Michael P. Marcotte

Antenatal Steroids for Treatment of Fetal Lung Immaturity After 34 Weeks of Gestation: An Evaluation of Neonatal Outcomes

OBJECTIVE: To estimate whether antenatal corticosteroids given after fetal lung immaturity in pregnancies at 34 weeks of gestation or more would improve neonatal outcomes and, in particular, respiratory outcomes. METHODS: We compared outcomes of 362 neonates born at 34 weeks of gestation or more after fetal lung maturity testing: 102 with immature fetal lung indices were treated with antenatal corticosteroids followed by planned delivery within 1 week; 76 with immature fetal lung indices were managed expectantly; and 184 were delivered after mature amniocentesis. Primary outcomes were composites of neonatal and respiratory morbidity. RESULTS: Compared with corticosteroid-exposed neonates those born after mature amniocentesis had lower rates of adverse neonatal (26.5% compared with 14.1%, adjusted odds ratio [OR] 0.51, 95% confidence interval [CI] 0.27–0.96) and adverse respiratory outcomes (9.8% compared with 3.3%, adjusted OR 0.33, 95% CI 0.11–0.98); newborns born after expectant management had significantly less respiratory morbidity (1.3% compared with 9.8%, adjusted OR 0.11, 95% CI 0.01–0.92) compared with corticosteroid-exposed newborns. CONCLUSION: Administration of antenatal corticosteroids after immature fetal lung indices did not reduce respiratory morbidity in neonates born at 34 weeks of gestation or more. Our study supports prolonging gestation until delivery is otherwise indicated. LEVEL OF EVIDENCE: II

Methotrexate pneumonitis after systemic treatment for ectopic pregnancy

Pneumonitis is an infrequent complication of methotrexate therapy. Described is a case of pneumonitis after treatment of an ectopic pregnancy. A 20-year-old white woman, gravida 3, para 0, ectopic pregnancy 2, was treated for her third ectopic pregnancy with 88 mg (50 mg/m2) of intramuscular methotrexate. Four days later acute dyspnea, tachypnea, fever, patchy infiltrates on chest x-ray films, and a PO2 of 30 mm Hg developed. Respiratory distress resolved over 48 hours. Pneumonitis should be suspected in any patient treated with methotrexate who has unexplained dyspnea.

A Statewide Progestogen Promotion Program in Ohio

OBJECTIVE To promote use of progestogen therapy to reduce premature births in Ohio by 10%. METHODS The Ohio Perinatal Quality Collaborative initiated a quality improvement project in 2014 working with clinics at 20 large maternity hospitals, Ohio Medicaid, Medicaid insurers, and service agencies to use quality improvement methods to identify eligible women and remove treatment barriers. The number of women eligible for prophylaxis, the percent prescribed a progestogen before 20 and 24 weeks of gestation, and barriers encountered were reported monthly. Clinics were asked to adopt protocols to identify candidates and initiate treatment promptly. System-level changes were made to expand Medicaid eligibility, maintain Medicaid coverage during pregnancy, improve communication, and adopt uniform data collection and efficient treatment protocols. Rates of singleton births before 32 and 37 weeks of gestation in Ohio hospitals were primary outcomes. We used statistical process control methods to analyze change and generalized linear mixed models to estimate program effects accounting for known risk factors. RESULTS Participating sites tracked 2,562 women eligible for treatment between January 1, 2014, and November 30, 2015. Late entry to care, variable interpretation of treatment guidelines, maintenance of Medicaid coverage, and inefficient communication among health care providers and insurers were identified as treatment barriers. Births before 32 weeks of gestation decreased in all hospitals by 6.6% and in participating hospitals by 8.0%. Births before 32 weeks of gestation to women with prior preterm birth decreased by 20.5% in all hospitals, by 20.3% in African American women, and by 17.1% in women on Medicaid. Births before 37 weeks of gestation were minimally affected. Adjusting for risk factors and birth clustering by hospital confirmed a program-associated 13% (95% confidence interval 0.3-24%) reduction in births before 32 weeks of gestation to women with prior preterm birth. CONCLUSION The Ohio progestogen project was associated with a sustained reduction in singleton births before 32 weeks of gestation in Ohio.

Using improvement science to increase accuracy and reliability of gestational age documentation.

Our aim was to improve the reliability of recording gestational age (GA) in the mothers obstetric record, as this record is used for clinical management, research databases, and eventual transmission to the Ohio Department of Health birth certificates. We performed a prospective cohort study, including all hospital births. We began quality improvement interventions in October 2009. Improvement test cycles were targeted to four working groups, including nursing staff, community obstetric providers, and the process itself. Test cycle results were evaluated to determine which successful interventions could spread further. Rates of process outcome measurements were compared by statistical process control and univariate analysis pre- and postintervention. During the preintervention period, the median daily GA reliability was 25%. To date, over 30 small sample size tests of change have been completed. Of 8795 births studied, significant improvement in GA accuracy/completeness was detected (median postintervention = 78%, p < 0.01). Increased communication of and completion of the prenatal record, in addition to GA recording in high-risk groups, such as premature infants, were also achieved (all p < 0.01). GA reliability can be increased using standardized improvement science methods. Better communication of GA will enable better clinical decisions and foster population-based perinatal research.

Changes in the indications for scheduled births to reduce nonmedically indicated deliveries occurring before 39 weeks of gestation.

OBJECTIVE: To estimate the change in indications for scheduled deliveries during the Ohio Perinatal Quality Collaboratives initiative to decrease scheduled deliveries for nonmedical indications before 39 weeks of gestation. METHODS: Documented indications for scheduled deliveries between 36 0/7 and 38 6/7 weeks were categorized as: strong medically accepted reasons for delivery; intermediate acceptability; and unnecessary before 39 weeks. We describe each of these indication categories as a proportion of all deliveries in the participating hospitals between October 2008 and December 2009. RESULTS: The percentage of scheduled deliveries that were unnecessary before 39 weeks or had intermediate indications decreased over time (P=.03). There were 145 fewer with intermediate reasons and 265 fewer that were unnecessary when the first 4 months of the project were compared with the last 4 months. Strong medical indications as a percentage of all deliveries did not change significantly over time (P=.99). CONCLUSION: Our quality collaborative reduced scheduled deliveries of medically unnecessary and intermediate indications for delivery at 36 0/7 and 38 6/7 weeks. However, scheduled deliveries with strong medical indication did not change significantly over time. LEVEL OF EVIDENCE: III

Intrauterine fetal demise after prenatal diagnosis of congenital heart disease: assessment of risk

Elective deliveries in fetal congenital heart disease (CHD) attempt to balance fetal and neonatal risk with the goal of optimizing overall outcome. However, the magnitude of the risk for intrauterine fetal demise (IUFD) is unclear. This study aimed to (1) determine the rate of IUFD and (2) identify fetal risk factors associated with IUFD.

Using a State Birth Registry as a Quality Improvement Tool

Background Birth registry data are universally collected, generating large administrative datasets. However, these data are typically not used for quality improvement (QI) initiatives in perinatal medicine because the quality and timeliness of the information is uncertain. Objective We sought to identify and address causes of inaccuracy in recording birth registry information so that birth registry data could support statewide obstetrical quality initiatives in Ohio. Study Design The Ohio Perinatal Quality Collaborative and the Ohio Department of Health Vital Statistics used QI techniques in 15 medium‐sized maternity hospitals to identify and remove systemic sources of inaccuracy in birth registry data. The primary outcome was the rate of scheduled deliveries without medical indication between 370/7 and 386/7 weeks at participating hospitals from birth registry data. Results Inaccurate birth registry data most commonly resulted from limited communication between clinical and medical record staff. The rate of scheduled births between 370/7 and 386/7 weeks’ gestation without a documented medical indication as recorded in the birth registry declined by 35%. Conclusion A QI initiative aimed at increasing the accuracy of birth registry information demonstrated the utility of these data for surveillance of perinatal outcomes and has led to ongoing efforts to support birth registrars in submitting accurate data.

Dissemination of a quality improvement intervention to reduce early term elective deliveries and improve birth registry accuracy at scale in Ohio

Methods Participating hospitals were exposed to an 8-month QI intervention to reduce non-medically indicated scheduled deliveries <39 weeks and reflect those improvements in accurate state vital statistics data. The intervention was implemented using a step-wedge design with hospitals divided into three balanced waves. Effectiveness was assessed using interrupted time-series analysis. Interviews with a sample of participants and project call recordings were analyzed using qualitative methods to understand implementation.