Martin Jn

The national partnership for maternal safety

Recognition of the need to reduce maternal mortality and morbidity in the United States has led to the creation of the National Partnership for Maternal Safety. This collaborative, broad-based initiative will begin with three priority bundles for the most common preventable causes of maternal death and severe morbidity: obstetric hemorrhage, severe hypertension in pregnancy, and peripartum venous thromboembolism. In addition, three unit-improvement bundles for obstetric services were identified: a structured approach for the recognition of early warning signs and symptoms, structured internal case reviews to identify systems improvement opportunities, and support tools for patients, families, and staff that experience an adverse outcome. This article details the formation of the National Partnership for Maternal Safety and introduces the initial priorities.

Putting the “M” back in maternal–fetal medicine

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.

Sonographic examination does not predict twin growth discordance accurately

Objective To assess the accuracy of estimating birth weight among twins with discordancy (intra-pair difference in actual birth weight of more than 25%) and to determine the relative accuracy of an intra-pair difference in abdominal circumference (Δ AC) of 20 mm or more or in estimated fetal weight (Δ EFW) of 25% or more for the identification of discordant growth in twins. Methods Over a 6-year period, we identified all nonanomalous twin pairs with gestational ages greater than 23 weeks and sonographic examinations within 3 weeks of birth. Ultrasonographic biometry of both twins included AC, head circumference, and femur length; these indices were used to estimate fetal weight by Hadlocks formula. Likelihood ratios, receiver-operating characteristic curves, and prediction limits were applied to assess the accuracy of the two diagnostic methods to predict an abnormal outcome. Results A total of 242 twin pairs were studied. The mean gestational age among the 21 twins with abnormal growth (30.6 ± 4.6 weeks) was significantly less than among the 221 twins with normal growth (33.2 ± 4.0 weeks) (P < .005). The biometric measurements of fetal parts, sonographic estimate of fetal weight, and actual birth weight for both fetuses were significantly less for discordant twin pairs (P < .05). The accuracy of predicting birth weight, as determined by mean error and percentage of the estimate within 10% of the actual weight, was similar between the groups. Receiver-operating characteristic curves showed that both diagnostic tests yielded areas under the two curves not significantly different from the area under the nondiagnostic line (P > .05). Most important, prediction limit calculations indicated that a 90% certainty that the actual birth weight discordance was at least 25% was achievable only if Δ AC was 172 mm or greater or Δ EFW was 112% or more. Conclusion The most popular current methods (difference in AC or EFW) for predicting discordant growth in twin gestations have limited accuracy when held to a standard for discordance that requires a birth weight difference of at least 25%.

Intra-operative haemorrhage by blunt versus sharp expansion of the uterine incision at caesarean delivery: a randomised clinical trial

Objective To determine whether the method used to expand the uterine incision for caesarean delivery affects the incidence of intra‐operative haemorrhage.

ANGIOGRAPHIC ARTERIAL EMBOLIZATION AND COMPUTED TOMOGRAPHY-DIRECTED DRAINAGE FOR THE MANAGEMENT OF HEMORRHAGE AND INFECTION WITH ABDOMINAL PREGNANCY

Hemorrhage during or after surgery, pelvic abscess, bowel obstruction, and prolonged febrile morbidity can complicate the puerperal course of the gravida after removal of an extrauterine fetus with nondisturbance of the extrauterine placenta. In this report we describe the successful angiographic arterial gelfoam embolization of the placental vascular bed to control heavy postoperative hemorrhage in a mother suffering adult respiratory distress syndrome after removal of the fetal portion of her abdominal pregnancy. Six weeks later, computed tomography (CT)-directed drainage by catheter of a placental abscess was performed. Selective angiographic transcatheter embolization with gelfoam is a useful tool for the control of hemorrhage in the gravida who is an unfavorable operative candidate or who may present technical hemostasis problems peculiar to the placenta with abdominal pregnancy. Later use of CT-directed catheter drainage of the infected residual placental mass provided a nonoperative means of treatment.

Detection of growth-restricted fetuses in preeclampsia: a case-control study ☆

OBJECTIVE To determine the diagnostic accuracy of detecting growth-restricted fetuses in women with and without preeclampsia. METHODS Over 2 years, parturients with reliable gestational ages, preeclampsia, and sonographic estimates of birth weights were matched (1:1) for gestational age with women without preeclampsia. Paired and unpaired t tests were used; P < .05 was significant. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. RESULTS Two hundred eighty-seven preeclamptic women were identified and matched. In each group, mean (+/- standard deviation [SD]) gestational age was 34.9 +/- 4.2 weeks, and 166 (57.8%) infants were born preterm. Fetal growth restriction (FGR) was significantly more common among women with preeclampsia (14.9%) than among controls (5.6%; OR 2.98, 95% CI 1.64, 5.44). The percentage of sonographic estimates within 10% of actual birth weight (57.5% versus 53.6%) was similar in the two groups (OR 1.16; 95% CI 0.84,1.62). Compared with normal growth, the mean (+/- SD) standardized absolute error was significantly higher among those with FGR regardless of group (preeclampsia 109 +/- 100 versus 158 +/- 152 g/kg; P = .009; control 117 +/- 103 versus 233 +/- 206 g/kg; P < .001). Fetal growth restriction was detected more commonly among preeclamptic women than among controls (11.6% versus 0%; OR 4.74 95% CI 0.25, 90.31). The sensitivity and positive predictive value of FGR detection were 10% and 50%, respectively, among women with preeclampsia and 0% each among controls. CONCLUSION Although FGR was detected more frequently in fetuses of women with preeclampsia than in those of controls, the ability to predict it with sonography remained poor.

Ultrasonic Assessment of the Amniotic Fluid Volume in Diamniotic Twins

Objective: We sought to determine amniotic fluid (AF) volume in diamniotic twin gestations and to relate these findings to estimates using standard ultrasonic techniques. Methods: In this prospective study, AF volume in 45 diamniotic twin gestations at 27-38 weeks was assessed by sonography using the largest vertical pocket technique, the AF index, and the two-diameter pocket method. After the three different sonographic estimations of AF volume, the true amount of AF was determined using amniocentesis and a dye-dilution technique. Results: The individual sac AF volume was less than 500 mL in 35 amniotic cavities, 500-2000 mL in 48 sacs, and greater than 2000 mL in seven. Individual AF volume between 500 and 2000 mL was correctly predicted by sonographic use of the largest vertical pocket in 47 of 48 patients (98%), the AF index in 47 of 48 (98%), and the two-diameter pocket method in 39 of 48 (81%). Estimation of AF volume less than 500 mL was significantly more accurate using the two-diameter pocket method compared with either the AF index (P = .015) or the largest vertical pocket technique (P < .0001). Conclusions: Currently available ultrasonic techniques to assess mid-range AF volume (500-2000 mL) in twin pregnancy are very accurate (81-98%). Oligohydramnios (less than 500 mL) is poorly identified by any sonographic method.

Cesarean delivery for fetal distress: Rate and risk factors

Objective The objective of this article was to review the recent English language literature on cesarean delivery for fetal distress to determine its incidence, diagnostic tests, and the contributing factors to this obstetric complications. A PubMed search (1990–2000) with items of “cesarean, fetal distress,” “cesarean, non-reassuring fetal heart rate,” “cesarean, neonatal acidosis,” and “cesarean, umbilical arterial pH,” was undertaken. Reports, letters to the editor, focus on anomalous fetuses, and papers not specifically focused on this topic were excluded. Of the 392 articles that the search yielded, 169 met the inclusion criteria. Based on 37 reports with more than 1,000 patients each, the overall risk of prompt cesarean delivery for fetal concern was 3.1% (43,340 of 13,989,74). The risk exceeded 20% in patients with moderate/severe asthma, severe hypothyroidism, severe preeclampsia, and postterm or fetal growth restricted fetuses with abnormal Doppler studies. Use of likelihood ratios suggests that Doppler of the umbilical artery is a superior diagnostic test to amniotic fluid index in identifying parturients at risk for cesarean for non-reassuring fetal heart rate tracing. Although several risk factors increase the need for cesarean delivery for fetal distress, in general, most are unpreventable. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to estimate the incidence of cesarean delivery for non-reassuring fetal heart rate tracing, outline potential diagnostic tests that are useful for the detection of fetal distress, and summarize medical and obstetric conditions that place patients at risk for cesarean delivery for fetal distress.

Intrapartum assessment by house staff of birth weight among twins.

Objective: To determine among twins in labor: 1) the relative accuracy of an intrapartum sonographic estimate of the birth weight for both fetuses using biparietal diameter and abdominal circumference, 2) the accuracy of detecting discordant growth (difference in actual birth weights greater than or equal to 15%), and 3) the estimate of fetal weight for nonvertex twin B that would reliably avoid breech extraction of infants less than 1500 g. Methods: Retrospectively, we identified and analyzed parturients with twins who had an intrapartum sonogram performed by a house officer assigned to the labor and delivery suite. Results: The mean birth weight (± standard deviation) for the twin A group was 1910 ± 628 g and for twin B was 1869 ± 668 g. The mean standardized absolute errors for the twin A group (121 ± 118 g/kg) and the twin B group (92 ± 67 g/kg) were not significantly different (P = .06). Analysis of variance revealed that regardless of the presentation of the fetuses, the mean standardized absolute error was not significantly different (P = .10). Using a difference in the estimates of birth weight of 15% or greater, the positive and negative predictive values of detecting discordant growth within a twin pair were 53 and 83%, respectively. Among 30 vertex‐nonvertex twin pairs, 12 of the second fetuses had actual birth weights of 1500 g or less, and all were estimated to weigh less than 1700 g. Conclusions: The intrapartum sonographic estimate of fetal weight in twin pregnancy by house staff appears reliable, and the accuracy of prediction is similar regardless of presentation, discordance, or actual birth weight greater or less than 1500 g. To avoid vaginal delivery of a persistent nonvertex twin B with a birth weight of 1500 g or less, a sonographic estimate of 1700 g for the second fetus may be adequate. (Obstet Gynecol 1993;82:523‐6)

Is amniotic fluid volume status predictive of fetal acidosis at delivery

Objective: To ascertain if dye‐determined amniotic fluid volume just prior to delivery correlates with fetal acidosis at delivery.