Reliability of birth certificate data: a multi-hospital comparison to medical records information

OBJECTIVE

To examine the reliability of birth certificate data and determine if reliability differs between teaching and nonteaching hospitals.

METHODS

We compared information from birth certificates and medical records in 33,616 women admitted for labor and delivery in 1993-95 to 20 hospitals in Northeast Ohio. Analyses determined the agreement for 36 common data elements, and the sensitivity, specificity, and positive and negative predictive values of birth certificate data, using medical record data as a "gold standard."

RESULTS

Sensitivity and positive predictive value varied widely (9-100% and 2-100%, respectively), as did agreement, which was "almost perfect" for measures of prior obstetrical history, delivery type, and infant Apgar score (K = 0.854-0.969) and "substantial" for several other variables (e.g., tobacco use (K = 0.766), gestational age (K = 0.726), prenatal care (K = 0.671)). However, agreement was only "slight" to "moderate" for most maternal risk factors and comorbidities (K = 0.085-0.545) and for several complications of pregnancy and/or labor and delivery (K = 0.285-0.734). Overall agreement was similar in teaching (mean K = 0.51) and nonteaching (K = 0.52) hospitals. Although agreement in teaching and nonteaching hospitals varied for some variables, no systematic differences were seen across types of variables.

CONCLUSIONS

Our findings indicate that the reliability of birth certificate data vary for specific elements. Researchers and health policymakers need to be cognizant of the potential limitations of specific data elements.

The use of a modified classification system in the treatment of low back pain during pregnancy: a case report

STUDY DESIGN

Case study.

OBJECTIVE

To describe the use of a classification approach in the evaluation and treatment of a pregnant patient with low back pain (LBP).

BACKGROUND

The patient was a 28-year-old primigravida in her 20th week of pregnancy. She presented with a chief complaint of LBP without precipitating trauma. Her pain limited her sitting to 20 minutes or less and restricted her ability to bend forward.

METHODS AND MEASURES

This patient was treated 4 times during a period of 2 weeks. The patient was classified as stage 1 extension syndrome. Because of the patient's pregnancy, treatment with active extension exercises commonly prescribed for this syndrome was deemed inadequate. Therefore, manual joint mobilization was applied to the symptomatic vertebral segment. Additional intervention included moist heat, soft tissue mobilization to the thoracolumbar paraspinals, manual stretching of the hip flexors, abdominal bracing, and wall squat exercises.

RESULTS

After 4 treatments, the patient was able to bend forward without pain, sit longer than 1 hour without discomfort, and work with minimal discomfort. She improved from a stage 1 classification to a stage 3 classification.

CONCLUSION

This case illustrates the use of a classification system to guide physical therapy intervention. It also demonstrates an effective and safe use of manual techniques in the treatment of a pregnant patient.

Antepartum findings and obstetric aspects in pregnancies followed by neonatal persistent hyperinsulinemic hypoglycemia

In this study we report antepartum and obstetric findings in cases of persistent hyperinsulinemic hypoglycemia of infancy (PHHI). The study is retrospective and covers the years 1983 to 1994, when there were 9 infants treated for PHHI in the region of the University Hospital of Kuopio. One of the mothers had gestational diabetes mellitus and one had insulin-dependent diabetes mellitus (IDDM). There were signs of fetal distress in cardiotocography (CTG) in 3 of 9 cases prenatally and in 3 of 9 cases intrapartum (33%). There were 5 premature deliveries (56%) and 5 cesarean sections (56%) in this series. Five neonates (56%) were macrosomic and one delivery was complicated by shoulder dystocia. Three neonates (33%) had a 1-minute Apgar score of <6, but there were no cases at 5 minutes. In cases of fetal macrosomia without a maternal diabetic problem amniocentesis may be carried out after 34 weeks of gestation to assay amniotic fluid insulin, C-peptide and erythropoietin to reveal rare cases of PHHI where there may be problems of fetal hypoxemia similar to those in diabetic pregnancies.

Public versus private hospital maternity length of stay: a gamma mixture modelling approach

Application of a gamma mixture model to obstetrical diagnosis-related groups (DRGs) revealed heterogeneity of maternity length of stay (LOS). The proportion of long-stay subgroups identified, which can account for 30% of admissions, varied between DRGs. The burden of long-stay patients borne was estimated to be much higher in private hospitals than public hospitals for normal delivery, but vice versa for Caesarean section. Such differences highlights the impact of DRG-based casemix funding on inpatient LOS and have significant implications for health insurance companies to integrate casemix funding across the public and private sectors. The analysis also benefits hospital administrators and managers to budget expenditures accordingly.

The effect of sociocultural status on periodontal conditions in pregnancy

BACKGROUND

The effects of sociocultural status on periodontal conditions in pregnant women have been reported by a number of researchers and there have been speculations about the effects of hormonal changes, patients' systemic health, and socio-cultural characteristics on periodontal health during pregnancy.

METHODS

This study evaluates the periodontal condition of 61 pregnant women at their first, second, and third trimesters, and the relation between the demographic (age, professional level, education) and clinical variables (previous periodontal care, frequency of tooth brushing). The clinical indices, including plaque index, gingival index, and probing depth measurements were repeated at the first, second, and third trimesters. The statistical tests used were stepwise analysis and paired sample test.

RESULTS

The results of the study showed that the plaque index, gingival index, and probing depth scores increased gradually in the first, second, and third trimesters, although oral hygiene instructions were given to the entire study population. The level of statistical significance was established at P <0.05. When the clinical parameters and demographic variables were compared, only educational level and periodontal care seemed to be statistically significant (P<0.05).

CONCLUSIONS

Our clinical index scores were related to the educational level of the study population. When the educational level of the study group decreased, the plaque, gingival index, and probing depth scores contrarily increased. Also non-attendance for previous periodontal care increased the scores of plaque index and probing depth. In view of the results of our study, it might be suggested that simple preventive oral hygiene programs may help maintain healthy gingiva during pregnancy.

Epidemiological, clinical, and microbiological characteristics of late-onset sepsis among very low birth weight infants in Israel: a national survey

OBJECTIVE

Nosocomial infections are a serious problem among very low birth weight (VLBW) infants. We studied the association between late-onset sepsis (LOS) and mortality and morbidity in VLBW infants. Methods. From a national cohort of 5555 VLBW infants born in Israel during 1995 through 1998, 4829 survived at least 3 days and composed the study population. Maternal, perinatal, or postnatal variables that showed a significant association with LOS in a univariate analysis were tested in a bivariate analysis (adjusted for gestational age). Variables with P </=.1 were then tested by a multiple logistic regression for assessing the net effect of each variable on the risk for LOS.

RESULTS

One or more episodes of bloodstream-proven LOS occurred in 1453 infants (30%). Gram-positive and Gram-negative bacteria accounted for 55.4% and 31.2% of microbes, respectively, mainly coagulase-negative Staphylococci and KLEBSIELLA: Compared with those without LOS, infants with LOS had a significantly higher mortality rate (16.9% vs 8.6%). Mortality after Gram-negative LOS (26.2%) and Candida LOS (27.6%) was similar and significantly higher than with Gram-positive LOS (8.7%). Significant independent predictors of LOS were decreasing gestational age, cesarean section, mechanical ventilation, patent ductus arteriosus, necrotizing enterocolitis, and bronchopulmonary dysplasia.

CONCLUSIONS

LOS occurred in 30% of Israeli VLBW infants. Six strong independent predictors for LOS were identified. Recognition and awareness of the epidemiologic, clinical, and microbiologic characteristics of LOS remain the keystones for management of this nosocomial infection.

Alterations of placental vascular function in asthmatic pregnancies

Asthma during pregnancy is associated with low-birthweight neonates at term but the mechanisms that cause this outcome are presently unknown. Changes in placental vascular function resulting from asthma or its treatment could contribute to altered fetal growth. We have prospectively followed women with asthma and a control group of women without asthma during their pregnancies, classified them based on asthma severity and glucocorticoid intake, and monitored fetal development and placental blood flow using Doppler ultrasound at 18 and 30 wk gestation. The placentae from these women were collected after delivery and vascular responses to dilator and constrictor agonists assessed using an in vitro placental perfusion method. At 18 wk gestation, umbilical artery flow velocity waveforms were significantly reduced in the moderate and severe asthmatic groups and in those women using high-dose inhaled glucocorticoid for the treatment of their asthma (ANOVA, p < 0.05). However, at 30 wk gestation there were no significant differences in umbilical artery flow velocity between control and asthmatic women (ANOVA, p > 0.05). Corticotropin-releasing hormone (CRH), a potent vasodilator that acts via the nitric oxide pathway, caused a dose-dependent vasodilatory response in all placentae in vitro. However, CRH-induced dilation was significantly reduced in moderate and severe asthmatics (ANOVA, p < 0.05). Vasoconstrictor responses to potassium chloride and prostaglandin F(2alpha) were reduced in placentae from moderate and severe asthmatic women (ANOVA, p < 0.05). These studies demonstrate significant differences in placental vascular function in pregnancies complicated by asthma, which may relate directly to the asthma or be a consequence of the associated glucocorticoid treatment. These changes in vascular function in asthmatic pregnancies may contribute to the low-birthweight outcome observed in this condition.

Rhodes Index of Nausea and Vomiting--Form 2 in pregnant women. A confirmatory factor analysis

BACKGROUND

Despite widespread application of Rhodes Index of Nausea and Vomiting-Form 2 (INV2) in practice and research, empirical analyses have not been consistently performed to verify the a priori factors that guided the subclass construction of the symptoms.

OBJECTIVES

To examine the dimensional structure of Rhodes INV in a sample of pregnant women.

METHOD

Data were collected from 152 pregnant women who were experiencing some degree of nausea and vomiting during early pregnancy and analyzed using structural equation modeling techniques. Five competing measurement structures were tested and compared. The structure (model) that provided the closest fit to the data was selected and relationships (factor loadings) between the constructs and indicators were established.

RESULTS

The model fitting the data the closest was a three-factor structure measuring nausea, vomiting, and retching as three separate, but correlated dimensions. The factor loadings were high (0.73-0.96) and significant (p < .001). The model treating nausea and vomiting as a one-factor concept as well as the model including two factors named symptom occurrence and symptom distress did not fit the data.

CONCLUSION

Rhodes INV2 is a valid measurement tool if subscales are formed to reflect the multidimensional structure of nausea and vomiting in pregnancy.

[Characteristics of a population of drug dependent pregnant women in the Czech Republic]

OBJECTIVE

The aim of the study was to characterise the population of drug abused pregnant women in Czech republic and chart their socioeconomic situation.

DESIGN

Prospective study.

SETTING

The Department of Gynaecology and Obstetrics of the General Teaching Hospital and the 1st Medical Faculty of Charles University in Prague.

METHODS

This prospective study coursed since January 1998 till the end of the year 2000. This study covered a group of pregnant women addict on illegal drugs (heroin, pervitin). The group was set in close cooperation with Prague's contact anti-drugs centers (DROP-IN, K-centrum, Sanopin), Dependence therapy department and Department for genetics Teaching hospital Prague and of course in cooperation with the district gynaecologists. During 3 years we succeeded in gathering 41 addict women for prenatal care. Twenty of them were heroin and 18 pervitin addict. The control groups were selected by method of accidental choice. We compared each group with its control and both groups of addicted mutually. We focused mainly on characteristics which could have a negative impact on the course of pregnancy, labour and lying-in period and the health condition of the foetus and the neonate (age, status, employment, parity, length of drug abuse, mode of application, attempt of therapy or abstinence, STD, hepatitis B and C, quality of prenatal care).

RESULTS

We proved, that drug abused pregnant women are statistically significantly younger than pregnant women from control groups (by equal parity), mostly single and unemployed. The majority of them prefer intravenous way of drug application. The heroin--addict choose this type of application statistically significantly more often (94.4%) and also more often they report efforts at abstinence or therapy. A big part of drug abused pregnant women has insufficient prenatal care. 33% of heroin-addict and 25% of pervitin-addict never attended the obstetrician during their pregnancy. We revealed a significantly higher incidence of HBsAg a mainly anti HCV and active hepatitis C among women from both "drugs" groups compared to their controls. We did not encounter any HIV positive case among the Czech addict pregnant.

CONCLUSION

The population of drugs-addict pregnant women may be characterised as a high risk group from the view of prenatal care. The pregnancy is not a sufficient impulse for the majority of drugs-addict women to change their life stereotypes.

Pregnancy in women with epilepsy

The aim of this study was to analyze the outcome of pregnancy and delivery in epileptic women. A retrospective review of the 41 pregnant women with epilepsy who delivered in the Department of Obstetrics and Perinatology of the University School of Medicine in Lublin over 7 years (1993-1999) was carried out. Women with epilepsy had more pregnancy complications including premature labor, anemia, hypertension, vaginal bleeding, urinary tract infection, nausea and vomiting. An increased risk of congenital malformations and intrauterine fetal growth retardation was observed. Women with epilepsy require more extensive pregnancy planning including neurologic and preconceptional care.

Pregnant women's perceptions of abuse

OBJECTIVE

To determine whether pregnant women's perceptions of abuse severity and danger, and their ability to control the abuse, are significantly correlated with the acts of abuse they experience, and to find out whether relationships exist among women's appraisals of abuse severity, danger, and their perceived ability to stop the abuse.

DESIGN

A correlational design was used to compare the abusive acts experienced by the women and their perceptions of that abuse.

SETTING

Nine prenatal clinics in urban areas of the northeastern United States.

PARTICIPANTS

Sixty-one ethnically diverse, pregnant abused women were interviewed.

MAIN OUTCOME MEASURE

Pearson's product-moment correlations were used to examine relationships between abusive experiences and women's perceptions of abuse.

RESULTS

Women's perceptions of abuse severity were modestly correlated with threatened (r = .25) and actual violence (r = .36). Perceptions of abuse severity and danger were correlated (r = .41).

CONCLUSIONS

Women's beliefs about abuse severity, danger, and their ability to control abuse cannot be fully comprehended by exploring the discrete acts they experience. Further research is needed to identify additional factors that influence those beliefs.

Multicenter study of obstetric admissions to 14 intensive care units in southern England

OBJECTIVES

To identify pregnant and postpartum patients admitted to intensive care units (ICUs), the cause for their admission, and the proportion that might be appropriately managed in a high-dependency environment (HDU) by using an existing database. To estimate the goodness-of-fit for the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation (APACHE) II, and the APACHE III scoring systems in the obstetrical population.

DESIGN

Retrospective analysis of demographic, diagnostic, treatment, and severity of illness data.

SETTING

Fourteen ICUs in Southern England.

PATIENTS

Pregnant or postpartum (<42 days) admissions between January 1, 1994, and December 31, 1996.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 210 patients, constituting 1.84% (210 of 11,385) of all ICU admissions and 0.17% (210 of 122,850) of all deliveries. Most admissions followed postpartum complications (hypertensive disease of pregnancy [39.5%] and major hemorrhage [33.3%]). Seven women were transferred to specialist ICUs. There was considerable variation between ICUs with respect to the number and type of interventions required by patients. Some 35.7% of patients stayed in ICU for <2 days and received no specific ICU interventions; these patients might have been safely managed in an HDU. There were seven maternal deaths (3.3%); fetal mortality rate was 20%. The area under the receiver operator characteristic curve and the standardized mortality ratio were 0.92 (confidence interval [CI], 0.85-0.99) and 0.43 for the Simplified Acute Physiology Score II, 0.94 (CI, 0.86-1.0) and 0.24 for APACHE II, and 0.98 (CI, 0.96-1.0) and 0.43 for APACHE III, respectively.

CONCLUSIONS

Existing databases can both identify critically ill obstetrical patients and provide important information about them. Obstetrical ICU admissions often require minimal intervention and are associated with low mortality rates. Many might be more appropriately managed in an HDU. The commonly used severity of illness scoring systems are good discriminators of outcome from intensive care admission in this group but may overestimate mortality rates. Severity of illness scoring systems may require modification in obstetrical patients to adjust for the normal physiologic responses to pregnancy.

Management of thrombosis in women with antiphospholipid syndrome

1) Antiphospholipid antibody syndrome may be associated with unusual sites of thrombosis. 2) Laboratory evaluation involves testing for antiphospholipid antibodies: lupus anticoagulant and anticardiolipin antibodies. 3) Acute management of thrombosis involves immediate anticoagulation. Low-molecular-weight heparins are as safe and effective as unfractionated heparin in this setting. Arterial events may require emergent thrombolytic therapy. Monitoring of the APTT with unfractionated heparin in the presence of a lupus anticoagulant is ineffective; these patients require monitoring of antifactor Xa levels or the use of LMWH, which does not require monitoring. 4) The pharmacokinetics of LMWH change in pregnancy, resulting in a shorter plasma half-life and larger volume of distribution. Monitoring of antifactor Xa levels is necessary. 5) Chronic anticoagulation is best achieved with warfarin, with significantly decreased rates of recurrent events when the INR is > or = 3.0. Long-term, if not life-long, anticoagulation is often necessary. Warfarin is teratogenic, and individuals desiring pregnancy will need to convert to therapeutic, not prophylactic, doses of either unfractionated heparin or LMWH. 6) As part of optimal management of thrombosis in APS, additional risk factors for thrombosis should be eliminated or reduced. These include comorbid illnesses such as hypertension and hyperlipidemia, as well as smoking. 7) Tamoxifen, raloxifene, oral contraceptives, and hormone replacement therapy are all associated with an increased risk of DVT in the general population. In APS patients receiving therapeutic anticoagulation, the addition of these drugs should not increase thrombosis risk. In APS patients not receiving anticoagulant therapy, these hormonal therapies may increase the thrombosis risk.

The problem of obstetrical complications and schizophrenia

The use of the term "obstetrical complications" (OCs) and its variations to encompass diverse physiological mechanisms (e.g., genetic, ischemic, hemorrhagic, infectious) of disruption to fetal/neonatal brain development has engendered inconsistency, confusion, and controversy. The principal reason is that the term OCs belies the absence of a fully adequate conceptual framework for characterizing neurodevelopmental risk. We propose that neurodevelopmental risk factors for schizophrenia can be assessed more clearly if broad OC scales are replaced by measures representing more homogeneous pathways of disturbed brain development. Using a new OC classification, we found that disordered growth related to hypoxic-ischemic compromise to early brain development may confer an elevated risk of schizophrenia and other adult-onset psychoses, particularly in the presence of familial risk. Abnormal fetal and neonatal brain growth and development in schizophrenia and OCs may also, at least in part, result from genetic factors and could help explain the relation between seemingly inconsistent OCs identified in prior research.

Perioperative management of a patient with congenital myasthenia gravis for elective caesarean section

Congenital disorders of neuromuscular transmission are commonly referred to as congenital myasthenia gravis because of their clinical similarity to the immune-mediated disease. Differentiation between the immune-mediated and congenital forms of the disease is important, because therapy established for the former may not be appropriate for patients with the latter presentation. The course of this rare neuromuscular disorder during pregnancy and its influence on anaesthesia remain largely unknown. We report on the case of a 32-year-old parturient suffering from congenital myasthenia gravis scheduled for elective caesarean section. The perioperative management of this patient who underwent the operation under spinal anaesthesia was reviewed. The effects of anaesthetic agents and techniques on the course of congenital myasthenic patients may need further review in the light of latest findings in the electrophysiology, genetic and therapeutic studies of this syndrome.

Severity and risk adjusting relating to obstetric outcomes, DRG assignment, and reimbursement

Obstetric risk has important implications for reporting and benchmarking quality in today's managed health care environment. Administrative data, including diagnosis related group (DRG) information collected by hospitals, is used by payers and governmental groups for reimbursement, monitoring quality, and setting financial rates. Obstetric conditions that affect the patient experience are coded but do not often contribute to the overall DRG assignment. This strategy, therefore, may provide comparisons that are misleading to consumers and payers. Additionally, financial rates often do not provide adequate reimbursement for the cost incurred in caring for high-risk patients. Finally, risk prediction strategies have historically been used to both identify vulnerable patients for early management and make more equitable comparisons of groups of patients.

Effect of acupressure by Sea-Bands on nausea and vomiting of pregnancy

OBJECTIVE

To determine the effect of continuous acupressure at P6 applied by Sea-Bands with acupressure buttons on the frequency and severity of nausea and vomiting of pregnancy during the 1 st trimester.

DESIGN

A two-group, quasi-experimental, posttest-only and posttest-repeated measure.

SETTING

Seventeen medical clinics or offices in southern Michigan.

PARTICIPANTS

Convenience sample of English-speaking, healthy pregnant women in their 1 st trimester, who had at least one episode of nausea, vomiting, or both before their prenatal clinic/office visit where they were recruited. After being accepted for the study, the women were randomly assigned to treatment or placebo groups.

INTERVENTION

Treatment group 1 applied SeaBands with acupressure buttons to both wrists for 4 days and removed the Sea-Bands for 3 subsequent days. Placebo group 2 applied the Sea-Bands without acupressure buttons to both wrists on the same time schedule as group 1.

MAIN OUTCOME MEASURE

Self-report daily diaries of the number of times per day that participants experienced nausea, the severity of nausea, the number of vomiting episodes per day, and the severity of vomiting.

RESULTS

Mann-Whitney U procedures revealed that the treatment group had significantly less frequency and severity of nausea and vomiting of pregnancy while wearing the Sea-Bands than did the placebo group. The treatment group also had significantly less frequency and severity of nausea and vomiting of pregnancy while wearing the SeaBands than when not wearing the Sea-Bands.

CONCLUSIONS

Sea-Bands with acupressure buttons are a noninvasive, inexpensive, safe, and effective treatment for the nausea and vomiting of pregnancy.

The role of a high-dependency unit in a regional obstetric hospital

The aim of our study was to review a series of critically ill patients admitted to a high-dependency unit (HDU) in a regional obstetric centre, to assess our HDU utilisation rate and to determine the indications for and rate of transfer to an intensive care unit (ICU) in a tertiary referral centre. A 4-year retrospective review of case notes and HDU/ICU registers was performed. One hundred and twenty-three patients were admitted to the HDU in the 2 years following its inception, representing 1.02% of all deliveries. Obstetric complications accounted for 81.3% of admissions. Seventeen patients were admitted to an ICU during the study period; 12 (0.08%) were transferred before and five (0.04%) after the development of HDU facilities (p = 0.25). The advantages of a HDU within this setting include the concurrent availability of expert obstetric care and critical care management, the avoidance of the hazards of emergency transport and improved continuity of antenatal and postnatal care.

Fetal death after trauma in pregnancy

Trauma in pregnancy places the mother and fetus at risk. The objective of this study is to identify risk factors independently associated with acute termination of pregnancy and/or fetal mortality after trauma. The medical and trauma registry records of 80 injured pregnant patients were reviewed. Data were collected and then analyzed by univariate and multivariate analysis. Three patients died (3.7%), 23 had the pregnancy acutely terminated (30%), and 14 suffered fetal death (17.5%). The only independent risk factors for fetal mortality were an Injury Severity Score (ISS) > or =9 and a nonviable pregnancy (<23 weeks). The combination of both risk factors increased the likelihood of fetal mortality by fivefold over that of patients without either risk factor. Maternal hemodynamic parameters did not predict fetal loss. Two patients lost their fetuses despite insignificant trauma (ISS = 1) and normal hemodynamic parameters, whereas eight delivered normal babies despite major trauma (ISS > or = 16). Hemodynamic stability on admission does not predict fetal mortality. Although the presence of moderate to severe injuries (ISS > or = 9) increases the likelihood of fetal mortality, this complication may occur even with insignificant trauma. Close maternal and fetal monitoring is justified, regardless of maternal hemodynamic presentation or severity of injury.