Sindhu Srinivas

Can transabdominal ultrasound be used as a screening test for short cervical length

OBJECTIVEnUniversal transvaginal cervical length screening can be associated with a significant logistical burden. We hypothesized that there is a threshold cervical length measured by transabdominal ultrasound above which risk for short transvaginal cervical length is extremely low.nnnSTUDY DESIGNnThis prospective cohort study evaluated a consecutive series of women offered universal transvaginal cervical length screening during anatomy ultrasound. Transabdominal measurement of the cervix-obtained before and after voiding for each patient-was performed before transvaginal ultrasound. The study was powered to detect a transabdominal cervical length cutoff with 95% sensitivity (95% confidence interval, 90-99%) for transvaginal cervical length of ≤25 mm.nnnRESULTSnOne thousand two hundred seventeen women were included in the analysis. Prevoid transabdominal cervical length ≤36 mm detects 96% of transvaginal cervical lengths ≤25 mm with 39% specificity. A prevoid transabdominal cervical length ≤35 mm detects 100% of transvaginal cervical lengths ≤20 mm with 41% specificity. Transabdominal images of the cervix could not be obtained in 6.2% of women prevoid and 17.9% of women postvoid.nnnCONCLUSIONnTransabdominal cervical length screening successfully identifies women at very low risk for short transvaginal cervical length. Transabdominal screening may significantly reduce the burden of universal cervical length screening by allowing approximately 40% of women to avoid transvaginal ultrasound. To ensure high sensitivity of transabdominal screening, approximately 60% of patients will still require a transvaginal study.

Excessive weight gain and hypertensive disorders of pregnancy in the obese patient.

Abstract Objective: To evaluate the association between excessive weight gain and pregnancy-related hypertension (PRH) among obese women (body mass index (BMI) ≥30u2009kg/m2). Methods: We performed a case control study among women with (nu2009=u2009440) and without (nu2009=u2009600) PRH from 2005 to 2007. Height and weight were recorded at initial and final prenatal visits. 695 women had BMI recorded at ≤18 weeks of gestation, of which 257 (36.9%) were obese. Obese women were divided into three categories based on 2009 Institute of Medicine (IOM) guidelines: (1) below recommended amount (under weight gain – UWG); (2) more than recommended (excessive weight gain – EWG) or (3) within recommended amount (normal weight gain – NWG). PRH was defined as gestational hypertension, mild or severe preeclampsia. Patients with and without PRH were prospectively identified. The association between weight gain category and development of PRH was analyzed. Results: We noticed a 1.5-fold higher odds of having PRH with an initial BMI ≥30u2009kg/m2 compared to BMI <30u2009kg/m2 (OR 1.64, 95% CI 1.2–2.2, pu2009=u20090.002). Among obese women, we noted a 2-fold higher odds of having PRH with EWG compared to NWG (OR 2.52, 95% CI 1.2–3.9, pu2009=u20090.012). The increased odds persisted after adjusting for race, chronic hypertension and diabetes, and length of gestation (AOR 2.61, 95% CI 1.4–4.9, pu2009=u20090.003). Among obese women with PRH, those with EWG had a 76% decreased odds of having severe disease compared to NWG (ORu2009=u20090.242 [0.07–0.79], pu2009=u20090.019). Conclusion: We have demonstrated that EWG among obese patients increases overall risk of PRH.

Antenatal corticosteroid administration: understanding its use as an obstetric quality metric.

OBJECTIVEnIn 1994, the National Institutes of Health recommended a full course of antenatal corticosteroids (ACS) to women who were at risk of delivery at 24-32 weeks of gestation. In 2010, the Joint Commission on Accreditation of Healthcare Organization incorporated ACS administration rates as a perinatal core quality measure. The objective of this study is (1) to assess ACS administration rates among eligible patients at a tertiary care center and (2) to identify modifiable factors to optimize administration rates.nnnSTUDY DESIGNnA retrospective chart review of preterm deliveries at <37 weeks of gestation from July 2009 to July 2011 was performed. Hospital level data, delivery information, obstetric history, and neonatal outcomes were abstracted. Categoric variables were compared with the use of the χ(2) test. Continuous variables were compared with the use of a 2-sample t-test, Wilcoxon rank-sum, or Kruskal Wallis tests.nnnRESULTSnNine hundred four women had preterm delivery; 38% of them delivered from 24-34 weeks of gestation. Of the eligible patients, 81.3% received at least 1 dose of ACS, and 69.6% received both doses before delivery. The median time from evaluation to ACS administration was 2.6 hours (interquartile range, 1.6-4.8 hours). Thirty-three percent of the patients who did not receive ACS had had a previous triage visit within 2 weeks of delivery (66.6% of them were evaluated for symptoms of preterm labor) vs 2.8% for those women who received ACS.nnnCONCLUSIONnOf the eligible patients, 81.3% received at least 1 dose of ACS. Tangible opportunities that were identified for systems-based improvement in ACS administration rates included decreasing the time interval from patient evaluation to ACS administration and standardizing outpatient follow-up evaluation for patients who were discharged with symptoms of preterm labor.

Epidemiology of maternal morbidity and mortality

Maternal morbidity and mortality remains a significant health care concern in the United States, as the rates continue to rise despite efforts to improve maternal health. In 2013, the United States ranked 60th in maternal mortality worldwide. We review the definitions, rates, trends, and top causes of severe maternal morbidity and mortality, as well as risk factors for adverse maternal outcomes. We describe current local and national initiatives in place to reduce maternal morbidity and mortality and offer suggestions for future research.

Incidence, determinants and outcomes of pregnancy-associated hepatitis B flares: A regional hospital-based cohort study

There is limited knowledge about hepatitis B virus (HBV) flare among pregnant women. We evaluated the incidence, determinants and outcomes of HBV flare in a multicultural cohort of pregnant HBV‐infected women in the United States.

Interdisciplinary Skills Review Program to Improve Team Responses During Postpartum Hemorrhage

Objective: To develop an interdisciplinary, interactive, skills review program to improve team responses during a postpartum hemorrhage (PPH). Design: Online didactic modules in combination with an interdisciplinary skills program consisting of seven hemorrhage‐related stations. Setting/Local Problem: The project was conducted in the Womens Health Department in a quaternary‐care Magnet‐ and Baby Friendly–designated academic medical center in Philadelphia, Pennsylvania. Women cared for at this center have comorbidities that place them at greater risk for PPH. A need was identified to implement a multidisciplinary and comprehensive program to assess hemorrhage risk and appropriately recognize and intervene with all PPHs in this setting. Participants: The 276 participants, including registered nurses, obstetric and family medicine attending physicians and residents, advanced practice nurses, and ancillary staff in the hospitals Womens Health Department, completed the initial obstetric hemorrhage program. Intervention/Measurements: The program included online didactic modules, seven interdisciplinary skills stations led by trained nurses and providers, and an in situ simulation. Successful completion of the online modules was a prerequisite for participation in the skills stations. All participants completed a written program evaluation at the conclusion of the program. Results: Results of the postassessment survey indicated that participants rated the program 3.94 of 4.00 for overall effectiveness to improve interdisciplinary team responses to PPH. Comments were overwhelmingly positive, and participants expressed increased confidence and knowledge related to PPH after completion of the program. Conclusion: An interdisciplinary program that included online didactic modules, interactive skills stations, and simulation improved team confidence and responses to PPH.

IMPROVING HANDOFFS BETWEEN TRIAGE AND LABOR AND DELIVERY AT A UNIVERSITY HOSPITAL: A PILOT STUDY

Background Labor and Delivery (LD) is a high turnover unit with approximately 300 triage admission handoffs monthly. This results in a high potential for errors, inefficiency and decreased staff and patient satisfaction. Objectives Our objective was to improve efficiency, communication and safety through collaboration and standardization of the process for patients being admitted from triage to LD. Methods An interdisciplinary team developed and implemented the standardized process at a University Hospital. The process was developed to communicate critical information prior to transferring a patient from triage to LD utilizing hard stops. Once transferred, a bedside safety huddle with the patient, nurse and provider was implemented to review the care plan utilizing a newly devised safety board. Times from decision to admit to communication of plan (DTC) and plan implementation (DTI) were assessed. Pre (N=104) and post (N=52) surveys assessed staff perception of handoffs. Kruskall-wallis tests were used to compare groups. Results During the initial 4-week implementation, we decreased DTC from 155 to 87 minutes (p=0.18) and DTI from 202 to 154 minutes (p=0.6). The staff perception of incomplete handoffs was decreased by 45%. The perception that incomplete handoffs negatively affect patient care always or often decreased from 10% pre to 0% post. Conclusions Our data demonstrates that our process decreases DTC and DTI while improving the perception of incomplete handoffs. We plan to pursue continued education of the process and an expansion to all admissions to labor and delivery with continued tracking of process compliance and metrics.

The High-Risk Postpartum Transitional Program: A Multidisciplinary Approach to Caring for Postpartum Woman With Hypertensive Disease

Childbearing Poster Presentation Purpose for the Program Preeclampsia complicates 5% to 8% of all pregnancies, is the second leading cause of maternal death in the United States, and a common cause of unplanned postpartum hospital readmissions. Women with perinatal hypertensive disease are also at increased risk of future cardiovascular disease. The High-Risk Postpartum Transitional Program targets postpartum women at risk of persistent hypertensive disease and includes women with the diagnoses of preeclampsia, eclampsia, hemolysis, elevated liver enzymes, and low platelet counts (HELLP), gestational hypertension, and chronic hypertension. The purpose and goal of the program is to standardize care for postpartum women with hypertensive disease, decrease postpartum morbidity, and decrease hospital readmissions related to hypertension. Proposed Change A multidisciplinary team developed a standardized clinical protocol that addressed surveillance, treatment, education, and follow-up across the continuum from identification through delivery and beyond discharge. Identified patients received education about their disease, future health implications, lifestyle modifications, and medication education if appropriate. Home care blood pressure (BP) and symptom monitoring was arranged, and an appointment was made for the patient to return within 2 weeks to the High-Risk Postpartum Transitional Clinic. A follow-up phone call was made before the appointment as reinforcement. Implementation, Outcomes, and Evaluation Overall readmission rates for patients involved in the High-Risk Postpartum Transitional Program have decreased since it was initiated in the summer of 2012. Recently, we initiated follow-up telephone calls with the goal of bolstering the current clinic admittance rate of 45% to 60%. Our multidisciplinary Unit-Based Clinical Leadership is exploring additional strategies that will enable us to serve more women through partnerships with community outreach programs and additional home care agencies. Implications for Nursing Practice As primary coordinators of postpartum care, the nurses role is a critical factor in its development, implementation, and success. Postpartum clinical nurses educate these women about their disease and its effect on future health, and consult with other professional disciplines such as social work and the unit-based clinical pharmacist to provide additional resources. Unit-based clinical resource coordinator nurses arrange postdischarge home care nursing services for BP and symptom monitoring and womens health nurse practitioners offer inpatient support and a mechanism for home care nurses to triage identified concerns and reinforce education. This program offers nursing research opportunities to study the effect of nursing interventions on postpartum morbidities, such as hypertensive disease.