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Moaddab A, Klassen M, Priester CD, Munoz EH, Belfort MA, Clark SL, Dildy GA. Reproductive decisions after the diagnosis of amniotic fluid embolism. Eur J Obstet Gynecol Reprod Biol 2017; 211:33-36. [PMID: 28192732 DOI: 10.1016/j.ejogrb.2017.01.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study aims to describe the subsequent reproductive outcomes in women who either correctly or incorrectly were diagnosed with amniotic fluid embolism (AFE). STUDY DESIGN Medical records were obtained, abstracted and reviewed by authors with extensive experience in critical care obstetrics. Telephone interviews of all survivors were conducted to determine obstetrical and contraceptive history. A subgroup underwent further telephone interview to address subsequent reproductive decisions. RESULTS By November 2015, 116 medical records of patients diagnosed with AFE were reviewed. Patients who had undergone hysterectomy (n=26), died (n=9), or developed Sheehan's syndrome (n=1) at the time of the original event were excluded from the present analysis. Of the remaining 80 women, 30% (24/80) had subsequently conceived and 32.5% (26/80) patients or their partners had undergone permanent sterilization. At the time of this report, 66% (21/32) of registry participants were categorized to have had AFE and 34% (11/32) as not likely AFE or indeterminate. CONCLUSIONS The syndrome of AFE is over-diagnosed. Women diagnosed with AFE who survive conceive another pregnancy less frequently than US women over similar time intervals and often choose a permanent sterilization method, whether or not they actually had AFE, largely out of fear of AFE recurrence.
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Bateni ZH, Sangi-Haghpeykar H, Arian S, Moaddab A, Fox KA, Shamshirsaz AA, Salmanian B, Erfani H, Espinoza J, Ramin SM, Dildy GA, Clark SL, Belfort MA, Shamshirsaz A. 249: Congenital anomalies among twins conceived by infertility treatment. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Erfani H, Fox KA, Bateni ZH, Shamshirsaz AA, Salmanian B, Dildy GA, Kassir E, Moaddab A, Dunn TN, Podany EL, Ballas J, Rac M, Espinoza J, Diaz-Arrastia C, Baker BW, Cassady C, Rocky Hui SK, Teruya J, Bandi V, Coburn M, Lee W, Popek EJ, Clark SL, Belfort MA, Shamshirsaz AA. 724: Morbidly adherent placenta - comparison of characteristics and outcomes between scheduled and unscheduled deliveries managed within a single, multidisciplinary team-based referral center. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Podany EL, Fox KA, Erfani H, Bateni ZH, Shamshirsaz AA, Eppes C, Salmanian B, Moaddab A, Kassir E, Dunn TN, Espinoza J, Clark SL, Dildy GA, Belfort MA, Shamshirsaz AA. 792: Characteristics and outcomes of pregnancies with antenatal diagnosis of placenta previa without suspected morbidly adherent placentation in a tertiary center. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Erfani H, Fox KA, Bateni ZH, Shamshirsaz AA, Salmanian B, Dildy GA, Kassir E, Moaddab A, Dunn TN, Podany EL, Ballas J, Rac M, Espinoza J, Diaz-Arrastia CR, Baker BW, Cassady C, Rocky Hui SK, Teruya J, Bandi V, Coburn M, Lee W, Popek EJ, Clark SL, Belfort MA, Shamshirsaz AA. 865: Multidisciplinary team learning in management of morbidly adherent placenta - outcome improvements over time. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Moaddab A, Davidson CM, Sangi-Haghpeykar H, Dildy GA, Belfort MA, Clark SL. 59: Association between day and month of delivery and maternal-fetal mortality: weekend effect and july phenomenon in current obstetric practice. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Salmanian B, Fox KA, Erfani H, Bateni ZH, Shamshirsaz AA, Dildy GA, Kassir E, Moaddab A, Dunn TN, Podany EL, Ballas J, Rac M, Espinoza J, Diaz-Arrastia C, Baker BW, Cassady C, Hui SKR, Teruya J, Bandi V, Coburn M, Lee W, Popek EJ, Clark SL, Belfort MA, Shamshirsaz AA. 245: Posterior placentation in morbidly adherent placenta: a nested case-control study of characteristics and outcomes. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Rajagopalan S, Suresh M, Clark SL, Serratos B, Chandrasekhar S. Airway management for cesarean delivery performed under general anesthesia. Int J Obstet Anesth 2016; 29:64-69. [PMID: 27884665 DOI: 10.1016/j.ijoa.2016.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 09/29/2016] [Accepted: 10/20/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND With the increasing popularity of neuraxial anesthesia, there has been a decline in the use of general anesthesia for cesarean delivery. We sought to examine the incidence, outcome and characteristics associated with a failed airway in patients undergoing cesarean delivery under general anesthesia. METHODS A retrospective review of airway management in women undergoing cesarean delivery under general anesthesia over an eight-year period from 2006-2013 at an academic medical center was conducted. RESULTS During the study period, 10 077 cesarean deliveries were performed. Neuraxial anesthesia was used in 9382 (93%) women while general anesthesia was used in 695 (7%). Emergent cesarean delivery was the most common indication for general anesthesia. Failed intubation was encountered in only three (0.4%) women, who were successfully managed with a laryngeal mask airway. The overall incidence of failed intubation was 1 in 232 (95% CI 1:83 to 1:666) and general anesthesia was continued in all cases. There were no adverse maternal or fetal outcomes directly related to failed intubation. CONCLUSION Advances in adjunct airway equipment, availability of an experienced anesthesiologist and simulation-based teaching of failed airway management in obstetrics may have contributed to our improved maternal outcomes in patients undergoing cesarean delivery under general anesthesia.
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Clark SL, Romero R, Dildy GA, Callaghan WM, Smiley RM, Bracey AW, Hankins GD, D'Alton ME, Foley M, Pacheco LD, Vadhera RB, Herlihy JP, Berkowitz RL, Belfort MA. Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies. Am J Obstet Gynecol 2016; 215:408-12. [PMID: 27372270 PMCID: PMC5072279 DOI: 10.1016/j.ajog.2016.06.037] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Revised: 06/16/2016] [Accepted: 06/21/2016] [Indexed: 11/24/2022]
Abstract
Amniotic fluid embolism is a leading cause of maternal mortality in developed countries. Our understanding of risk factors, diagnosis, treatment, and prognosis is hampered by a lack of uniform clinical case definition; neither histologic nor laboratory findings have been identified unique to this condition. Amniotic fluid embolism is often overdiagnosed in critically ill peripartum women, particularly when an element of coagulopathy is involved. Previously proposed case definitions for amniotic fluid embolism are nonspecific, and when viewed through the eyes of individuals with experience in critical care obstetrics, would include women with a number of medical conditions much more common than amniotic fluid embolism. We convened a working group under the auspices of a committee of the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation whose task was to develop uniform diagnostic criteria for the research reporting of amniotic fluid embolism. These criteria rely on the presence of the classic triad of hemodynamic and respiratory compromise accompanied by strictly defined disseminated intravascular coagulopathy. It is anticipated that limiting research reports involving amniotic fluid embolism to women who meet these criteria will enhance the validity of published data and assist in the identification of risk factors, effective treatments, and possibly useful biomarkers for this condition. A registry has been established in conjunction with the Perinatal Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to collect both clinical information and laboratory specimens of women with suspected amniotic fluid embolism in the hopes of identifying unique biomarkers of this condition.
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Kahr MK, De La Torre R, Racusin DA, Suter MA, Mastrobattista JM, Ramin SM, Clark SL, Dildy GA, Belfort MA, Aagaard KM. Birth Rates Among Hispanics and Non-Hispanics and their Representation in Contemporary Obstetric Clinical Trials. Am J Perinatol 2016; 33:1115-20. [PMID: 27367281 DOI: 10.1055/s-0036-1584543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective Our study aims were to establish whether subjects enrolled in current obstetric clinical trials proportionately reflects the contemporary representation of Hispanic ethnicities and their birth rates in the United States. Methods Using comprehensive source data over a defined interval (January 2011-September 2015) on birth rates by ethnicity from the Centers for Disease Control and Prevention (CDC), we evaluated the proportional rate by ethnicity, then analyzed the observed to expected relative ratio of enrolled subjects. Results Hispanic women comprise a significant contribution to births in the United States (23% of all births). Systematic analysis of 90 published obstetric clinical trials showed a correlation between inclusion of Hispanic gravidae and the corresponding state's birth rates (r = 0.501, p < 0.001). While the mean was strongly correlated, individual clinical trials may have relatively over-enrolled (n = 31, or 34%) or under-enrolled (n = 33, or 37%) relative to their regional population. In 48% of obstetric clinical trials the Hispanic proportion of the study population was not reported. Conclusion Hispanic gravidae represent a significant number of contemporary U.S. births, and are generally adequately represented as obstetric subjects in clinical trials. However, this is trial-dependent, with significant trial-specific under- and over-enrollment of Hispanic subjects relative to the regional birth population.
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Bateni ZH, Clark SL, Sangi-Haghpeykar H, Aagaard KM, Blumenfeld YJ, Ramin SM, Lee HC, Fox KA, Moaddab A, Shamshirsaz AA, Salmanian B, Hosseinzadeh P, Racusin DA, Erfani H, Espinoza J, Dildy GA, Belfort MA, Shamshirsaz AA. Trends in the delivery route of twin pregnancies in the United States, 2006–2013. Eur J Obstet Gynecol Reprod Biol 2016; 205:120-6. [DOI: 10.1016/j.ejogrb.2016.08.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/02/2016] [Accepted: 08/13/2016] [Indexed: 10/21/2022]
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Pacheco LD, Saade G, Hankins GDV, Clark SL. Amniotic fluid embolism: diagnosis and management. Am J Obstet Gynecol 2016; 215:B16-24. [PMID: 26987420 DOI: 10.1016/j.ajog.2016.03.012] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 02/22/2016] [Accepted: 03/02/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We sought to provide evidence-based guidelines regarding the diagnosis and management of amniotic fluid embolism. STUDY DESIGN A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and the Cochrane Library. The search was restricted to English-language articles published from 1966 through March 2015. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion. Evidence reports and published guidelines were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used for defining the strength of recommendations and rating quality of the evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence. RESULTS AND RECOMMENDATIONS We recommend the following: (1) we recommend consideration of amniotic fluid embolism in the differential diagnosis of sudden cardiorespiratory collapse in the laboring or recently delivered woman (GRADE 1C); (2) we do not recommend the use of any specific diagnostic laboratory test to either confirm or refute the diagnosis of amniotic fluid embolism; at the present time, amniotic fluid embolism remains a clinical diagnosis (GRADE 1C); (3) we recommend the provision of immediate high-quality cardiopulmonary resuscitation with standard basic cardiac life support and advanced cardiac life support protocols in patients who develop cardiac arrest associated with amniotic fluid embolism (GRADE 1C); (4) we recommend that a multidisciplinary team including anesthesia, respiratory therapy, critical care, and maternal-fetal medicine should be involved in the ongoing care of women with AFE (Best Practice); (5) following cardiac arrest with amniotic fluid embolism, we recommend immediate delivery in the presence of a fetus ≥23 weeks of gestation (GRADE 2C); (6) we recommend the provision of adequate oxygenation and ventilation and, when indicated by hemodynamic status, the use of vasopressors and inotropic agents in the initial management of amniotic fluid embolism. Excessive fluid administration should be avoided (GRADE 1C); and (7) because coagulopathy may follow cardiovascular collapse with amniotic fluid embolism, we recommend the early assessment of clotting status and early aggressive management of clinical bleeding with standard massive transfusion protocols (GRADE 1C).
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Abstract
Since its inception, many have questioned the utility of electronic fetal heart rate (FHR) monitoring. However, it arrived without the benefit of clear, standard nomenclature, leading to difficulty interpreting studies regarding its benefit. In 2008, the National Institute of Child Health and Human Development (NICHD) developed standard nomenclature for interpreting eFHR tracings. Understanding what drives the tracings is key to managing them. Category II FHR patterns are by far the most common and most diverse patterns, leading to broad variation in care. Presented here is an algorithm for standardization of management of category II FHR tracings, based on the pathophysiology of decelerations, that can be followed in any labor unit.
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Abstract
Despite the availability of potent drugs, effective surgical techniques, and extensive blood banking facilities, post-partum hemorrhage remains a major cause of death in the United States. A hemorrhage bundle developed by the New York Safe Motherhood Initiative provides clear guidelines for reducing such deaths. This bundle focuses on risk assessment, preparation, diagnosis, and the provision of several management algorithms. Implementation of the protocols and approaches contained in this document, or their equivalent, on a systems basis and a consideration of several additional recommendations for individual care will reduce the likelihood of death from hemorrhage.
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Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GDV. An update on the use of massive transfusion protocols in obstetrics. Am J Obstet Gynecol 2016; 214:340-4. [PMID: 26348379 DOI: 10.1016/j.ajog.2015.08.068] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/14/2015] [Accepted: 08/31/2015] [Indexed: 12/16/2022]
Abstract
Obstetrical hemorrhage remains a leading cause of maternal mortality worldwide. New concepts involving the pathophysiology of hemorrhage have been described and include early activation of both the protein C and fibrinolytic pathways. New strategies in hemorrhage treatment include the use of hemostatic resuscitation, although the optimal ratio to administer the various blood products is still unknown. Massive transfusion protocols involve the early utilization of blood products and limit the traditional approach of early massive crystalloid-based resuscitation. The evidence behind hemostatic resuscitation has changed in the last few years, and debate is ongoing regarding optimal transfusion strategies. The use of tranexamic acid, fibrinogen concentrates, and prothrombin complex concentrates has emerged as new potential alternative treatment strategies with improved safety profiles.
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Salmanian B, Bateni ZH, Clark SL, Vidaeff AC, Moaddab A, Hosseinzadeh P, Sangi-haghpeykar H, Racusin DA, Fox KA, Espinoza J, Lee W, Shamshirsaz AA, Ramin SM, Aagaard KM, Belfort M, Shamshirsaz AA. 449: Trends in cesarean delivery among twins in different gestational age groups and risk factors, in the United States; 2006 -2013. Am J Obstet Gynecol 2016. [DOI: 10.1016/j.ajog.2015.10.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Eppes CS, Clark SL. Extended-spectrum β-lactamase infections during pregnancy: a growing threat. Am J Obstet Gynecol 2015; 213:650-2. [PMID: 25771212 DOI: 10.1016/j.ajog.2015.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 02/27/2015] [Accepted: 03/09/2015] [Indexed: 10/23/2022]
Abstract
Extended-spectrum β-lactamases (ESBLs) are rapidly evolving plasmid transferrable enzymes that confer unique patterns of antibiotic resistance on various bacterial species. Such organisms pose special challenges to laboratory identification, as well as antibiotic selection, administration, and follow-up. Although such infections are increasingly common in the obstetric population, issues surrounding ESBLs are not widely recognized by practicing obstetricians, and controversies exist regarding diagnosis and management. This article provides the practitioner with a summary of clinically pertinent information that will assist in the proper care of pregnant patients with ESBL infection.
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Stevens TA, Swaim LS, Clark SL. The Role of Obstetrics/Gynecology Hospitalists in Reducing Maternal Mortality. Obstet Gynecol Clin North Am 2015; 42:463-75. [PMID: 26333636 DOI: 10.1016/j.ogc.2015.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The United States experienced a 6.1% annual increase in the maternal death rate from 2000 to 2013. Maternal deaths from hemorrhage and complications of preeclampsia are significant contributors to the maternal death rate. Many of these deaths are preventable. By virtue of their continuous care of laboring patients, active involvement in hospital safety initiatives, and immediate availability, obstetric hospitalists are uniquely positioned to evaluate patients, initiate care, and coordinate a multidisciplinary effort. In cases of significant maternal hemorrhage, hypertensive crisis, and acute pulmonary edema, the availability of an obstetrics hospitalist may facilitate improved patient safety and fewer maternal deaths.
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Clark SL. Cardiac disease in pregnancy - some good news. BJOG 2015; 122:1456. [PMID: 26119133 DOI: 10.1111/1471-0528.13493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Belfort MA, Arnold J, Clark SL. Practice may not always make perfect (outcomes). BJOG 2015; 123:119. [PMID: 25846485 DOI: 10.1111/1471-0528.13371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Clark SL, Meyers JA, Frye DK, Garthwaite T, Lee AJ, Perlin JB. Recognition and response to electronic fetal heart rate patterns: impact on newborn outcomes and primary cesarean delivery rate in women undergoing induction of labor. Am J Obstet Gynecol 2015; 212:494.e1-6. [PMID: 25460835 DOI: 10.1016/j.ajog.2014.11.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 10/17/2014] [Accepted: 11/17/2014] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The objective of the study was to examine the clinical impact of specific fetal monitoring-related practices during induced labor. STUDY DESIGN This was a prospective, nonrandomized study. RESULTS We studied 14,398 women undergoing oxytocin induction of labor. A decrease in the infusion rate of oxytocin in the face of specified category II fetal heart rate tracings was associated with a significantly reduced rate of neonatal intensive care unit admission (3.8% vs 5.2%, P = .01) and Apgar score less than 7 at 1 and 5 minutes (4.9% vs 6.4%, P = .01, 0.6% vs 1.1%, P = .04). Compliance with an in-use checklist was associated with both a reduction in the rate of neonatal intensive care unit admission (2.9 vs 4.4, P = .00) and a reduction in the cesarean delivery rate (15.8% vs 18.8%, P = .00). CONCLUSION Electronic fetal heart rate monitoring improves neonatal outcomes when unambiguous definitions of abnormal fetal heart rate and tachysystole are coupled with specific interventions. Utilization of a checklist for oxytocin monitoring is associated with improved neonatal outcomes and a reduction in the cesarean delivery rate.
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Clark SL, Christmas JT. Reply: To PMID 24631705. Am J Obstet Gynecol 2014; 211:713. [PMID: 25108140 DOI: 10.1016/j.ajog.2014.07.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 07/30/2014] [Indexed: 10/24/2022]
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Clark SL, Christmas JT, Frye DR, Meyers JA, Perlin JB. Maternal mortality in the United States: predictability and the impact of protocols on fatal postcesarean pulmonary embolism and hypertension-related intracranial hemorrhage. Am J Obstet Gynecol 2014; 211:32.e1-9. [PMID: 24631705 DOI: 10.1016/j.ajog.2014.03.031] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 02/08/2014] [Accepted: 03/12/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the efficacy of specific protocols that have been developed in response to a previous analysis of maternal deaths in a large hospital system. We also analyzed the theoretic impact of an ideal system of maternal triage and transport on maternal deaths and the relative performance of cause of death determination from chart review compared with a review of discharge coding data. STUDY DESIGN We conducted a retrospective evaluation of maternal deaths from 2007-2012 after the introduction of disease-specific protocols that were based on 2000-2006 data. RESULTS Our maternal mortality rate was 6.4 of 100,000 births in just >1.2 million deliveries. A policy of universal use of pneumatic compression devices for all women who underwent cesarean delivery resulted in a decrease in postoperative pulmonary embolism deaths from 7 of 458,097 cesarean births to 1 of 465,880 births (P = .038). A policy that involved automatic and rapid antihypertensive therapy for defined blood pressure thresholds eliminated deaths from in-hospital intracranial hemorrhage and reduced overall deaths from preeclampsia from 15-3 (P = .02.) From 1-3 deaths were related causally to cesarean delivery. Only 7% of deaths were potentially preventable with an ideal system of admission triage and transport. Cause of death analysis with the use of discharge coding data was correct in 52% of cases. CONCLUSION Disease-specific protocols are beneficial in the reduction of maternal death because of hypertensive disease and postoperative pulmonary embolism. From 2-6 women die annually in the United States because of cesarean delivery itself. A reduction in deaths from postpartum hemorrhage should be the priority for maternal death prevention efforts in coming years in the United States.
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Clark SL, Saade GA, Meyers JA, Frye DR, Perlin JB. The clinical and economic impact of nurse to patient staffing ratios in women receiving intrapartum oxytocin. Am J Perinatol 2014; 31:119-24. [PMID: 23508699 DOI: 10.1055/s-0033-1338175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To examine the relationship between nurse-to-patient staffing ratios and perinatal outcomes in women receiving oxytocin during labor. STUDY DESIGN A retrospective analysis of perinatal outcomes in women receiving oxytocin for induction or augmentation of labor during 2010. Outcomes examined were fetal distress, birth asphyxia, primary cesarean delivery, chorioamnionitis, endomyometritis, and a composite of adverse events. Frequency of 1:1 nurse-to-patient staffing was determined for each hospital. Outcomes were compared between hospitals categorized into quartiles of staffing ratios. RESULTS In 208,033 women delivering during 2010, there was no relation between frequency of 1:1 nurse-to-patient staffing ratio and improved perinatal outcomes. Adoption of universal 1:1 staffing in the United States would result in the need for an additional 27,000 labor nurses and a cost of $1.6 billion. CONCLUSION Available data do not support the imposition of mandatory 1:1 nurse-to-patient staffing ratios for women receiving oxytocin in all U.S. facilities.
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Chambliss LR, Clark SL. Paper gestational age wheels are generally inaccurate. Am J Obstet Gynecol 2014; 210:145.e1-4. [PMID: 24036402 DOI: 10.1016/j.ajog.2013.09.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 07/03/2013] [Accepted: 09/09/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the estimated date of confinement of paper gestational wheels to the estimated date of confinement of APPs wheels using a standard last menstrual period. METHODS Obstetric providers were asked for their gestational wheels. The last menstrual period was set at Jan. 1, 2013, and the estimated date of confinement obtained was compared with the estimated date of confinement of Oct. 8th if the pregnancy completed 280 days. The process was performed on 20 electronic APPs downloadable to cell phones. The process was repeated for both for the leap year of 2012. RESULTS Thirty-one paper wheels from a variety of sources were collected. Ten wheels (35%) were consistent with the standard pregnancy duration of 280 days. Among the wheels surveyed, the largest discrepancy was 4 days short of 280 days. Two wheels gave an estimated date of confinement that differed from each other by 7 days. Wheels from the same source did not agree with each other. Twenty electronic gestational age calculators were examined. All 20 gave an estimated date of confinement of Oct. 8 consistent with 280 days. None of the paper gestational wheels but all of the APPs corrected for a leap year. CONCLUSION In contrast to APPs gestational age calculators, the estimated date of confinement of the majority of paper wheels deviated from the standard pregnancy duration of 280 days. Precision in gestational age assessment is critical in a variety of clinical settings and heightened by the focus by payers and reporting agencies on elective deliveries before 39 weeks. The use of paper gestational age wheels should be abandoned.
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Clark SL, Nageotte MP, Garite TJ, Freeman RK, Miller DA, Simpson KR, Belfort MA, Dildy GA, Parer JT, Berkowitz RL, D'Alton M, Rouse DJ, Gilstrap LC, Vintzileos AM, van Dorsten JP, Boehm FH, Miller LA, Hankins GD. Intrapartum management of category II fetal heart rate tracings: towards standardization of care. Am J Obstet Gynecol 2013; 209:89-97. [PMID: 23628263 DOI: 10.1016/j.ajog.2013.04.030] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 03/27/2013] [Accepted: 04/24/2013] [Indexed: 12/29/2022]
Abstract
There is currently no standard national approach to the management of category II fetal heart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Under such circumstances, it would be difficult to demonstrate the clinical efficacy of FHR monitoring even if this technique had immense intrinsic value, since there has never been a standard hypothesis to test dealing with interpretation and management of these abnormal patterns. We present an algorithm for the management of category II FHR patterns that reflects a synthesis of available evidence and current scientific thought. Use of this algorithm represents one way for the clinician to comply with the standard of care, and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.
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Pacheco LD, Saade GR, Costantine MM, Clark SL, Hankins GDV. The role of massive transfusion protocols in obstetrics. Am J Perinatol 2013; 30:1-4. [PMID: 22836824 DOI: 10.1055/s-0032-1322511] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Obstetric hemorrhage is a leading cause of maternal mortality worldwide. New concepts involving the pathophysiology of hemorrhage have been described and include early activation of both the protein C and fibrinolytic pathways. New tendencies in hemorrhage treatment include the use of hemostatic resuscitation. Massive transfusion protocols involve the early utilization of blood products and limit the traditional approach of early massive crystalloid based resuscitation. The evidence behind hemostatic resuscitation is still limited.
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Clark SL, Meyers JA, Frye DR, McManus K, Perlin JB. A systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system. Am J Obstet Gynecol 2012; 207:441-5. [PMID: 23063015 DOI: 10.1016/j.ajog.2012.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 08/17/2012] [Accepted: 09/12/2012] [Indexed: 10/27/2022]
Abstract
We describe a systematic approach to the identification and classification of near-miss events on labor and delivery in a large, national health care system. Voluntary reports of near-miss events were prospectively collected during 2010 in 203,708 deliveries. These reports were analyzed according to frequency and potential severity. Near-miss events were reported in 0.69% of deliveries. Medication and patient identification errors were the most common near-miss events. However, existing barriers were found to be highly effective in preventing such errors from reaching the patient. Errors with the greatest potential for causing harm involved physician response and decision making. Fewer and less effective existing barriers between these errors and potential patient harm were identified. Use of a comprehensive system for identification of near-miss events on labor and delivery units have proven useful in allowing us to focus patient safety efforts on areas of greatest need.
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Clark SL, Adkins DE, Aberg K, Hettema JM, McClay JL, Souza RP, van den Oord EJCG. Pharmacogenomic study of side-effects for antidepressant treatment options in STAR*D. Psychol Med 2012; 42:1151-1162. [PMID: 22041458 PMCID: PMC3627503 DOI: 10.1017/s003329171100239x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Understanding individual differences in susceptibility to antidepressant therapy side-effects is essential to optimize the treatment of depression. METHOD We performed genome-wide association studies (GWAS) to search for genetic variation affecting the susceptibility to side-effects. The analysis sample consisted of 1439 depression patients, successfully genotyped for 421K single nucleotide polymorphisms (SNPs), from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Outcomes included four indicators of side-effects: general side-effect burden, sexual side-effects, dizziness and vision/hearing-related side-effects. Our criterion for genome-wide significance was a prespecified threshold ensuring that, on average, only 10% of the significant findings are false discoveries. RESULTS Thirty-four SNPs satisfied this criterion. The top finding indicated that 10 SNPs in SACM1L mediated the effects of bupropion on sexual side-effects (p = 4.98 × 10(-7), q = 0.023). Suggestive findings were also found for SNPs in MAGI2, DTWD1, WDFY4 and CHL1. CONCLUSIONS Although our findings require replication and functional validation, this study demonstrates the potential of GWAS to discover genes and pathways that could mediate adverse effects of antidepressant medication.
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Clark SL, Meyers JA, Perlin JB. Oversight of elective early term deliveries: avoiding unintended consequences. Am J Obstet Gynecol 2012; 206:387-9. [PMID: 21963311 DOI: 10.1016/j.ajog.2011.08.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 08/05/2011] [Accepted: 08/15/2011] [Indexed: 11/16/2022]
Abstract
The national movement to eliminate elective delivery at <39 weeks' gestation has engendered much enthusiasm and is a major step forward in the evolution of perinatal patient safety. Our experience with >1 million births in the past 5 years suggests the existence of a number of potential pitfalls that should be considered in policy development, enforcement, and compliance monitoring. Attention to these details will ensure continued patient benefit from these policies without endangering those fetuses in whom early term delivery is warranted medically.
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Abstract
The maternal death rate in the United States has shown no improvement in several decades and may be increasing. On the other hand, hospital systems that have instituted comprehensive programs directed at the prevention of maternal mortality have demonstrated rates that are half of the national average. These programs have emphasized the reduction of variability in the provision of care through the use of standard protocols, reliance on checklists instead of memory for critical processes, and an approach to peer review that emphasizes systems change. In addition, elimination of a small number of repetitive errors in the management of hypertension, postpartum hemorrhage, pulmonary embolism, and cardiac disease will contribute significantly to a reduction in maternal mortality. Attention to these general principles and specific error reduction strategies will be of benefit to every practitioner and more importantly to the patients we serve.
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Clark SL, Meyers JA, Frye DK, Perlin JA. Patient safety in obstetrics--the Hospital Corporation of America experience. Am J Obstet Gynecol 2011; 204:283-7. [PMID: 21306701 DOI: 10.1016/j.ajog.2010.12.034] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 12/11/2010] [Accepted: 12/17/2010] [Indexed: 11/30/2022]
Abstract
We report an update on obstetric patient safety efforts and results in the nation's largest obstetric health care delivery system. The application of principles advocated by the Institute of Medicine a decade ago has resulted in reduced adverse outcomes, as reflected by claims experience. Particular progress has been made in standardization and documentation of critical processes, establishment of national quality benchmarks, reduction in elective deliveries <39 weeks' gestation, and reduction in fatal postcesarean pulmonary embolism. Our experience provides a useful blueprint for similar progress in other health care systems.
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Clark SL, Frye DR, Meyers JA, Belfort MA, Dildy GA, Kofford S, Englebright J, Perlin JA. Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. Am J Obstet Gynecol 2010; 203:449.e1-6. [PMID: 20619388 DOI: 10.1016/j.ajog.2010.05.036] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 04/09/2010] [Accepted: 05/19/2010] [Indexed: 11/16/2022]
Abstract
OBJECTIVE No studies exist that have examined the effectiveness of different approaches to a reduction in elective early term deliveries or the effect of such policies on newborn intensive care admissions and stillbirth rates. STUDY DESIGN We conducted a retrospective cohort study of prospectively collected data and examined outcomes in 27 hospitals before and after implementation of 1 of 3 strategies for the reduction of elective early term deliveries. RESULTS Elective early term delivery was reduced from 9.6-4.3% of deliveries, and the rate of term neonatal intensive care admissions fell by 16%. We observed no increase in still births. The greatest improvement was seen when elective deliveries at <39 weeks were not allowed by hospital personnel. CONCLUSION Physician education and the adoption of policies backed only by peer review are less effective than "hard stop" hospital policies to prevent this practice. A 5% rate of elective early term delivery would be reasonable as a national quality benchmark.
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Mah MP, Clark SL, Akhigbe E, Englebright J, Frye DK, Meyers JA, Perlin JB, Rodriguez M, Shepard A. Reduction of severe hyperbilirubinemia after institution of predischarge bilirubin screening. Pediatrics 2010; 125:e1143-8. [PMID: 20368324 DOI: 10.1542/peds.2009-1412] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The objective of this study was to demonstrate efficacy of universal predischarge neonatal bilirubin screening in reducing potentially dangerous hyperbilirubinemia in a large, diverse national population. METHODS This was a 5-year prospective study directed at neonates who were aged < or =28 days and evaluated at facilities of the Hospital Corporation of America with a serum bilirubin level of > or =20.0 mg/dL. This time frame includes periods before, during, and after the initiation of systemwide institution of a program of universal predischarge neonatal bilirubin screening. The primary outcome measures were serum bilirubin 25.0 to 29.9 and > or =30.0 mg/dL. Neonatal phototherapy use during these years was also analyzed. RESULTS Of the 1,028,817 infants who were born in 116 hospitals between May 1, 2004, and December 31, 2008, 129,345 were delivered before implementation and 899,472 infants were delivered after implementation of this screening program in their individual hospitals. With a program of universal screening, the incidence of infants with total bilirubin 25.0 to 29.9 mg/dL declined from 43 per 100,000 to 27 per 100,000, and the incidence of infants with total bilirubin of > or =30.0 mg/dL dropped from 9 per 100,000 to 3 per 100,000 (P = .0019 and P = .0051, respectively). This change was associated with a small but statistically significant increase in phototherapy use. CONCLUSIONS A comprehensive program of prevention, including universal predischarge neonatal bilirubin screening, significantly reduces the subsequent development of bilirubin levels that are known to place newborns at risk for bilirubin encephalopathy.
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Belfort MA, Clark SL, Saade GR, Kleja K, Dildy GA, Van Veen TR, Akhigbe E, Frye DR, Meyers JA, Kofford S. Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period. Am J Obstet Gynecol 2010; 202:35.e1-7. [PMID: 19889389 DOI: 10.1016/j.ajog.2009.08.029] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 07/13/2009] [Accepted: 08/19/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The purpose of this study was to analyze reasons for postpartum readmission. STUDY DESIGN We conducted a database analysis of readmissions within 6 weeks after delivery during 2007, with extended (180 day) analysis for pneumonia, appendicitis, and cholecystitis. Linear regression analysis, survival curve fitting, and Gehan-Breslow statistic with Holm-Sidak all-pairwise analysis for multiple comparisons were used. Probability values of < .05 were considered significant. RESULTS Of 222,751 women delivered, 2655 women (1.2%) were readmitted within 6 weeks (0.83% vaginal delivery and 1.8% cesarean section delivery; P < .001). A high percentage of these readmittances occurred within the first 6 weeks: pneumonia (84%), appendicitis (43%), or cholecystitis (46%). Cumulative readmission rates were higher in the first 6 weeks after delivery than in the next 20 weeks (pneumonia curve gradient, 3.7 vs 0.11; appendicitis curve gradient, 1.1 vs 0.36; cholecystitis curve gradient, 6.6 vs 1.7). CONCLUSION The cause of postpartum readmission is primarily infectious in origin. A recent pregnancy appears to increase the risk of pneumonia, appendicitis, and cholecystitis.
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Clark SL, Knox GE, Garite TJ. Reply. Am J Obstet Gynecol 2009. [DOI: 10.1016/j.ajog.2009.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Clark SL. Sleep deprivation: implications for obstetric practice in the United States. Am J Obstet Gynecol 2009; 201:136.e1-4. [PMID: 19344882 DOI: 10.1016/j.ajog.2009.01.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 10/23/2008] [Accepted: 01/13/2009] [Indexed: 10/20/2022]
Abstract
Recent advances in basic science have expanded our understanding of the function of sleep and of the effects of sleep deprivation on human cognitive and psychomotor performance. In addition, a growing volume of data documents potential detrimental effects of sleep deprivation on medical practice. Such data have special implications for a specialty in which sleep deprivation is sometimes the norm. A review of this evidence suggests the pressing need for a reassessment of individual and small group obstetric practice, particularly as it relates to labor and delivery care; the current model of care in which each woman is delivered by the same provider who delivers prenatal care is generally not tenable in a culture increasingly focused on patient safety.
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Porreco RP, Clark SL, Belfort MA, Dildy GA, Meyers JA. The changing specter of uterine rupture. Am J Obstet Gynecol 2009; 200:269.e1-4. [PMID: 19136093 DOI: 10.1016/j.ajog.2008.09.874] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 09/26/2008] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of the study was to review all patient records discharged with codes for uterine rupture in 2006 in Hospital Corporation of America hospitals. STUDY DESIGN All patient charts were distributed to a committee of perinatologists and general obstetricians. Case report forms were analyzed for variables of interest to determine validity of coding and quality of care. RESULTS Of 69 cases identified, only 41 were true ruptures. Twenty patients had previous cesareans, and in 9 of these patients, concurrent use of oxytocics was documented. Among the 21 patients without previous cesareans, 7 had previous uterine surgery, and oxytocics were documented in 12 of the remaining 14 patients. Standard of care violations were identified in 10 of 41 true rupture cases. CONCLUSION Epidemiological data on uterine rupture based on hospital discharge codes without concurrent chart review may be invalid. Patients with previous cesareans represent only half of true uterine ruptures in contemporary practice.
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Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol 2009; 200:35.e1-6. [PMID: 18667171 DOI: 10.1016/j.ajog.2008.06.010] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2008] [Revised: 03/21/2008] [Accepted: 06/03/2008] [Indexed: 10/21/2022]
Abstract
Oxytocin is the drug most commonly associated with preventable adverse perinatal outcomes and was recently added by the Institute for Safe Medication Practices to a small list of medications "bearing a heightened risk of harm," which may "require special safeguards to reduce the risk of error." Current recommendations for the administration of this drug are vague with respect to indications, timing, dosage, and monitoring of maternal and fetal effects. A review of available clinical and pharmacologic data suggests that specific, evidence-based guidelines for the intrapartum administration of oxytocin may be derived from available data. If implemented, such practices may reduce the likelihood of patient harm. These suggested guidelines focus on limited elective administration of oxytocin, consideration of strategies that have been shown to decrease the need for indicated oxytocin use, reliance on low-dose oxytocin regimens, adherence to specific semiquantitative definitions of adequate and inadequate labor, and an acceptance that once adequate uterine activity has been achieved, more time rather than more oxytocin is generally preferable. The use of conservative, specific protocols for monitoring the effects of oxytocin on mother and fetus is likely not only to improve outcomes but also reduce conflict between members of the obstetric team. Implementation of these guidelines would seem appropriate in a culture increasingly focused on patient safety.
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Stafford I, Dildy GA, Clark SL, Belfort MA. Visually estimated and calculated blood loss in vaginal and cesarean delivery. Am J Obstet Gynecol 2008; 199:519.e1-7. [PMID: 18639209 DOI: 10.1016/j.ajog.2008.04.049] [Citation(s) in RCA: 217] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2007] [Revised: 02/19/2008] [Accepted: 04/30/2008] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of the study was to compare visually estimated blood loss (vEBL) with calculated estimated blood loss (cEBL) according to mode of delivery and degree of perineal laceration. STUDY DESIGN Pre- and postdelivery hematocrit (HCT) and other variables including vEBL were prospectively recorded into an obstetrical database between January and September 2005. The cEBL was derived by multiplying the calculated pregnancy blood volume (0.75 x {[maternal height (inches) x 50] + [maternal weight in pounds x 25]}) by percent of blood volume lost ({predelivery HCT - postdelivery HCT}/predelivery HCT). cEBL and vEBL were compared according to mode of delivery and degree of perineal laceration. RESULTS There were 677 subjects with complete data. vEBL was statistically different from cEBL between each degree of laceration and between all modes of delivery, demonstrating an underestimation of vEBL with increasing cEBL. CONCLUSION Improved methods for calculating blood loss include the use of a modified version of the formula used for pregnancy blood volume calculation.
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Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol 2008; 199:105.e1-7. [PMID: 18468573 DOI: 10.1016/j.ajog.2008.02.031] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Revised: 11/26/2007] [Accepted: 02/14/2008] [Indexed: 11/19/2022]
Abstract
In a health care delivery system with an annual delivery rate of approximately 220,000, a comprehensive redesign of patient safety process was undertaken based on the following principles: (1) uniform processes and procedure result in an improved quality; (2) every member of the obstetric team should be required to halt any process that is deemed to be dangerous; (3) cesarean delivery is best viewed as a process alternative, not an outcome or quality endpoint; (4) malpractice loss is best avoided by reduction in adverse outcomes and the development of unambiguous practice guidelines; and (5) effective peer review is essential to quality medical practice yet may be impossible to achieve at a local level in some departments. Since the inception of this program, we have seen improvements in patient outcomes, a dramatic decline in litigation claims, and a reduction in the primary cesarean delivery rate.
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Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, Hankins GD. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 2008; 199:36.e1-5; discussion 91-2. e7-11. [PMID: 18455140 DOI: 10.1016/j.ajog.2008.03.007] [Citation(s) in RCA: 341] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Revised: 12/10/2007] [Accepted: 03/03/2008] [Indexed: 12/17/2022]
Abstract
OBJECTIVE We sought to examine etiology and preventability of maternal death and the causal relationship of cesarean delivery to maternal death in a series of approximately 1.5 million deliveries between 2000 and 2006. STUDY DESIGN This was a retrospective medical records extraction of data from all maternal deaths in this time period, augmented when necessary by interviews with involved health care providers. Cause of death, preventability, and causal relationship to mode of delivery were examined. RESULTS Ninety-five maternal deaths occurred in 1,461,270 pregnancies (6.5 per 100,000 pregnancies.) Leading causes of death were complications of preeclampsia, pulmonary thromboembolism, amniotic fluid embolism, obstetric hemorrhage, and cardiac disease. Only 1 death was seen from placenta accreta. Twenty-seven deaths (28%) were deemed preventable (17 by actions of health care personnel and 10 by actions of non-health care personnel). The rate of maternal death causally related to mode of delivery was 0.2 per 100,000 for vaginal birth and 2.2 per 100,0000 for cesarean delivery, suggesting that the number of annual deaths resulting causally from cesarean delivery in the United States is about 20. CONCLUSION Most maternal deaths are not preventable. Preventable deaths are equally likely to result from actions by nonmedical persons as from provider error. Given the diversity of causes of maternal death, no systematic reduction in maternal death rate in the United States can be expected unless all women undergoing cesarean delivery receive thromboembolism prophylaxis. Such a policy would be expected to eliminate any statistical difference in death rates caused by cesarean and vaginal delivery.
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Clark SL, Vines VL, Belfort MA. Fetal injury associated with routine vacuum use during cesarean delivery. Am J Obstet Gynecol 2008; 198:e4. [PMID: 18295178 DOI: 10.1016/j.ajog.2007.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Revised: 11/29/2007] [Accepted: 12/19/2007] [Indexed: 11/17/2022]
Abstract
The use of a vacuum device as a routine procedure at the time of repeat cesarean delivery was associated with major fetal intracranial hemorrhage. In the absence of clear evidence of benefit, the routine use of vacuum extraction at the time of cesarean delivery is not justified, given its potential for serious fetal injury.
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Clark SL, Crawford P, Nichols W, Reamy BV. Clinical inquiries. When should travelers begin malaria prophylaxis? THE JOURNAL OF FAMILY PRACTICE 2007; 56:950-952. [PMID: 17976346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
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Alexopoulos E, Hope A, Clark SL, McHugh S, Hosey MT. A report on dental anxiety levels in children undergoing nitrous oxide inhalation sedation and propofol target controlled infusion intravenous sedation. Eur Arch Paediatr Dent 2007; 8:82-6. [PMID: 17555689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
AIM To report on two separate child sedation cohorts; one undergoing propofol intravenous sedation (IVS) and the other, nitrous oxide inhalation sedation (IS) in respect to changes in dental anxiety and subject characteristics. STUDY DESIGN The age, gender, level of social deprivation and amount of treatment performed and observed patient behaviour during treatment, using the Frankl and a VAS scale, were recorded for each subject. Anxiety questionnaires were completed before and after treatment. These were: - Modified Child Dental Anxiety Scale (MCDAS); Children's Fear Survey Schedule- Dental Subscale (CFSS-DS) and two Visual Analogue Scales (VAS). RESULTS AND STATISTICS Participants (36) attended for treatment under IS and 40 attended for treatment under propofol IVS. The IVS cohort was older (p<0.01), by between 1.9 and 4.1 years and had more treatment [p = 0.015, 95% confidence interval for the difference between the cohort medians was (0, 3) units]. The two cohorts were closely matched in respect to pre-operative anxiety as measured by the MCDAS and CFSS-DS scales. There were significant anxiety reductions within each cohort as measured by three of the scales: - MCDAS, CFSS-DS and VAS (1) (p< or = 0.001) but no significant change in the VAS (2) scores. When the two cohorts were compared, there was no significant difference in the reduction of the self-reported anxiety for any of the four scales (p>0.05). The observed behaviour was good for both cohorts. CONCLUSION Propofol target-controlled intravenous sedation and nitrous oxide inhalation sedation were similarly efficacious at anxiety reduction in referred dentally anxious children. Subjects undergoing propofol IVS were older than those undergoing IS. Propofol TCI may offer the opportunity for more treatment at each visit. Further propofol TCI conscious sedation studies are required.
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Clark SL, Belfort MA, Hankins GDV, Meyers JA, Houser FM. Variation in the rates of operative delivery in the United States. Am J Obstet Gynecol 2007; 196:526.e1-5. [PMID: 17547880 DOI: 10.1016/j.ajog.2007.01.024] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Revised: 11/21/2006] [Accepted: 01/16/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study was undertaken to examine the national and regional rates of operative delivery among almost one quarter million births in a single year in the nation's largest healthcare delivery system, using variation as an arbiter of the quality of decision making. STUDY DESIGN We compared the variation in rates of primary cesarean and operative vaginal delivery in facilities of the Hospital Corporation of America during the year 2004. RESULTS In 124 facilities representing almost 220,000 births during a 1-year period, the primary cesarean and operative vaginal delivery rates were 19% +/- 5% (range 9-37) and 7% +/- 4% (range 1-23). Within individual geographic regions, we consistently found variations of 200-300% in rates of primary cesarean delivery and variations approximating an order of magnitude for operative vaginal delivery. CONCLUSION Within broad upper and lower limits, rates of operative delivery in the United States are highly variable and suggest a pattern of almost random decision making. This reflects a lack of sufficient reliable, outcomes-based data to guide clinical decision making.
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Dildy GA, Clark SL. Effects of maternal oxygen administration on fetal pulse oximetry measured by fetal pulse oximetry. Am J Obstet Gynecol 2007; 196:e13; author reply e13. [PMID: 17403386 DOI: 10.1016/j.ajog.2006.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Accepted: 11/16/2006] [Indexed: 11/19/2022]
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