Lisa M. Korst

Stage-based outcomes of 682 consecutive cases of twin–twin transfusion syndrome treated with laser surgery: the USFetus experience

OBJECTIVE We sought to describe stage-specific perinatal outcomes after selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome. STUDY DESIGN Patients with twin-twin transfusion syndrome underwent SLPCV preferentially using sequential vs standard laser technique. Patient characteristics and outcome data were examined by Quintero stage. RESULTS Of 682 consecutive women studied, the Quintero stage distribution was: 114 stage I (17%), 177 stage II (26%), 328 stage III (48%), and 63 stage IV (9%). Perinatal survival of at least 1 twin did not differ according to stage (I-92%, II-93%, III-88%, IV-92%; P = .30). However, dual twin survival differed by stage (I-79%, II-76%, III-59%, IV-68%; P < .01), primarily because stage III pregnancies were associated with decreased donor twin survival (P < .01). Sequential SLPCV was associated with improved donor survival, independent of stage (odds ratio, 1.67; 95% confidence interval, 1.16-2.40; P < .01). CONCLUSION Stage-specific perinatal outcomes after laser therapy may assist physicians in patient counseling and in planning future studies.

Nursing Documentation Time During Implementation of an Electronic Medical Record

Objective To determine, within the context of all nursing duties, the amount of time nurses spend on documentation during the implementation of an electronic medical record (EMR) on an intrapartum unit. Background Increased documentation needs during EMR implementation may necessitate increased staffing requirements in an already labor-intensive and demanding environment. Methods A work-sampling study was conducted over a 14-day study period, and 18 of 84 (21%) potential 4-hour observation periods were selected. During each period, a single observer made 120 observations and, on locating a specific nurse, immediately recorded that nurse’s activity on a standardized and validated instrument. Categories of nursing activities included documentation, bedside care, bedside supportive care, nonbedside care, and nonpatient care. Results A total of 2160 observations were made. The total percentage of nursing time spent for documentation was 15.8%, 10.6% on paper and 5.2% on the computer. The percentage of time spent on documentation was independently associated with day versus night shifts (19.2% vs 12.4%, respectively). Conclusions Despite charting concurrently on both paper and computer, the amount of time spent on documentation was not excessive, and was consistent with previous studies in which neither electronic nor “double charting” occurred.

Vaginal birth after cesarean and uterine rupture rates in California

OBJECTIVE To describe attempted and successful vaginal birth after cesarean (VBAC) rates and uterine rupture rates for women with and without prior cesareans, and compare delivery outcomes in hospitals with different attempted VBAC rates. METHODS We used California hospital discharge summary data for 1995 to calculate attempted and successful VBAC rates and uterine rupture rates. We used multivariate logistic regression models to evaluate and adjust for age, ethnicity, and payment source. We report the relative risk (RR), attributable fraction, and 95% confidence intervals (CIs) for uterine rupture. RESULTS There were 536,785 delivery discharges during 1995. The cesarean rate was 20.8%, and 12.5% of women had histories of cesareans. Of women with histories of cesareans, 61.4% attempted VBAC and 34.8% were successful. There were 392 uterine ruptures (0.07%). Women with prior cesareans were 16.98 (95% CI 13.51, 21.43) times more likely to experience uterine rupture, attributable fraction 66% (95% CI 60%, 73%). Among women with prior cesareans, those who attempted VBAC were 1.88 (95% CI 1.45, 2.44) times as likely to have uterine rupture, attributable fraction 34% (95% CI 21%, 46%). Women who delivered in hospitals with high attempted VBAC rates were less likely to have cesarean deliveries, more likely to have successful VBACs, and more likely to experience uterine ruptures. CONCLUSION Uterine rupture occurs at a low rate in women with and without prior cesarean delivery. Risk of rupture is increased among women with prior cesarean delivery and among those who attempt VBAC.

The psychosocial burden of hyperemesis gravidarum

Objective:To describe the psychosocial burden of hyperemesis gravidarum (HG) in a large cohort of affected women, focusing on previously unreported problems.Study Design:Women with HG described their pregnancy history in an open-ended survey administered internationally through an HG website during 2003 to 2005.Result:Of the 808 participants, 626 (77.5%) were American. A large majority (82.8%) reported that HG caused negative psychosocial changes, consisting of (1) socioeconomic changes, for example, job loss or difficulties, (2) attitude changes including fear regarding future pregnancies and (3) psychiatric sequelae, for example, feelings of depression and anxiety, which for some continued postpartum. Women who reported that their health-care provider was uncaring or unaware of the severity of their symptoms were nearly twice as likely to report these psychiatric sequelae (odds ratio 1.86, 95% confidence interval 1.06 to 3.29, P=0.032).Conclusion:Over 80% of a large cohort of women with HG reported that HG caused a negative psychosocial impact.

Variations in the Incidence of Postpartum Hemorrhage Across Hospitals in California

Objective: Because postpartum hemorrhage may result from factors related to obstetrical practice patterns, we examined the variability of postpartum hemorrhage and related risk factors (obstetrical trauma, chorioamnionitis, and protracted labor) across hospital types and hospitals in California. Methods: Linked birth certificate and hospital discharge data from 507,410 births in California in 1997 were analyzed. Cases were identified using International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes. Comparisons were made across hospital types and individual hospitals. Risk adjustments were made using 1) sample restriction to a subset of 324,671 low-risk women, and 2) Bayesian hierarchical logistic regression model to simultaneously quantify the effects of patient-level and hospital-level risk factors. Results: Postpartum hemorrhage complicated 2.4% of live births. The incidence ranged from 1.6% for corporate hospitals to 4.9% for university hospitals in the full sample, and from 1.4% for corporate hospitals to 3.9% for university hospitals in the low-risk sample. Low-risk women who delivered at government, HMO and university hospitals had two- to threefold increased odds (odds ratios 1.98 to 2.71; 95% confidence sets ranged from 1.52 to 4.62) of having postpartum hemorrhage compared to women who delivered at corporate hospitals, irrespective of patient-level characteristics. They also had significantly higher rates of obstetrical trauma and chorioamnionitis. Greater variations were observed across individual hospitals. Conclusion: The incidence of postpartum hemorrhage and related risk factors varied substantially across hospital types and hospitals in California. Further studies using primary data sources are needed to determine whether these variations are related to the processesof care.

Corticotrophin-releasing hormone and CRH-binding protein. Differences between patients at risk for preterm birth and hypertension.

Abstract: Background: During pregnancy in the second and third trimester there is a progressive rise in plasma CRH thought to be secreted by the placenta. Plasma CRH‐BP inactivates CRH, which may prevent its peripheral action on the maternal pituitary and myometrium. In the last few weeks of pregnancy CRH‐BP decreases, thereby causing an increase in free CRH or a CRH/CRH‐BP complex available to play a role in the onset of parturition. Objective: We tested the hypothesis that differences in CRH, CRH‐BP, or a CRH/CRH‐BP complex in patients at risk for preterm birth (PTB) and hypertension (HYP) account for the differences in the timing of parturition. Methods: From a Behavior in Pregnancy Study database, we identified 18 patients who had spontaneous PTB and 23 patients who developed HYP. Both groups were case controlled and matched with patients who delivered at term (Normal). Maternal plasma samples had been appropriately collected from these patients at 18‐20, 28‐30, and 35‐36 weeks gestational age. CRH levels were measured by double antibody RIA kit and the CRH‐BP by a immunoradiometric technique. A CRH‐BP/CRH dimer complex index was calculated. Statistical analysis was done using Kruskal‐Wallis test for two cases. Results: Maternal CRH (pg/ml) in the PTB cases compared to the HYP cases was significantly elevated at all three time periods. Maternal CRH‐BP (pg/ml) in the PTB versus HYP cases was significantly lower at all three time periods in the PTB cases compared to the HYP cases. Maternal CRH‐BP/CRH dimer complex index was significantly lower in the PTB cases at all three time periods than either the controls or the HYP cases, suggesting excessive CRH. The mean GA at delivery for the PTB cases was significantly lower than the control or HYP cases. Conclusions: These results suggest that those patients at risk for PTB have significantly elevated CRH, lower CRH‐BP, and a reduced CRH‐BP/CRH dimer complex index at all three time periods of assessment.

Cesarean versus vaginal delivery: whose risks? Whose benefits?

We reviewed the risks and benefits of vaginal and cesarean delivery to help frame the inherent trade-offs that should be considered as part of the informed consent discussion between patients and providers. We performed a targeted literature review for common complications of childbirth. Approximately 30% of women will experience a maternal or neonatal complication during childbirth. Both cesarean and vaginal delivery is associated with well-known measurable short- and long-term maternal and neonatal complications and benefits. Childbirth is not risk free. There are data available that can guide the informed consent process with objective quantifiable data that patients and providers can use to weigh risks and benefits of delivery methods.

Permanent Erb palsy: A traction-related injury?

Historically, the primary risk factor attributed to brachial plexus injury during birth has been excessive traction applied at delivery to an entrapped anterior shoulder. However, recent evidence has suggested that not all cases of brachial plexus palsy are attributable to traction. We have encountered several cases of permanent Erb palsy associated with birth that were not attributable to traction applied at delivery. We reviewed cases of neonates with documented permanent Erb palsy that occurred either in the absence of shoulder dystocia or in the neonates posterior arm in the presence of anterior shoulder dystocia. We identified four cases that occurred in the absence of shoulder dystocia and four cases that occurred in the posterior arm of infants with anterior shoulder dystocia. These data further support the notion that the etiology of permanent brachial plexus palsy associated with birth may not be related to traction.

Neonatal nucleated red blood cell and lymphocyte counts in fetal brain injury

Objective To determine whether neonatal lymphocyte or nucleated red blood cell (RBC) counts can be used to date fetal neurologic injury. Methods Singleton, term infants with hypoxic-ischemic encephalopathy, permanent neurologic impairment, and sufficient laboratory data were divided into two groups: infants with preadmission injury, manifested by a nonreactive fetal heart rate (FHR) pattern from admission until delivery; and infants with acute injury, manifested by a normal FHR pattern followed by a sudden prolonged FHR deceleration. Lymphocyte and nucleated RBC values were compared with published high normal counts for normal neonates: 8000 lymphocytes/mm3 and 2000 nucleated RBCs/mm3. Results The study population consisted of 101 neonates. In the first hours of life, lymphocyte counts were elevated among injured newborns, and then the counts rapidly normalized. Brain-injured neonates were 25 times more likely to have a lymphocyte count greater than 8000 than were normal neonates (54 [62%] of 87 versus 6 [7%] of 84; odds ratio 25.5; 95% confidence interval 8.8, 80.1; P < .001). The mean lymphocyte count tended to be higher in the pread-mission-injury group than in the acute-injury group. In comparison, nucleated RBC values were not correlated as strongly with neonatal hours of life; nucleated RBC counts tended to be higher and persist longer among neonates with preadmission injury than among those with acute injury. Conclusion Compared with normal levels, both lymphocyte and nucleated RBC counts were elevated among neonates with fetal asphyxial injury. Both counts appear to be more elevated and to remain elevated longer in newborns with preadmission injury than in infants with acute injury. However, the rapid normalization of lymphocyte counts in these injured neonates limits the clinical usefulness of these counts after the first several hours of life.

Health-related quality of life in women with nausea and vomiting of pregnancy: the importance of psychosocial context

Objective:To test whether women with hyperemesis gravidarum (HG) demonstrated lower health-related quality of life (HRQoL) scores compared with those with nausea and vomiting of pregnancy (NVP).Study Design:Women with HG or NVP were examined during the first trimester. Multivariate models identified characteristics of women at risk for low HRQoL, as measured by an NVP-specific HRQoL test and a generic HRQoL test, the Short Form (SF)-36.Result:Although the SF-36 assessment did not discriminate between the two groups, the NVP-specific test showed that women with HG (N=29) were 3–6 times more likely than women with NVP (N=48) to have low HRQoL. Both tests demonstrated that perceived physical symptoms and multiple psychosocial factors, such as depression and marital status, seemed to be equally or more important than having HG.Conclusion:Although a low HRQoL was associated with an HG diagnosis, multiple physical symptoms and psychosocial factors placed both groups of women at risk.