Monica A. Lutgendorf

A review of idiopathic hydramnios and pregnancy outcomes.

Idiopathic hydramnios is defined as hydramnios that is not associated with congenital anomalies of the central nervous system or gastrointestinal tract, maternal diabetes, isoimmunizaton, fetal infection (CMV or toxoplasmosis), placental tumors, or multiple gestations. Hydramnios is diagnosed when the AFI is ≥24 or ≥25 (≥95 or ≥97.5%), the single deepest pocket (SDP) as being ≥8, or the examiners subjective assessment of having an increased amount of amniotic fluid volume. The prevalence of hydramnios is 1%–2% with 50%–60% of those cases as being idiopathic. A PUBMED search from 1950 to 2007 and Science Citation search from 2001 to 2007 revealed only 3 studies that compared pregnancies with idiopathic hydramnios to pregnancies without hydramnios, and 4 studies that evaluated perinatal mortality with hydramnios after correcting for congenital anomalies. Idiopathic hydramnios was found in the larger studies to be linked to fetal macrosomia, an increase in the risk of adverse pregnancy outcomes, and a 2- to 5-fold increase in the risk of perinatal mortality. Tests that may be helpful in the antenatal evaluation of these at-risk pregnancies are: Doppler flow velocimetry of the middle cerebral artery, nonstress test, biophysical profile, and contraction stress test. Prospective studies are needed in this area that is understudied where risk of an adverse pregnancy outcome and perinatal mortality are increased. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state the prevalence of idiopathic hydramnios, recall the lack of data relating to outcome, explain that there is a 2- to 5-fold increase in the risk of perinatal mortality, and summarize the lack of consensus in monitoring pregnancies afflicted with idiopathic hydramnios.

Peripartum outcomes of high-risk pregnancies complicated by oligo- and polyhydramnios: A prospective longitudinal study

Aim:  To determine pregnancy outcomes in high‐risk non‐anomalous singleton pregnancies with oligo‐ and polyhydramnios.

Noninvasive prenatal testing: limitations and unanswered questions

The clinical use of noninvasive prenatal testing to screen high-risk patients for fetal aneuploidy is becoming increasingly common. Initial studies have demonstrated high sensitivity and specificity, and there is hope that these tests will result in a reduction of invasive diagnostic procedures as well as their associated risks. Guidelines on the use of this testing in clinical practice have been published; however, data on actual test performance in a clinical setting are lacking, and there are no guidelines on quality control and assurance. The different noninvasive prenatal tests employ complex methodologies, which may be challenging for health-care providers to understand and utilize in counseling patients, particularly as the field continues to evolve. How these new tests should be integrated into current screening programs and their effect on health-care costs remain uncertain.Genet Med 2014:16(4):281–285.

A multicenter assessment of 1,177 cases of shoulder dystocia: lessons learned.

The purposes of this review were to describe deliveries complicated by shoulder dystocia (SD) at three tertiary centers and discern the differences between SD with and without brachial plexus injury (BPI). The inclusion criteria for this multicenter, retrospective study were singletons, delivered vaginally with SD. To discern the risk factors for SD with and without injury, a case (SD and BPI) versus control (3 SD without injury at the same institution) design was used. Multiple linear regression was employed. Over a 7-year period, among 46,637 vaginal deliveries, SD occurred in 1,177 cases (2.5%) and BPI was noted in 11%. The results of multiple regression indicate that gestational age, operative delivery, and the number of maneuvers and concomitant fracture (4%) were statistically associated with BPI following SD (p < 0.001). SD was not associated with BPI in 89% and 88% of the cases that were resolved with McRoberts maneuver and suprapubic pressure, whereas only 0.2% of cases were litigated.

Implementation of a Protocol to Reduce Occurrence of Retained Sponges After Vaginal Delivery

BACKGROUND Retained sponges (gossypiboma) following vaginal delivery are an uncommon occurrence. Although significant morbidity from such an event is unlikely, there are many reported adverse effects, including symptoms of malodorous discharge, loss of confidence in providers and the medical system, and legal claims. OBJECTIVE To report a protocol intended to reduce the occurrence of retained sponges following vaginal delivery. METHODS After identification of limitations with existing delivery room protocols, we developed a sponge count protocol to reduce occurrence of retained vaginal sponges. We report our experience at Naval Medical Center Portsmouth, a large tertiary care military treatment facility with our efforts to implement a sponge count protocol to reduce retained sponges following vaginal delivery. CONCLUSIONS With appropriate pre-implementation training, protocols which incorporate post-delivery vaginal sweep and sponge counts are well accepted by the health care team and can be incorporated into the delivery room routine.

Association of obstructive sleep apnea with adverse pregnancy-related outcomes in military hospitals

BACKGROUND Obstructive sleep apnea (OSA) is associated with significant morbidity and mortality in non-obstetrical and obstetrical patients. OBJECTIVES To estimate the prevalence of OSA and its relationship with pregnancy-related complications in a general obstetric population of Department of Defense beneficiaries receiving direct-care at military treatment facilities. STUDY DESIGN A retrospective cohort study of all women (N=305,001) who gave birth at a military treatment facility from 2008 to 2014. OSA cases were randomly selected and matched on age (3:1 ratio) to non OSA cases. Multivariable logistic regression was used to examine the risks of adverse pregnancy outcomes (cesarean delivery, gestational diabetes, gestational hypertension, preeclampsia, postoperative wound complications, hospital stay greater than five days, acute renal failure, pulmonary edema, preterm delivery, poor fetal growth, and stillbirth) between pregnant women with and without a diagnosis of OSA. Cases were identified using ICD-9 codes, while controlling for demographics, obesity, and medical comorbidities associated with OSA and the outcomes of interest. RESULTS We identified 266 cases of OSA (OSA rate=8.7 per 10,000; increased from 6.4 to 9.9 per 10,000 from 2009 to 2013). OSA was associated with a higher odds of cesarean delivery (AOR,1.60; 95% CI, 1.06-2.40), gestational hypertension, (AOR, 2.46; 95% CI, 1.30-4.68), preeclampsia (AOR, 2.42; 95% CI, 1.43-4.09), and preterm delivery (AOR, 1.90; 95% CI, 1.09-3.30). CONCLUSIONS Obstructive sleep apnea is associated with adverse maternal and fetal outcomes.

Prevalence of Domestic Violence in a Pregnant Military Population

OBJECTIVE: To estimate the prevalence of domestic violence and the characteristics of pregnant women reporting domestic violence in a military setting. METHODS: This was a prospective observational study of patients presenting for prenatal care to a Naval hospital from January 2007 to March 2008. Participants were screened anonymously for domestic violence using the Abuse Assessment Screen. Data were summarized using medians, interquartile ranges, and frequency distributions. Univariable comparisons between groups were conducted using Mann–Whitney tests for continuous data and &khgr;2 tests for categorical outcomes RESULTS: Of the 1,162 surveys, 14.5% screened positive for abuse (either current or past), and 1.5% of respondents reported current pregnancy abuse. Relative to married women, single women (odds ratio [OR] 1.81, 95% confidence interval [CI] 1.04–3.16, P=.036) and separated or divorced women (OR 3.45, 95% CI 1.59–7.46, P=.002) were at an overall increased risk of physical or emotional partner abuse. Compared with married women, the single women (OR 2.80, 95% CI 1.35–5.78, P=.005), but not the separated or divorced women (P=.172), were at increased risk for partner abuse in the previous 12 months. A family history of abuse also was associated with an increased risk of abuse within the previous 12 months (OR 5.99, 95% CI 2.99–11.99, P<.001). CONCLUSION: The prevalence of domestic violence in our pregnant military population was 14.5%, which is in the upper range of the prevalence reported in a nonmilitary population (0.9–23%). Unmarried status and a history of abuse may indicate a higher abuse risk. LEVEL OF EVIDENCE: III

Effect of Dexamethasone Administered With Magnesium Sulfate on Inflammation-Mediated Degradation of the Blood–Brain Barrier Using an In Vitro Model

Patients at risk for preterm delivery are frequently administered both antenatal steroids for fetal maturation and magnesium sulfate for neuroprotection. In this study, we investigate whether steroids coadministered with magnesium sulfate preserve blood–brain barrier integrity in neuroinflammation. Human umbilical vein endothelial cells were grown in astroglial conditioned media in a 2-chamber cell culture apparatus. Treatment with tumor necrosis factor-α (TNF-α) or catalytically active recombinant matrix metalloproteinase 9 (MMP-9) simulated neuroinflammation. Membrane integrity was assessed by zona occludens 1 (ZO-1) immunoreactivity, permeability to fluorescently conjugated dextran, and transendothelial electrical resistance (TEER). The TNF-α and MMP-9 treatment increased the rate of dextran transit, decreased TEER, and decreased ZO-1 immunoreactivity at junctional interfaces. Dexamethasone pretreatment alone or in combination with 0.5 mmol/L magnesium sulfate preserved monolayer integrity after inflammatory insult. Magnesium sulfate alone was not protective. This study supports a possible interaction between steroids and magnesium in neuroprotection.

Multidisciplinary In Situ Simulation-Based Training as a Postpartum Hemorrhage Quality Improvement Project

BACKGROUND Postpartum hemorrhage is a common obstetric emergency affecting 3 to 5% of deliveries, with significant maternal morbidity and mortality. Effective management of postpartum hemorrhage requires strong teamwork and collaboration. We completed a multidisciplinary in situ postpartum hemorrhage simulation training exercise with structured team debriefing to evaluate hospital protocols, team performance, operational readiness, and real-time identification of system improvements. Our objective was to assess participant comfort with managing obstetric hemorrhage following our multidisciplinary in situ simulation training exercise. METHODS This was a quality improvement project that utilized a comprehensive multidisciplinary in situ postpartum hemorrhage simulation exercise. Participants from the Departments of Obstetrics and Gynecology, Anesthesia, Nursing, Pediatrics, and Transfusion Services completed the training exercise in 16 scenarios run over 2 days. The intervention was a high fidelity, multidisciplinary in situ simulation training to evaluate hospital protocols, team performance, operational readiness, and system improvements. Structured debriefing was conducted with the participants to discuss communication and team functioning. Our main outcome measure was participant self-reported comfort levels for managing postpartum hemorrhage before and after simulation training. A 5-point Likert scale (1 being very uncomfortable and 5 being very comfortable) was used to measure participant comfort. A paired t test was used to assess differences in participant responses before and after the simulation exercise. We also measured the time to prepare simulated blood products and followed the number of postpartum hemorrhage cases before and after the simulation exercise. RESULTS We trained 113 health care professionals including obstetricians, midwives, residents, anesthesiologists, nurse anesthetists, nurses, and medical assistants. Participants reported a higher comfort level in managing obstetric emergencies and postpartum hemorrhage after simulation training compared to before training. For managing hypertensive emergencies, the post-training mean score was 4.14 compared to a pretraining mean score of 3.88 (p = 0.01, 95% confidence interval [CI] = 0.06-0.47). For shoulder dystocia, the post-training mean score was 4.29 compared to a pretraining mean score of 3.66 (p = 0.001, 95% CI = 0.41-0.88). For postpartum hemorrhage, the post-training mean score was 4.35 compared to pretraining mean score of 3.86 (p = 0.001, 95% CI = 0.36-0.63). We also observed a decrease in the time to prepare simulated blood products over the course of the simulation, and a decreasing trend of postpartum hemorrhage cases, which continued after initiating the postpartum hemorrhage simulation exercise. DISCUSSION Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality in the United States. Comprehensive hemorrhage protocols have been shown to improve outcomes related to postpartum hemorrhage, and a critical component in these processes include communication, teamwork, and team-based practice/simulation. As medicine becomes increasingly complex, the ability to practice in a safe setting is ever more critical, especially for low-volume, high-stakes events such as postpartum hemorrhage. These events require well-functioning teams and systems coupled with rapid assessment and appropriate clinical action to ensure best patient outcomes. We have shown that a multidisciplinary in situ simulation exercise improves self-reported comfort with managing obstetric emergencies, and is a safe and effective way to practice skills and improve systems processes in the health care setting.

Risk factors for a prolonged third stage of labor and postpartum hemorrhage.

Objectives To determine the effect of a third stage of labor ≥15 minutes on bleeding after delivery and other risk factors for a postpartum hemorrhage (PPH). Methods This was a case-control study of women undergoing vaginal delivery with placental delivery ≥15 minutes matched by gestational age to the next delivery with placental delivery <15 minutes. Multiple risk factors were evaluated for association with delayed placenta and with PPH. Results There were 226 pregnancies ≥15 minutes (cases) versus 226 whose placental time was <15 minutes (controls). The best-fit model identified placental delivery ≥15 minutes, history of retained placenta, nulliparity, and increased length of first stage of labor as significant factors for PPH. Conclusions The best risk model for PPH includes placental delivery ≥15 minutes, history of retained placenta, nulliparity, and longer first stage of labor.