Melissa A. Schiff

Factors Associated With Peripartum Hysterectomy

OBJECTIVE: To identify factors associated with peripartum hysterectomy performed within 30 days postpartum. METHODS: This was a population-based case–control study using Washington State birth certificate registry (1987–2006) linked to the Comprehensive Hospital Abstract Reporting System. Cases underwent hysterectomy within 30 days postpartum. Controls were frequency matched 4:1. Exposures included factors related to hemorrhage, delivery method, multiple gestations, and infection. Incidence rates of peripartum hysterectomy and maternal and neonatal morbidity and mortality were assessed. Adjusted odds ratios (aORs) by maternal age, parity, gestational age, year of birth, and mode of delivery and 95% confidence intervals (CIs) were computed. RESULTS: There were 896 hysterectomies. Incidence rates ranged from 0.25 in 1987 to 0.82 per 1,000 deliveries in 2006 (&khgr;2 for trend, P<.001). Factors related to hemorrhage were strongly related to peripartum hysterectomy. Placenta previa (192 cases compared with 23 controls; aOR 7.9, 95% CI 4.1–15.0), abruptio placenta (71 compared with 55; aOR 3.2, 95% CI 1.8–5.8), and retained placenta (214 compared with 28; aOR 43.0, 95% CI 19.0–97.7) increased the risk of hysterectomy, as did uterine atony, uterine rupture, and thrombocytopenia. Having multiple gestations did not. As compared with vaginal delivery, vaginal delivery after cesarean (27 cases compared with 105 controls; aOR 1.9, 95% CI 1.2–3.0), primary cesarean (270 compared with 504; aOR 4.6, 95% CI 3.5–6.0), and repeat cesarean (296 compared with 231; aOR 7.9, 95% CI 5.8–10.7) increased the risk of peripartum hysterectomy. Among the 111 women who had hysterectomy on readmission (12.8% of cases), hemorrhage- and infection-related factors were still strongly associated with peripartum hysterectomy. CONCLUSION: Incidence rates of peripartum hysterectomy are increasing over time. The most important risk factor for peripartum hysterectomy is hemorrhage, most notably caused by uterine rupture, retained placenta, and atony of uterus. LEVEL OF EVIDENCE: II

Maternal and infant outcomes after injury during pregnancy in Washington State from 1989 to 1997.

BACKGROUND Few population-based studies have assessed maternal and infant outcomes after nonfatal injuries occurring during pregnancy. METHODS We performed a retrospective cohort study to assess outcomes of pregnant women hospitalized for injury in Washington State from 1989 to 1997. We used the Injury Severity Score (ISS) to classify 266 nonseverely injured (ISS of 1-8) and 28 severely injured (ISS > 9) pregnant women who delivered at their injury hospitalization. We compared these women to 12,578 pregnant women randomly selected from Washington State birth and fetal death certificates who had no injury hospitalization during pregnancy. RESULTS Nonseverely injured pregnant women were at increased risk of placental abruption and their infants were at increased risk of hypoxia and fetal death. Severely injured pregnant women were at a 17-fold (95% confidence interval, 6.2-46.8) increased risk of placental abruption and their infants were at increased risk of prematurity, low birth weight, and fetal distress, and a 30-fold (95% confidence interval, 9.4-97.1) increased risk of fetal death. CONCLUSION Nonsevere as well as severe injuries resulting in hospitalization during pregnancy can result in adverse maternal and infant outcomes.

Epidemiology of injury in Olympic sports

This new volume in the Encyclopaedia of Sports Medicine series, published under the auspices of the International Olympic Committee, provides a state-of-theart account of the epidemiology of injury across a broad spectrum of Olympic sports. The book uses the public health model in describing the scope of the injury problem, the associated risk factors, and in evaluating the current research on injury prevention strategies described in the literature.

The sex ratio of pregnancies complicated by hospitalisation for hyperemesis gravidarum

Objective  To evaluate the sex ratio among pregnancies complicated by first trimester hyperemesis gravidarum and extend previous findings to include a measure of severity.

The Injury severity score in pregnant trauma patients: Predicting placental abruption and fetal death

BACKGROUND The Injury Severity Score (ISS) is the national standard for injury severity assessment but has been rarely validated in the pregnant population. METHODS We evaluated 294 pregnant women who were hospitalized for injury in Washington State from 1989 to 1997. We used ICDMAP-90 computer software to assign an ISS to all women. We identified injured pregnant women who experienced a placental abruption or a fetal death using the Washington State delivery hospitalization data and the birth certificate or fetal death records. We evaluated the accuracy of the ISS in predicting these adverse outcomes using sensitivity analysis. RESULTS We found that the ISS was not accurate in predicting placental abruption and fetal death. We also found that relatively minor injuries were associated with adverse pregnancy outcomes. CONCLUSION A more comprehensive injury assessment tool is needed to accurately predict adverse outcomes in the pregnant trauma population.

Ambient carbon monoxide and fine particulate matter in relation to preeclampsia and preterm delivery in western Washington State.

Background Preterm delivery and preeclampsia are common adverse pregnancy outcomes that have been inconsistently associated with ambient air pollutant exposures. Objectives We aimed to prospectively examine relations between exposures to ambient carbon monoxide (CO) and fine particulate matter [≤ 2.5 μm in aerodynamic diameter (PM2.5)] and risks of preeclampsia and preterm delivery. Methods We used data from 3,509 western Washington women who delivered infants between 1996 and 2006. We predicted ambient CO and PM2.5 exposures using regression models based on regional air pollutant monitoring data. Models contained predictor terms for year, month, weather, and land use characteristics. We evaluated several exposure windows, including prepregnancy, early pregnancy, the first two trimesters, the last month, and the last 3 months of pregnancy. Outcomes were identified using abstracted maternal medical record data. Covariate information was obtained from maternal interviews. Results Predicted periconceptional CO exposure was significantly associated with preeclampsia after adjustment for maternal characteristics and season of conception [adjusted odds ratio (OR) per 0.1 ppm = 1.07; 95% confidence interval (CI), 1.02–1.13]. However, further adjustment for year of conception essentially nullified the association (adjusted OR = 0.98; 95% CI, 0.91–1.06). Associations between PM2.5 and preeclampsia were nonsignificant and weaker than associations estimated for CO, and neither air pollutant was strongly associated with preterm delivery. Patterns were similar across all exposure windows. Conclusions Because both CO concentrations and preeclampsia incidence declined during the study period, secular changes in another preeclampsia risk factor may explain the association observed here. We saw little evidence of other associations with preeclampsia or preterm delivery in this setting.

Correlates of medical and legal help seeking among women reporting intimate partner violence.

OBJECTIVE To examine the relationship between intimate partner violence (IPV) type, severity, and duration and abused womens use of medical and legal services. METHODS Participants were 1509 randomly sampled women from a large health plan who were interviewed by telephone to assess (1) self-reported lifetime exposure to IPV type (physical, sexual, and psychological), severity, and duration and (2) womens use of medical and legal services (civil protection orders). RESULTS Compared with women who experienced psychological abuse only, sexually abused women were 1.3 times as likely to seek medical care, and women exposed to physical IPV or sexual IPV were 3.2 times and 1.6 times as likely, respectively, to seek legal services. Rates of medical and legal help seeking increased with increasing abuse severity among physically abused women, and rates of legal help seeking increased with abuse severity among sexually and psychologically abused women. Longer duration of physical and sexual IPV was also found to be associated with increased legal help seeking. CONCLUSIONS Abused women who sought formal help were more likely to be exposed to physical or sexual IPV, severe psychological IPV, and severe and long-lasting physical and sexual IPV. Efforts should be considered to improve the healthcare and legal systems response to IPV.

Factors associated with contraceptive nonuse among US women ages 35-44 years at risk of unwanted pregnancy.

BACKGROUND Women ages 35 years and older have the greatest proportion of contraceptive nonuse and unintended pregnancies ending in abortion. STUDY DESIGN We conducted a population-based case-control study among women ages 35-44 years at risk of unwanted pregnancy using the National Survey of Family Growth (NSFG) data to investigate risk factors for contraceptive nonuse. RESULTS At last intercourse, 9.8% of women reported not using any contraceptive method. Contraceptive nonusers, as compared to users, were more likely to be ages 40-44 years (OR=2.0, 95% CI 1.1-3.7), foreign-born (OR=4.3, 95% CI 1.9-9.7), black (OR=2.8, 95% CI 1.1-7.0), with household incomes 100-249% of the federal poverty level (FPL) (OR=2.5, 95% CI 1.1-5.8). Women who received contraceptive counseling in the past year had an 80% decreased risk of nonuse (95% CI 0.1-0.5). CONCLUSION Public health strategies to reduce unintended pregnancy, particularly among women ages 35 years and older, should focus on addressing disparities in contraceptive use and promoting contraceptive counseling.

Risk factors for concussive symptoms 1 week or longer in high school athletes.

Objective: To identify risk factors for concussive symptoms ≥ 1 week. Methods: Retrospective cohort study of concussions in the RIO™ database 2006–2009 (n = 1412) analysing risk factors for concussive symptoms ≥ 1 week. This study examined athletes age, sex, weight, history of concussion, number of symptoms and specific symptoms. Data were stratified by football vs. non-football and analysed using Poisson regression to calculate relative risks and 95% confidence intervals. Results: Presenting with four or more symptoms was associated with double the risk for concussive symptoms ≥1 week for both football (95% CI = 1.3–3.5) and non-football players (95% CI = 1.4–4.6). History of prior concussion was associated with double the risk for concussive symptoms ≥1 week in football players only (95% CI = 1.3–3.5). Several symptoms were associated with concussive symptoms ≥1 week in all athletes: drowsiness, nausea and concentration difficulties. Sensitivity to light and noise was associated with concussive symptoms ≥1 week in non-football players only. Amnesia was associated with concussive symptoms ≥1 week in males, but not females. Loss of consciousness was not significant. Conclusions: Risk factors for concussive symptoms ≥1 week are identifiable and can potentially be used to prognosticate for athletes and design evidence-based return-to-play guidelines.

Physician Concussion Knowledge and the Effect of Mailing the CDC’s “Heads Up” Toolkit

Background. The Centers for Disease Control and Prevention’s (CDC) “Heads Up” toolkit was designed to educate physicians about concussion, but it has not been well studied. This study proposed to evaluate the effect of receiving the toolkit on physician concussion knowledge. Methods. The authors obtained a sample of physicians from the American Medical Association masterfile and randomly selected half to be mailed the CDC’s “Heads Up” toolkit. All physicians were then sent a survey on concussion knowledge. Data were analyzed to evaluate the effect of the toolkit on concussion knowledge. Results. The survey was completed by 414 physicians (183 intervention, 231 control). There were no differences in general concussion knowledge between intervention and control groups, but physicians in the intervention group were significantly less likely to recommend next day return to play after a concussion (adjusted odds ratio = 0.31, 95% confidence interval = 0.12-0.76). Conclusions. Mailing the CDC’s “Heads Up” toolkit appears to affect physicians’ recommendations regarding returning to play after a concussion.