Jeannie Kelly

Chorioamnionitis and sternoclavicular septic arthritis after drainage of Bartholin gland abscess.

BACKGROUND: Complications after drainage of Bartholin gland abscesses in pregnancy are rare. CASE: A 29-year-old primigravid at 35 weeks of gestation with dichorionic–diamniotic twins underwent Bartholin gland abscess drainage. Afterward, she reported shoulder pain and became febrile. Examination revealed maternal and fetal tachycardia with abdominal tenderness consistent with chorioamnionitis, and she underwent delivery. Blood cultures grew Escherichia coli, and antibiotics were begun. Her shoulder pain worsened, and examination demonstrated inflammation over the sternoclavicular joint. Fluid aspirate of this joint grew E coli. She experienced improvement after aspiration and was discharged home on antibiotics. CONCLUSION: Although rare, severe consequences can result from Bartholin gland abscesses in pregnant patients, including sepsis and septic arthritis. Close clinical follow-up should be considered in pregnant patients undergoing abscess drainage.

Prenatal consultation with the pediatric otolaryngologist

OBJECTIVES To examine the spectrum of fetal head and neck anomalies that may prompt prenatal referral and to determine the frequency of these consultations. STUDY DESIGN Case series with chart review. METHODS The billing databases of two urban pediatric otolaryngology practices were queried for ICD-9 codes corresponding to fetal anomalies between January 2010 and December 2012. The pediatric otolaryngology practices in this study evaluate all fetal head and neck anomalies referred to their respective institutions, including craniofacial disorders. RESULTS Over a three-year period, 53 women presented for fetal otolaryngology consultation, with each practice seeing approximately one consultation every 6 weeks (every 5 weeks (JDS) and every 7 weeks (ARS)). The average maternal and gestational age at presentation were 28.7 years and 27.2 weeks, respectively. 83% of the cases (n = 44) involved some form of cleft lip with or without cleft palate. Other head and neck anomalies included fetal goiter/other congenital neck mass (9% (n = 5)) and micrognathia (6% (n = 3)). Macroglossia (n = 1) and facial cleft (n = 1) each accounted for 2% of cases. Cleft mothers presented earlier in pregnancy (average 26.8 weeks) than those with a neck mass (average 32.3 weeks) (p < 0.05). Only 3 cases (6%) merited ex utero intrapartum treatment. CONCLUSIONS Depending on the referral practices at a given medical center, craniofacial surgeons rather than pediatric otolaryngologists may be evaluating the majority of fetal head and neck anomalies, as orofacial clefts account for most prenatal consultations. The wide spectrum of congenital neck masses may or may not demand monitoring of the airway during the peripartum period.

Does SSRI Antidepressant Use Influence APGAR Scores? [29N]

INTRODUCTION: SSRIs have been associated with low APGAR scores, independent of maternal depression, and with preterm birth. Our objective was to determine the association of SSRIs with low APGARs. METHODS: We performed a retrospective matched cohort study on patients who delivered at a tertiary care center from 2009–2014. Women who reported SSRI use on admission were matched to contemporary controls in a 2:1 fashion by completed weeks of gestation and mode of delivery. Fetal anomalies, stillbirths, and multiple gestations were excluded. Odds ratios and 95% confidence intervals were calculated. Fishers exact test was used to determine significance in the number of APGAR scores <7. RESULTS: 112 SSRI users (2% of deliveries) and 224 controls were included. Women reported using the following: citalopram (n=23), escitalopram (n=4), paroxetine (n=2), fluoxetine (n=34), and sertraline (n=49). 25% delivered preterm. Infants exposed to SSRIs had an increased rate of low APGAR scores at 1 minute (OR 2.0, 95% CI 1.1–3.5, P=.02) and 5 minutes (OR 8.8, 95% CI 2.4–32.0, P=.0009). 1 minute APGAR scores <7 (24% vs 14%, P=.02) and 5 minutes (11% vs 1%, P=.0002) were significantly higher in the SSRI group. CONCLUSION: SSRIs are associated with an increased risk of APGAR scores <7 at 1 and 5 minutes, with an almost 9-fold increased risk of 5 minute APGAR <7. APGAR scores <7 have previously been associated with future cognitive impairment. Further investigation into the impact of SSRI exposure is essential.

Yes We Can: How Our Community Hospital Lowered Its Cesarean Delivery Rate

INTRODUCTION: Efforts to lower cesarean delivery rates have largely been unsuccessful. At our community hospital, a multifaceted strategy was initiated to lower cesarean delivery rates, and we analyzed the results over a 4-year period. METHODS: Beginning in 2011, we reviewed cesarean delivery indications daily, initiated a physician and nursing education program, encouraged resident involvement, and implemented a laborist program. Cesarean delivery rates between January 2010 and June 2013 were calculated overall and per individual physician based on inpatient records. STATA 12.1 was used to calculate risk ratios of cesarean delivery by calendar year, which was compared using the &khgr;2 test. To explore the effect of individual physicians, a sensitivity analysis was performed to remove the highest individual physician rates from the 2010 data and compare the results with 2013. RESULTS: Cesarean delivery rates decreased from 44.6% to 35.6% from 2010 to 2013 with a 20% lower risk of having a cesarean delivery overall (relative risk [RR] 0.80, 95% confidence interval [CI] 0.69–0.92; P=.001) and a 28% lower risk of having a primary cesarean delivery (RR 0.72, 95% CI 0.57–0.90; P=.003) (Table 1). In 2010, the highest three individual rates were 72.0%, 63.8%, and 47.9%, accounting for 314 (22%) deliveries. After removing these physicians from the 2010 data set, there is no significant difference between 2010 and 2013 rates for primary CD (RR 0.87, 95% CI 0.69–1.11; P=.3) or cesarean delivery overall (RR 0.90, 95% CI 0.78–1.04; P=.1). Table 1 Deliveries Between January 2010 and June 2013 CONCLUSION: Implementing a comprehensive strategy can dramatically lower cesarean delivery rates. Although many factors were involved, the effect of the individual physician should not be underestimated.