Shravya Govindappagari

Outcome of pregnancy when gestational diabetes mellitus is diagnosed before or after 24 weeks of gestation.

INTRODUCTION: The objective of this study was to compare the outcome of pregnancy in women diagnosed with gestational diabetes mellitus (GDM) before 24 weeks of gestation with those diagnosed after 24 weeks of gestation. METHODS: The records of women with a GDM were reviewed over a 5-year period. All women are routinely screened for GDM at their first prenatal visit before 24 weeks of gestation and if negative, a repeat screening occurs at 24–28 weeks of gestation. Two groups were formed based on gestational age of the diagnosis of GDM, a group diagnosed before 24 weeks of gestation and a group diagnosed after 24 weeks of gestation. Multiple gestations, incomplete records, and delivery before 22 weeks of gestation were excluded. Standard statistics and regression analysis considered P<.05 significant and the study was approved by the institutional review board. RESULTS: There were 305 women diagnosed with GDM before 24 weeks of gestation and 401 women diagnosed after 24 weeks of gestation included in the study. The GDM before 24 weeks of gestation group was older, had more obese women (body mass index greater than 30 kg/m2), delivered earlier, and had a lower birth weight. The groups were similar when comparing cesarean delivery rates, preeclampsia, fetal demise, shoulder dystocia, and macrosomia (birth weight greater than 4,000 g) (Table 1). In multivariate regression analysis, diagnosis of GDM before 24 weeks of gestation was an independent predictor of preterm birth (less than 37 weeks of gestation; Table 2). Table 1 Maternal Demographics and Pregnancy Outcomes (Ngai, p. 162–3S) Table 2 Multivariate Regression Analysis of Independent Predictors of Preterm Birth (Ngai, p. 162–3S) CONCLUSION: The diagnosis of GDM before 24 weeks of gestation is associated with preterm delivery when compared with women diagnosed after 24 weeks of gestation.

Risk of Peripartum Hysterectomy and Center Hysterectomy and Delivery Volume.

OBJECTIVE: To characterize where women at risk for and undergoing peripartum hysterectomy delivered in terms of obstetric volume and procedural experience. METHODS: We used data from the Perspective database to retrospectively evaluate trends in peripartum hysterectomy and deliveries at high risk of peripartum hysterectomy based on placenta previa and prior cesarean delivery delivered from 2006 through 2014. Hospitals were categorized two separate ways for the analysis: 1) into five roughly equal quintiles based on annualized delivery volume and 2) by the mean number of hysterectomies performed annually over the study period. RESULTS: Four thousand eight hundred eleven hysterectomies occurred among 5,388,486 deliveries in 500 hospitals over the study period. The peripartum hysterectomy rate increased from 81.4 per 100,000 deliveries in 2006 to 98.4 in 2014. The prevalence rate of placenta previa in the setting of previous cesarean delivery also increased over the study period. Between 2006–2008 and 2012–2014, peripartum hysterectomy decreased in the lowest delivery volume quintile and increased in the highest delivery volume quintile (–14.9/100,000 deliveries, 95% confidence interval [CI] −25.6 to −4.2 and +35.4/100,000 deliveries, 95% CI 20.3–50.5, respectively). Similarly, hospitals performing high rates of hysterectomies saw the largest increase over the study period. CONCLUSION: With peripartum hysterectomy rates increasing in the population, hospitals with high delivery volumes and high rates of hysterectomies saw the largest increases in peripartum hysterectomy rates. These trends support that improved referral practices and uptake of evidence-based recommendations may be occurring.

Is Communication Improved With the Implementation of an Obstetrical Version of the World Health Organization Safe Surgery Checklist

Objective Communication failures are consistently seen as a root cause of preventable adverse outcomes in obstetrics. We assessed whether use of an Obstetric Safe Surgery Checklist for cesarean deliveries (CDs), based on the WHO Safe Surgery Checklist, can improve communication; reduce team member confusion about urgency of the case; and decrease documentation discrepancies among nursing, obstetric, anesthesia, and pediatric staff. Methods Retrospective review of 600 CDs on our 2 labor and delivery suites before and after the introduction of 2 consecutive versions of our obstetric safe surgery checklist (100 cases in each cohort) was undertaken. The first version was released in 2010, and after modifications based on initial findings, our current version was released in 2014. One hundred consecutive CDs were identified from each of the 3 periods at each hospital, and charts for those patients and newborns were abstracted. Notes by obstetricians, nurses, anesthesiologists, and pediatricians were reviewed. We compared the rates of agreement in the documentation of the indication for the CD between the different members of the team. Chi-square analyses were performed. Results Complete agreement among the 4 specialties in the documented indication for CD before introduction of our initial safe surgery checklist was noted in 59% (n = 118) of cases. After initial checklist introduction, agreement decreased to 43% (n = 86; P = 0.002). We then modified our checklist to include indication for CD and level of urgency and changed our policy to include pediatric staff participation in the timeout. Agreement in a subsequent chart review increased to 80% (n = 160), significantly better than in our initial analysis (P < 0.001) and our interim review (P < 0.001). The greatest improvement in agreement was observed between obstetricians and pediatricians. Conclusions Implementation of a safe surgery checklist can improve communication at CDs, but care should be taken when implementing checklists because they can have unanticipated consequences. Ongoing review and modification are critical to ensure safer medical care.

A SWIFT Method for Handing Off Obstetrical Patients on the Labor Floor

OBJECTIVE The aim of this study was to improve patient handoffs on the labor floor. METHODS A prospective cohort study of obstetrics residents at Montefiore Medical Center was performed between 2012 and 2014. Labor-floor handoffs were recorded before and after didactic sessions as well as after installation of whiteboards formatted with the mnemonic SWIFT (Subject, Why?, Issues, Fetus, Tasks). Handoff transcripts were evaluated by obstetricians blinded to timing and speaker identity. An intraclass correlation coefficient accounted for evaluator differences. Data analysis was by ordinal logistic regression, the generalized estimating equations method (correlated data), and Bonferroni adjustment (multiple comparisons). RESULTS Forty-five handoffs were evaluated (15 each predidactics, postdidactics, and postwhiteboard revision). Higher completeness scores over time were noted for admission reason, labor concerns, and task list (not statistically significant). Comprehensive score increases prelecture to postwhiteboard were seen in handoff clarity (2.81 versus 2.91) and overall quality (2.77 versus 2.81) (not statistically significant). A subanalysis of four residents who gave multiple handoffs over different periods revealed few significant changes over time. Greater interevaluator consistency was noted with more objective elements. CONCLUSIONS The mnemonic SWIFT, with formalized curricula for obstetrical resident training focusing on new learners and increased faculty involvement and reinforcement, may result in improvement of handoffs on the labor floor.

Using publicly reported hospital data to predict obstetric quality

Abstract Purpose: To determine the association between obstetric outcomes and publicly reported hospital data on patient satisfaction, surgical quality measures and medical outcomes. Materials and methods: Hospitals in the Nationwide Inpatient Sample in 2011 were linked to Hospital Compare, a source of hospital data on patient satisfaction, quality and mortality for medical conditions. The risk-adjusted hospital-level rates of obstetric morbidity, episiotomy and lacerations were compared across the hospitals and reported as the absolute reduction in risk (ARR). Results: We identified 528 708 women. There was no association between any of the metrics and risk-adjusted obstetric morbidity (range −0.15% to 0.03% difference). Hospitals with a high mortality rate for pneumonia had a 0.38% (95% CI: 0.13% to 0.64%) higher rate of risk-adjusted third- and fourth-degree lacerations, while hospitals with a higher death rate for myocardial infarction had a −0.74% (95% CI, −1.34% to −0.14%) lower risk-adjusted episiotomy rate. The differences in the remainder of the publicly reported metrics and the risk adjusted rates of third- and fourth-degree lacerations and episiotomy were small and not statistically significant (p  > 0.05). Conclusion: There is little association between currently available, publically reported hospital data and obstetric quality. Obstetric-specific hospital measures of quality and satisfaction are needed.

A SWIFT Method for Handing Off Obstetrical Patients on the Labor Floor [23B]

INTRODUCTION: Rapidly changing labor statuses and resident work hour restrictions resulting in multiple patient care transitions make obstetrical handoffs vulnerable to significant errors that may result in medical misfortunes. This study aimed to train obstetrical residents to improve handoffs using the novel mnemonic “SWIFT”: Subject, Why?, Issues, Fetus, Tasks. METHODS: A needs-assessment survey of obstetrics residents was performed. Resident labor-floor handoffs were recorded with a hidden voice recorder before and after didactic sessions, and after replacing the whiteboards used at shift turnover with ones formatted with the mnemonic SWIFT. Attending obstetricians blinded to timing and speaker identity evaluated handoff transcripts. An intraclass correlation coefficient accounted for evaluator differences. Data analysis was by ordinal logistic regression, the GEE method (for correlated data) and Bonferroni adjustment (for multiple comparisons). RESULTS: Forty-five individual handoffs were evaluated (15 each pre-didactics, post-didactics and post-whiteboard revision). Over time, higher completeness scores over were noted for admission reason, labor concerns, and task list, and comprehensive score increases were seen in handoff clarity (2.81 vs 2.91) and overall quality (2.77 vs 2.81) but none were significant. A subanalysis of four residents who gave multiple handoffs over different time periods revealed few changes over time. Greater inter-evaluator consistency was noted with more objective elements. CONCLUSION: The mnemonic SWIFT may be helpful in obstetrical handoffs. Formalized curricula for obstetrical resident training, focusing on new learners, with increased faculty involvement and reinforcement may result labor floor handoff improvements and fewer medical errors.

Delivery Outcomes After Acute Migraine Treatment in Pregnancy: A Retrospective Study [24C]

INTRODUCTION: Experiencing acute severe migraine attacks during pregnancy may indicate particularly severe and active disease. Data regarding delivery outcomes in this population is lacking. We aimed to describe birth outcomes in pregnant patients presenting to the hospital setting with acute severe migraine attacks. METHODS: We reviewed pregnancy and delivery records of consecutive inpatient neurology consultations for acute headache in pregnant women at a tertiary hospital over a 5 year period. RESULTS: Ninety pregnant women with acute migraine had a mean age of 29.3 years. Nearly half had migraine with aura (40.7%), 12.8% had chronic migraine, and 31.4% presented in status migrainosus. Delivery complications included 54.4% for at least one adverse outcome, 28.2% for preterm delivery, 20.5% for preeclampsia, 30.8% for Cesarean delivery, and 19.2% for low birthweight. In binary logistic regression analysis, migraine with aura was associated with a lower rate (OR 0.28, 95% CI 0.09–0.86) but chronic migraine (OR 1.59, 95% CI 0.29–8.78) and status migrainosus (OR 0.66, 95% CI 0.22–2.02) were not associated with adverse pooled outcomes. Age at or above 35 was independently associated with adverse outcomes (OR 7.37, 95% CI 1.97–30.4). CONCLUSION: Pregnant women seeking acute migraine treatment experienced a higher rate of preterm delivery, preeclampsia and low birthweight but a lower rate of cesarean delivery than the general population. However, there were no independent associations with chronic migraine or status migrainosus. Nonetheless, with more than half of patients in this study experiencing some type of adverse birth outcome pregnancies in such patients should be considered high risk.

Barriers to Exercise for Urban Parturients

INTRODUCTION: The objective of this study was to identify unique barriers to exercise during pregnancy in an underserved urban population. METHODS: Pregnant patients at scheduled prenatal appointments were given survey forms to fill out regarding willingness to exercise and preferred type of exercise while waiting to be seen. Verbal announcements and published flyers were also given to the patients about a novel weekly prenatal Zumba exercise program organized through the office, tutored by a licensed Zumba instructor. Patients who did not participate were queried by phone as to reasons for nonparticipation. Access to DVD players and willingness to exercise if provided with an exercise DVD were ascertained. RESULTS: Fifty-two patients completed surveys. All 52 women expressed an interest in participating in regular physical activity and (27/52 [52%]) noted an interest in the Zumba class. However, only three patients participated in the Zumba program. Thirty-one patients were reached by telephone (31/49 [63.3%]). The reasons for nonparticipation elucidated were: employment obligation (8/31 [25.8%]); child care responsibilities (5/31 [16.1%]); lack of awareness of class schedule (5/31 [16.1%]); pregnancy complications (3/31 [9.7%]); and inadequate access to transportation (2/31 [6.4%]). Despite the low class participation rate, 93.5% (29/31) of women reported access to audiovisual equipment and indicated that they would do exercise if provided with a DVD exercise video for home use. CONCLUSION: In our urban population, there are multiple barriers that prevented pregnant patients from participating in this structured outside exercise program. However, identifying previously unappreciated barriers to exercise in an urban population encourages us to provide an alternative home-based exercise regimen that may increase participation.