improve clinical practice and increase postpartum visit Type 2 diabetes mellitus (T2DM) screening rates in women with a history of gestational diabetes mellitus (GDM). Methods We recruited clinical sites with at least half of pregnant patients enrolled in Medicaid to participate in an 18-month quality improvement (QI) project. To support clinical practice changes, we developed provider and patient toolkits with educational and clinical practice resources. Clinical subject-matter experts facilitated a learning network to train sites and promote discussion and learning among sites. Sites submitted data from patient chart reviews monthly for key measures that we used to provide rapid-cycle feedback. Providers were surveyed at completion regarding toolkit usefulness and satisfaction. Results Of fifteen practices recruited, twelve remained actively engaged. We disseminated more than 70 provider and 2345 patient toolkits. Documented delivery of patient education improved for timely GDM prenatal screening, reduction of future T2DM risk, smoking cessation, and family planning. Sites reported toolkits were useful and easy to use. Of women for whom postpartum data were available, 67 % had a documented postpartum visit and 33 % had a postpartum T2DM screen. Lack of information sharing between prenatal and postpartum care providers was are barriers to provision and documentation of care. Conclusions for Practice QI and toolkit resources may improve the quality of prenatal education. However, postpartum care did not reach optimal levels. Future work should focus on strategies to support coordination of care between obstetrical and primary care providers.