Kaitlyn James

Mullerian-inhibiting substance/anti-Mullerian hormone as a predictor of preterm birth in polycystic ovary syndrome.

ContextnThere is increasing evidence for Müllerian-inhibiting substance (MIS)/anti-Müllerian hormone (AMH) physiologic activity in the human uterus, so it is relevant to study how MIS/AMH levels impact pregnancy.nnnObjectivenTo investigate the association of MIS/AMH levels with the risk of adverse obstetric outcomes.nnnDesignnRetrospective cohort study.nnnSettingnAcademic fertility center.nnnPatientsnWomen who became pregnant through in vitro fertilization between January 2012 and October 2016. Exclusion criteria were: oocyte donation, gestational carrier, multiple gestations, miscarriage before 20 weeks, or medically indicated preterm deliveries.nnnInterventionsnNone.nnnMain Outcome MeasuresnThere were two primary outcomes, preterm birth and cesarean delivery for arrest of labor. Because MIS/AMH level is highly skewed by certain infertility diagnoses, the preterm birth analysis was stratified by polycystic ovary syndrome (PCOS) diagnosis, and the cesarean delivery for arrest of labor analysis was stratified by diminished ovarian reserve diagnosis. χ2, Mann-Whitney, and t tests were used as appropriate. A P value of <0.05 was considered statistically significant.nnnResultsnAmong women with PCOS, those who delivered prematurely had substantially higher MIS/AMH levels (18 vs 6.4 ng/mL, P = 0.003) than did those who delivered at term. At the highest MIS/AMH values, preterm deliveries predominated; above the 90th percentile in women with PCOS, all deliveries were premature. No effect of MIS/AMH level was observed in women without PCOS. We found no association between MIS/AMH values and cesarean delivery for labor arrest.nnnConclusionnIn women with PCOS, substantially elevated MIS/AMH levels are significantly associated with preterm birth, suggesting closer follow-up and further studies to elucidate the underlying mechanisms.

New Challenges for a Core Procedure: Development of a Faculty Workshop for Skills Maintenance for Abdominal Hysterectomy

OBJECTIVEnTo describe the development of a low-cost educational module for OB/GYN faculty skills maintenance for total abdominal hysterectomy (TAH), a low frequency core procedure in obstetrics and gynecology.nnnDESIGNnAfter review of existing educational tools and utilization of a modified Delphi method to establish consensus regarding key procedural components for skills maintenance, a 2-hour workshop was developed to review knowledge and participate in a simulation focused on the critical steps in performing TAH. An expert in TAH delivered a lecture highlighting important surgical considerations. Participants then rotated through simulation stations for critical steps in TAH: dissecting the bladder, identifying the ureter, and closing the cuff. Knowledge gains were assessed with a written pre- and posttest. Consecutive focus groups were conducted with participants on effectiveness of the workshop, and suggestions for improvement. Ideas identified in the first focus group were incorporated into the second workshop.nnnSETTINGnMassachusetts General Hospital, an academic tertiary care facility with a single Obstetrics and Gynecology faculty group, located in Boston, Massachusetts.nnnPARTICIPANTSnEligible participants were recruited via email from full time specialists in General Obstetrics and Gynecology at Massachusetts General Hospital. Of the 25 eligible gynecology faculty subjects, 22 participated (88%).nnnRESULTSnOn pre or post-test comparison, 70% of participants scored higher on the posttest, demonstrating an increase in knowledge of critical TAH surgical steps. Focus group analyses identified the need for increased review and training demonstrations of TAH, and recommended continued offering of the workshop.nnnCONCLUSIONSnBased on focus group responses and pre or posttest comparisons, the workshop was deemed feasible and enhanced short-term learning. Future directions include utilizing more challenging anatomic models and simulation scenarios and optimizing integration of expert demonstration and individualized coaching, as well as identifying regionally tailored surgical workshop programming.

Hospital volume and cesarean delivery among low-risk women in a nationwide sample

Objective:We sought to determine if hospital delivery volume was associated with a patient’s risk for cesarean delivery in low-risk women.Study Design:This study retrospectively examines a cohort of 1u2009657u2009495 deliveries identified in the 2013 Nationwide Readmissions Database. Hospitals were stratified by delivery volume quartiles. Low-risk patients were identified using the Society for Maternal–Fetal Medicine definition (n=845u2009056). A multivariable logistic regression accounting for hospital-level clustering was constructed to assess the factors affecting a patient’s odds for cesarean delivery.Results:The range of cesarean delivery rates was 2.4–51.2% among low-risk patients, and the median was 16.5% (IQR 12.8–20.5%). The cesarean delivery rate was higher in the top two-volume-quartile hospitals (17.4 and 18.2%) compared to the bottom quartiles (16.4 and 16.3%) (P<0.001). Hospital volume was not associated with a patient’s odds for cesarean delivery after adjusting for patient and other hospital characteristics (P=0.188).Conclusion:Hospital delivery volume is not an independent predictor of cesarean delivery in this population.

The effect of hospital acuity on severe maternal morbidity in high-risk patients

BACKGROUND: In 2015, the Society for Maternal‐Fetal Medicine and the American College of Obstetricians and Gynecologists published guidelines that established levels of maternal care. These guidelines outlined the nursing, provider, and facility requirements for hospitals to be designated a birthing center or 1 of 4 levels of care. To date, these levels of maternal care have not been adopted widely; currently, no data exist on how these designations may affect maternal or neonatal outcomes. OBJECTIVE: Because the levels of maternal care attempt to reflect a hospitals ability to treat patients with certain conditions that are associated with increased risk of complications, our objective was to compare outcomes among high‐ and low‐risk patients between high‐ and low‐acuity hospitals. We hypothesized that hospitals that cared for a high rate of high‐risk patients, which we considered “high‐acuity” centers, would have a lower risk of severe maternal morbidity among high‐risk patients compared with low‐acuity centers. STUDY DESIGN: Deliveries were identified in the 2013 Nationwide Readmission Database. A patients comorbidity index was assigned based on diagnosis and procedure codes with the use of previously validated methods; a comorbidity index of ≥3 has been associated with increased odds of severe maternal morbidity. Patients were classified as low, intermediate, or high risk by their comorbidity index for analysis. Patients at hospitals with <100 deliveries per year and transferred patients were excluded. A hospital was defined as low or high‐acuity if it was in the bottom or top quartile, respectively, based on its percent of patients with a comorbidity index of ≥3. Log‐binomial regression models were constructed to assess the effects of a patients comorbidity index group on the risk of severe morbidity in high‐ and low‐acuity hospitals. The models controlled for available patient and hospital factors. The regression used patient‐level data with robust standard errors that were clustered at the level of the hospital. The Wald test was used to assess for the effect modification between comorbidity index group and hospital acuity. RESULTS: From 1203 hospitals, 1,656,659 delivering patients met the inclusion criteria. There were 58.7% low‐risk, 39.0% intermediate‐risk, and 2.3% high‐risk patients in the overall sample, and the overall rate of severe maternal morbidity was 1.2%. Less than 3.7% of delivering patients in low‐acuity hospitals had a high‐risk condition. In comparison, >7.1% patients in high‐acuity centers had a high‐risk condition. In the adjusted analysis, intermediate‐risk patients had a slightly increased risk of morbidity in both low‐acuity and high‐acuity centers compared with low‐risk patients (adjusted risk ratios, 1.53 [95% confidence interval, 1.33–1.77] vs 1.57 [95% confidence interval, 1.49–1.65]). However, there was a notable difference in the adjusted risk ratios for severe maternal morbidity in the high‐risk population: the adjusted risk ratio was 9.55 (95% confidence interval, 6.83–13.35) in low‐acuity hospitals compared with 6.50 (95% confidence interval, 5.94–7.09) in high‐acuity hospitals. CONCLUSION: High‐risk patients have a higher risk of severe maternal morbidity at low‐acuity hospitals compared with high‐acuity centers. These findings support the concept of regionalization of maternity care to improve outcomes for high‐risk patients.