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Morris JL, Armitage S, Davis J, Kaur J, Pretty M, Ea S, Seok J, de Vries I. Professional societies of obstetrics and gynecology as agents of change in sexual and reproductive health: FIGO's 10-country safe abortion advocacy project in Africa and Latin America. Int J Gynaecol Obstet 2024; 164 Suppl 1:31-41. [PMID: 38360034 DOI: 10.1002/ijgo.15334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
In 2019, FIGO started implementing its abortion project focusing on advocacy. The Advocacy for Safe Abortion (ASA) Project was conducted in partnership with 10 national professional societies of obstetrics and gynecology in Latin America and Africa. The project aimed to strengthen national societies, support them to be leaders in sexual and reproductive health, and enable them to obtain context-specific advocacy goals that improve access to safe abortion. Innovative monitoring and evaluation methodology enabled tracking of outcomes, consideration of their contribution to success, and cross-country evaluation. The project saw success through some key strategies: institutional capacity strengthening; enhanced work through collaborations; training to increase knowledge and reduce abortion-related stigma with a broad array of stakeholders; and generation and use of evidence to influence decision-makers. This article describes the project and methodology used and provides tangible examples of how societies have been agents of change in their countries and of the need for such important work to continue.
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Zea-Prado F, Espino-Y-Sosa JS, Sarria-Ortiz D, Muñoz-Córdoba L, Nieto-Calvache AJ. Postpartum bleeding visual underestimation: A persistent problem. Int J Gynaecol Obstet 2024; 164:803-804. [PMID: 37767781 DOI: 10.1002/ijgo.15155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/24/2023] [Accepted: 09/10/2023] [Indexed: 09/29/2023]
Abstract
SynopsisPostpartum bleeding volume calculated by the visual method is lower than the bleeding volume that is objectively quantified.
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Affiliation(s)
- Francisco Zea-Prado
- Departamento de Obstetricia y Ginecología, Instituto Nacional de Perinatología, Ciudad de México, Mexico
| | - J Salvador Espino-Y-Sosa
- División de Investigación Clínica, Instituto Nacional de Perinatología, Ciudad de México, Mexico
| | | | - Laura Muñoz-Córdoba
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
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Hamilton S, Olson S, Voegtline K, Lawson SM. Postpartum readmission in Maryland by race and ethnicity, 2016-2019. AJOG Glob Rep 2023; 3:100278. [PMID: 38046531 PMCID: PMC10692712 DOI: 10.1016/j.xagr.2023.100278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND The majority of maternal deaths occur in the postpartum period. We sought to compare postpartum readmission by race and ethnicity to better understand whether there are disparities in maternal health in the postpartum period as indicated by readmission to the hospital. OBJECTIVE This study aimed to use state-wide Maryland data to identify postpartum readmission rates by race and ethnicity, as well as the major risk factors, indications, and timing of readmission. STUDY DESIGN In this retrospective study (2016-2019), childbirth hospitalizations for patients of childbearing age were identified from the Maryland State Inpatient Database, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. Indication for readmission was described. Multivariable logistic regression models were employed to determine racial and ethnic differences in postpartum readmissions, adjusting for maternal and obstetrical characteristics. RESULTS Among total deliveries (n=260,778), 3914 patients (1.5%) were readmitted within 60 days of delivery. The most common primary diagnoses at readmission were hypertension and infection. The prevalence of readmission was 1.2% (1306/111,325) for White patients, 2.3% (1786/79,412) for Black patients, 1.2% (485/40,862) for Hispanic patients and 1.2% (337/29,179) for patients of Other race or ethnicity (P<.0001). Black patients had the highest rates of readmission for hypertensive disorders as compared with all other races (37%, P<.0001). In adjusted models, Black patients were more likely to be readmitted than White patients (odds ratio, 1.64; confidence interval, 1.52-1.77). The majority of all readmissions occurred in the first week after delivery with Black patients having higher rates of readmission in the second week relative to all other groups (P<.0001). CONCLUSION Hypertension is a leading cause of postpartum readmission in Maryland. Black patients were more likely to be readmitted for hypertensive disorders of pregnancy and to have delayed readmission relative to other race or ethnic groups. Maryland public health officials should address disparities with interventions targeting racial and ethnic minorities, patients at risk for hypertensive disorders, and barriers to timely care.
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Affiliation(s)
- Sonia Hamilton
- Johns Hopkins University School of Medicine, Baltimore, MD (Ms Hamilton)
| | - Sarah Olson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (Ms Olson and Dr Voegtline)
| | - Kristin Voegtline
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD (Ms Olson and Dr Voegtline)
| | - Shari M. Lawson
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Lawson)
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Grob PC, Tindal RR, Lundeberg KR, Hamilton JL, Gonzalez-Brown VM, Keyser EA. Increased maternal morbidity and mortality among Asian American and Pacific Islander women in the military health system. AJOG Glob Rep 2023; 3:100212. [PMID: 37205300 PMCID: PMC10185736 DOI: 10.1016/j.xagr.2023.100212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
BACKGROUND Rates of maternal morbidity and mortality experienced by women in the United States have been shown to vary significantly by race, most commonly attributed to differences in access to healthcare and socioeconomic status. Recent data showed that Asian Pacific Islanders have the highest rate of maternal morbidity despite having a higher socioeconomic status. In the military, women of all races are granted equal access to healthcare, irrespective of socioeconomic class. We hypothesized that within the military, there would be no racial disparities in maternal outcomes because of universal healthcare. OBJECTIVE This study aimed to evaluate if universal access to healthcare, as seen in the military healthcare system, leads to similar rates of maternal morbidity regardless of racial or ethnic background. STUDY DESIGN This was a retrospective cohort study of data from the National Perinatal Information Center reports obtained from participating military treatment facilities from April 2019 to March 2020 and included 34,025 deliveries. We compared racial differences in the incidence of each of the following 3 outcomes: postpartum hemorrhage, severe maternal morbidity among women with postpartum hemorrhage including transfusion, and severe maternal morbidity among women with postpartum hemorrhage excluding transfusion. RESULTS A total of 41 military treatment facilities (a list of participating military treatment facilities are provided in the Appendix) provided data that were included. There was an increased rate of postpartum hemorrhage (relative risk, 1.73; 95% confidence interval, 1.45-2.07), severe maternal morbidity including transfusion (relative risk, 1.22; 95% confidence interval, 0.93-1.61), and severe maternal morbidity excluding transfusion (relative risk, 1.97; 95% confidence interval, 1.02-3.8) among Asian Pacific Islander women when compared with Black or White women. CONCLUSION Even with equal access to healthcare in the military, Asian Pacific Islander women experience statistically significant increased rates of postpartum hemorrhage and severe maternal morbidity excluding transfusion when compared with Black or White women. The increased rates of severe maternal morbidity including transfusion were not statistically significant.
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Affiliation(s)
- Patrizia C. Grob
- Rocky Vista University College of Osteopathic Medicine, Parker, CO (Dr Grob)
- Corresponding author: Patrizia C. Grob, DO.
| | - Rachel R. Tindal
- University of Alabama Heersink School of Medicine, Birmingham, AL (Dr Tindal)
| | - Kathleen R. Lundeberg
- College of Osteopathic Medicine, Pacific Northwest University of Health Sciences, Yakima, WA (Dr Lundeberg)
| | - Jameaka L. Hamilton
- Department of Gynecologic Surgery & Obstetrics, Mike O'Callaghan Military Medical Center, Nellis Air Force Base, Las Vegas, NV (Dr Hamilton)
| | - Veronica M. Gonzalez-Brown
- Department of Gynecologic Surgery & Obstetrics, San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX (Drs Gonzalez-Brown and Keyser)
| | - Erin A. Keyser
- Department of Gynecologic Surgery & Obstetrics, San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, Fort Sam Houston, TX (Drs Gonzalez-Brown and Keyser)
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Kluck SL, Russo RM, Appel NB, Frankfurt AI, Weltge C, Shimer T, Feagins B, Frotan A, Rinehart B, Cohen RA. Aortic balloon occlusion in distal zone 3 reduces blood loss from obstetric hemorrhage in placenta accreta spectrum. J Trauma Acute Care Surg 2023; 94:710-717. [PMID: 36812423 PMCID: PMC10155693 DOI: 10.1097/ta.0000000000003917] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Peripartum hemorrhage is a significant cause of maternal death. We developed a standardized, multidisciplinary cesarean hysterectomy protocol for placenta accreta spectrum (PAS) using prophylactic resuscitative endovascular balloon occlusion of the aorta (REBOA). We initially placed the balloon in proximal zone 3, below the renal arteries. An internal review revealed more bleeding than expected, and we subsequently changed our protocol to occlude the origin of the inferior mesenteric artery (distal zone 3), to decrease blood flow through collateral circulation. We hypothesized that distal zone 3 occlusion would reduce blood loss and transfusion volume and may permit a longer duration of occlusion compared with proximal zone 3 occlusion without increasing ischemic complications. METHODS We conducted a single-center retrospective cohort study of patients with suspected PAS who underwent REBOA-assisted cesarean hysterectomy from December 2018 to March 2022. Medical records of all patients with PAS were reviewed. Data were extracted from hospital admission through 3 months postpartum. RESULTS Forty-four patients met the inclusion criteria. Nine never had the balloon inflated. Eighteen patients had placement in proximal zone 3, whereas twenty-six patients had placement in distal zone 3. Background and clinical characteristics were similar in both groups. Placental pathology was obtained in every case. After adjusting for relevant risk factors, multivariate analysis revealed that distal occlusion was associated with a 45.9% (95% confidence interval, 23.8-61.6%) decrease in estimated blood loss, 41.5% (13.7-60.4%) decrease in red blood cell transfusion volume, and 44.9% (13.5-64.9%) reduction in total transfusion volume. There were no vascular access or resuscitative endovascular balloon occlusion of the aorta-related complications in either group. CONCLUSION This study highlights the safety of prophylactic REBOA in planned cesarean hysterectomy for PAS and provides a rationale for distal zone 3 positioning to reduce blood loss. Resuscitative endovascular balloon occlusion of the aorta should be considered at other institutions with placenta accreta programs, especially in patients with extensive collateral flow. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Barr E, Noursi S, Roodzant E, Ubesie A, Amin S, Macioce N, Whitaker D, Clayton JA, Temkin SM. Public Priorities in Women's Health: Analysis of Request for Information Published to Inform "Advancing NIH Research on the Health of Women: A 2021 Conference". J Womens Health (Larchmt) 2023. [PMID: 37040314 DOI: 10.1089/jwh.2022.0488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
Objectives: To assist with planning a congressionally requested conference on women's health research, the National Institutes of Health (NIH) Office of Research on Women's Health (ORWH) invited comments to characterize public concerns related to any or all of the specified public health issues: maternal morbidity and mortality (MMM); stagnant rates of cervical cancer survival; and the growing incidence of chronic debilitating conditions in women (CDCW). This analysis summarizes public priorities in women's health research. Methods: All comments received in response to a request for information were open coded and a master list of keywords was created, and comments were categorized. Comments addressing CDCW were categorized using a conceptual framework developed by the NIH. Results: Two hundred forty-seven comments were coded and analyzed. One hundred four comments (42%) addressed MMM; 182 comments (73%) discussed CDCW; and 27 comments (10%) addressed cervical cancer. Comments focused on CDCW most frequently addressed female-specific conditions (83%). The 10 most frequently identified keywords in order of frequency from the manual coding were as follows: (1) MMM, (2) racial disparities, (3) access to care, (4) provider training, (5) mental health, (6) Black or African American women, (7) screening, (8) quality of care, (9) time to diagnosis, and (10) social determinants of health. Conclusions: Comments demonstrate a broad range of concerns related to the health of women, including MMM, CDCW, and cervical cancer. A wide array of commenters included patients, advocacy groups, and academic and professional organizations originating from geographically diverse locations. These comments reflect a strong desire from the public to prioritize research on the health of women.
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Affiliation(s)
- Elizabeth Barr
- National Institutes of Health, Office of Research on Women's Health, Bethesda, Maryland, USA
| | - Samia Noursi
- National Institutes of Health, Office of Research on Women's Health, Bethesda, Maryland, USA
| | - Erik Roodzant
- National Institutes of Health, Office of Research on Women's Health, Bethesda, Maryland, USA
- Booz Allen Hamilton, McLean, Virginia, USA
| | - Amelia Ubesie
- National Institutes of Health, Office of Research on Women's Health, Bethesda, Maryland, USA
- Booz Allen Hamilton, McLean, Virginia, USA
| | - Shilpa Amin
- National Institutes of Health, Office of Research on Women's Health, Bethesda, Maryland, USA
| | - Nikeya Macioce
- National Institutes of Health, Office of Research on Women's Health, Bethesda, Maryland, USA
- Scientific Consulting Group, Gaithersburg, Maryland, USA
| | - Damiya Whitaker
- National Institutes of Health, Office of Research on Women's Health, Bethesda, Maryland, USA
| | - Janine A Clayton
- National Institutes of Health, Office of Research on Women's Health, Bethesda, Maryland, USA
| | - Sarah M Temkin
- National Institutes of Health, Office of Research on Women's Health, Bethesda, Maryland, USA
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Minehart RD, Gallin H. Postpartum hemorrhage: The role of simulation. Best Pract Res Clin Anaesthesiol 2022; 36:433-439. [PMID: 36513437 DOI: 10.1016/j.bpa.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/10/2022] [Indexed: 11/17/2022]
Abstract
Postpartum hemorrhage (PPH) persists as a leading cause of maternal death worldwide, and in the United States, most maternal deaths due to hemorrhage are deemed preventable. While essential preparations for hemorrhage include protocols and checklists, implementation science has revealed that it is not enough to merely introduce these tools into units. Simulation affords safe opportunities for practice and produces reliable behavior change, and it does not always need to be highly expensive and resource consuming. We review how simulation can be applied to address a unit's vulnerabilities in identifying, managing, and resolving PPH, as well as considerations for crafting a comprehensive simulation program for your unit.
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Martin JN, Tucker JM. Maternal morbidity and mortality in pregnant/postpartum women with suspected HELLP syndrome identifiable as probable thrombotic thrombocytopenic purpura or atypical hemolytic uremic syndrome by high LDH to AST ratio. Int J Gynaecol Obstet 2022; 159:870-874. [PMID: 35301713 DOI: 10.1002/ijgo.14177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 02/28/2022] [Accepted: 03/09/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe findings in 8 women initially diagnosed as presumptive HELLP Syndrome, eventually confirmed as TTP/aHUS as distinguished by elevated calculated LDH:AST ratio > 22:1. METHODS All medicolegal files of patients evaluated between 1986 and 2015 with presumptive HELLP syndrome but later determined to have TTP/aHUS had LDH:AST ratios evaluated throughout care. RESULTS Fifty-eight pregnant/postpartum women presented with a diagnosis of presumptive HELLP syndrome. In the final analysis, 8 women had TTP/aHUS characterized by severe thrombocytopenia (<20 000/μl) at admission, rare epigastric pain, and the consistent demonstration of a very high calculated total LDH to AST ratio. This calculation greatly exceeded 22:1 with TTP/aHUS (mean = 32:1) versus 2:1 with HELLP and could be consistently demonstrated throughout care. Six of 8 women with TTP/aHUS died. CONCLUSION Correctly distinguishing between HELLP syndrome versus an imitator disorder continues to challenge obstetric specialists. This medicolegal data supplements prior findings supporting the concept of the LDH:AST ratio as a useful screening tool for clinicians to differentiate TTP/aHUS apart from HELLP syndrome in order to facilitate earlier hematology consultation, patient referral to tertiary care and emergent hemotherapy for these mothers.
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Affiliation(s)
- James Nello Martin
- Department of Obstetrics and Gynecology, The Winfred L. Wiser Hospital for Women & Infants at the University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - James Martin Tucker
- Department of Obstetrics and Gynecology, The Winfred L. Wiser Hospital for Women & Infants at the University of Mississippi Medical Center, Jackson, Mississippi, USA
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Ukoha EP, Snavely ME, Hahn MU, Steinauer JE, Bryant AS. Toward the elimination of race-based medicine: replace race with racism as preeclampsia risk factor. Am J Obstet Gynecol 2022; 227:593-596. [PMID: 35640703 DOI: 10.1016/j.ajog.2022.05.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/17/2022] [Accepted: 05/23/2022] [Indexed: 11/01/2022]
Abstract
Pregnancy-related morbidity and mortality continue to disproportionately affect birthing people who identify as Black. The use of race-based risk factors in medicine exacerbates racial health inequities by insinuating a false conflation that fails to consider the underlying impact of racism. As we work toward health equity, we must remove race as a risk factor in our guidelines to address disparities due to racism. This includes the most recent US Preventive Services Taskforce, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine guidelines for aspirin prophylaxis in preeclampsia, where the risk factor for "Black race" should be replaced with "anti-Black racism." In this commentary, we reviewed the evidence that supports race as a sociopolitical construct and the health impacts of racism. We presented a call to action to remove racial determination in the guidelines for aspirin prophylaxis in preeclampsia and more broadly in our practice of medicine.
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Greenberg MB, Gandhi M, Davidson C, Carter EB. Society for Maternal-Fetal Medicine Consult Series #62: Best practices in equitable care delivery-Addressing systemic racism and other social determinants of health as causes of obstetrical disparities. Am J Obstet Gynecol 2022; 227:B44-B59. [PMID: 35378098 DOI: 10.1016/j.ajog.2022.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The Centers for Disease Control and Prevention define social determinants of health as "the conditions in the places where people live, learn, work, and play" that can affect health outcomes. Systemic racism is a root cause of the power and wealth imbalances that affect social determinants of health, creating disproportionate rates of comorbidities and adverse outcomes in the communities of racial and ethnic minority groups. Focusing primarily on disparities between Black and White individuals born in the United States, this document reviews the effects of social determinants of health and systemic racism on reproductive health outcomes and recommends multilevel approaches to mitigate disparities in obstetrical outcomes.
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Abstract
OBJECTIVE Women with obesity and other comorbidities such as hypertension and diabetes are at an increased risk of preeclampsia and perinatal morbidity. This study evaluates whether screening echocardiogram can identify women with obesity at a higher risk of preeclampsia. METHODS We conducted a retrospective cohort study of women with class III obesity (body mass index [BMI] ≥40 kg/m2) and one or more medical comorbidities associated with an increased risk of preeclampsia (such as diabetes, hypertension, and rheumatologic disease) undergoing screening echocardiogram. Abnormal findings were defined as the presence of one or more of the following: diastolic dysfunction, ejection fraction of ≤45%, or cardiac chamber enlargement or hypertrophy. Multivariable logistic regression was used to estimate the odds ratio (OR) of gestational hypertension/mild preeclampsia, severe preeclampsia, and any preterm delivery <37 weeks associated with abnormal echocardiographic findings when controlling for potential confounders. RESULTS Of 267 eligible women, 174 (64%) underwent screening echocardiograms. Sixty-nine women (40%) had abnormal echocardiograms. Maternal clinical characteristics were similar between women with normal echocardiographic findings and women with abnormal findings. Women with abnormal echocardiograms were more likely to have chronic hypertension (78 vs. 62%, p = 0.04) and a history of preeclampsia (27 vs. 10%, p = 0.02). After controlling for confounders, women with abnormal echocardiogram were at an increased risk of hypertensive disorders of pregnancy, OR 6.80 (95% confidence interval [CI] 3.32-13.93, p = 0.01), and in particular severe preeclampsia, OR 8.77 (95% CI 3.90-19.74, p = 0.01). CONCLUSION Among pregnant women with class III obesity and medical comorbidities, screening echocardiogram may help identify a subset of women at the highest risk of developing preeclampsia. KEY POINTS · Women with obesity and comorbid conditions are at a high risk of abnormal echocardiogram.. · Women with obesity, medical comorbid conditions, and abnormal echo are at a high risk of preeclampsia.. · Screening echocardiogram can help identify obese women at the highest risk of severe preeclampsia..
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Affiliation(s)
- Maeve K. Hopkins
- Division of Maternal and Fetal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania,Address for correspondence Maeve Hopkins, MD Hospital of the University of Pennsylvania3400 Spruce Street, Silverstein Building, 2nd Floor, Philadelphia, PA 19104
| | - Lisa D. Levine
- Division of Maternal and Fetal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nathanael C. Koelper
- Department of Obstetrics and Gynecology, Center for Research on Reproduction and Women's Health, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Celeste Durnwald
- Division of Maternal and Fetal Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Bernstein SL, Kelechi TJ, Catchpole K, Nemeth LS. Prevention of Failure to Rescue in Obstetric Patients: A Realist Review. Worldviews Evid Based Nurs 2021; 18:352-360. [PMID: 34482602 DOI: 10.1111/wvn.12531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND At least 40% of maternal deaths are attributable to failure to rescue (FTR) events. Nurses are positioned to prevent FTR events, but there is minimal understanding of systems-level factors affecting obstetric nurses when patients require rescue. AIMS To identify the nurse-specific contexts, mechanisms, and outcomes underlying obstetric FTR and the interventions designed to prevent these events. METHODS A realist review was conducted to meet the aims. This review included literature from 1999 to 2020 to understand the systems-level factors affecting obstetric nurses during FTR events using a human factors framework designed by the Systems Engineering Initiative for Patient Safety. RESULTS Existing interventions addressed the prevention of maternal death through education of clinicians, improved protocols for care and maternal transfer, and an emphasis on communication and teamwork. LINKING EVIDENCE TO ACTION Few researchers addressed task overload or connected employee and organizational outcomes with patient outcomes, and the physical environment was minimally considered. Future research is needed to understand how systems-level factors affect nurses during FTR events.
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Affiliation(s)
| | - Teresa J Kelechi
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Kenneth Catchpole
- S.C. SmartState endowed Chair in Clinical Practice and Human Factors, Anesthesia and Perioperative Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Lynne S Nemeth
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
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Schonewille NN, Abheiden CNH, Bokslag A, Thijs A, De Groot CJM, De Vries JIP, De Boer MA. Cardiovascular risk after hypertensive disorders of pregnancy in women with and without inheritable Thrombophilia. Hypertens Pregnancy 2020; 39:203-210. [PMID: 32297536 DOI: 10.1080/10641955.2020.1753767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Aim of this study was to compare cardiovascular risk in women with and without inheritable thrombophilia after hypertensive disorders of pregnancy (HDP). Blood pressure, anthropometrics and blood samples were measured 9-13 years after early-onset (<34 weeks) HDP. Amongst the 114 women included, no differences in hypertension (31.1% vs. 33.7%, OR 0.90 95% CI (0.29-2.79)), body mass index > 25 kg/m2 (43.8% vs. 53.1%, OR 0.69 95% CI (0.24-2.00)) or metabolic syndrome (18.8% vs. 13.3%, OR 1.51 95% CI (0.38-6.02)) were found. These data show similar cardiovascular risk profile in women with and without inheritable thrombophilia.
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Affiliation(s)
- N N Schonewille
- Department of Obstetrics and Gynaecology, UMC, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - C N H Abheiden
- Department of Obstetrics and Gynaecology, UMC, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - A Bokslag
- Department of Obstetrics and Gynaecology, UMC, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - A Thijs
- Department of Obstetrics and Gynaecology, UMC, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - C J M De Groot
- Department of Obstetrics and Gynaecology, UMC, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - J I P De Vries
- Department of Obstetrics and Gynaecology, UMC, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - M A De Boer
- Department of Obstetrics and Gynaecology, UMC, Institute for Cardiovascular Research, Amsterdam, The Netherlands
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Epiu I, Alia G, Mukisa J, Tavrow P, Lamorde M, Kuznik A. Estimating the cost and cost-effectiveness for obstetric fistula repair in hospitals in Uganda: a low income country. Health Policy Plan 2018; 33:999-1008. [PMID: 30252051 PMCID: PMC6263022 DOI: 10.1093/heapol/czy078] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2018] [Indexed: 12/16/2022] Open
Abstract
In Africa, about 33 000 cases of obstetric fistula occur each year. Women with fistula experience debilitating incontinence of urine and/or faeces and are often socially ostracized. Worldwide, Uganda ranks third among countries with the highest burden of obstetric fistula. Obstetric fistula repair competes for scarce resources with other healthcare interventions in resource-limited settings, even though it is surgically efficacious. There is limited documentation of its cost-effectiveness in the most affected settings. We therefore sought to assess the cost-effectiveness of surgical intervention for obstetric fistula in Uganda so as to provide appropriate data for policy-makers to prioritize fistula repair and reduce women's suffering in similarly burdened countries. We built a decision-analytic model from the perspective of Uganda's National Health System to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery vs a competing strategy of no surgery for Ugandan women with fistula. Long-term disability outcomes were assessed based on a lifetime Markov state-transition cohort and effectiveness of surgery. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula and mortality rates among the general population in Uganda were based on published sources. The cost of providing fistula repair surgery in Uganda was estimated at $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the lifetime disability burden from 8.53 DALYs to 1.51 DALYs, yielding a cost per DALY averted of $54. The results were robust to variations in model inputs in one-way and probabilistic sensitivity analyses. Surgery for obstetric fistula appears highly cost-effective in Uganda. In similar low-income countries, governments and non-governmental organizations need to prioritize training and strengthening surgical capacity to increase access to fistula surgical care, which would be an important step towards achieving universal health coverage.
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Affiliation(s)
- Isabella Epiu
- NIH Fogarty Global Health Fellow, University of California Global Health Institute, CA, USA and Director Health Solutions International, Kampala, Uganda
| | - Godfrey Alia
- Department of Obstetrics and Gynecology, Mulago National Referral Hospital, Kampala, Uganda
| | - John Mukisa
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, Uganda
| | - Paula Tavrow
- Bixby Program in Population and Reproductive Health, University of California at Los Angeles, CA, USA
| | - Mohammed Lamorde
- Prevention Care and Treatment, Infectious Disease Institute, Makerere University College of Health Sciences, Uganda
| | - Andreas Kuznik
- Department of Health Economics and Outcomes Research, Regeneron Pharmaceuticals, Tarrytown, NY, USA
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McGee A, Jansen M, Sheldon S. Abortion law reform: Why ethical intractability and maternal morbidity are grounds for decriminalisation. Aust N Z J Obstet Gynaecol 2018; 58:594-597. [PMID: 29681079 DOI: 10.1111/ajo.12817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/22/2018] [Indexed: 12/13/2022]
Abstract
In this paper, we present two grounds for arguing that abortion should be decriminalised. First, we consider the implications of the fact that the long-standing ethical debate concerning the morality of abortion has to date proven intractable. We maintain that because the philosophical literature has failed to demonstrate conclusively that views either for or against abortion's moral acceptability are false, the matter remains at a stalemate in terms of rational debate, contributing to the ongoing absence of political and popular consensus about the issue in our society. In these circumstances, we argue, the law should adopt a minimalist position by not imposing criminal sanctions for abortion. Second, we present evidence, often neglected in the moral debates about abortion, that the risks of carrying a fetus to term and of delivery are substantial for a woman. Most laws recognise that, should her life be endangered by her pregnancy, a woman's right to life shall prevail. However, the impacts of carrying a fetus to term and delivery on a woman are not restricted to the risks to her life, but extend to significant permanent changes to her body, and include risks of injury that are not negligible. We argue that a woman should not be compelled to take these risks by laws prohibiting abortion, when no conclusive argument exists against the morality of abortion. We also address, albeit briefly, the issue of late-term abortion.
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Affiliation(s)
- Andrew McGee
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Melanie Jansen
- Intensive Care, Centre for Children's Health Ethics and Law, Children's Health Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Khouadja H, Rouissi W, Mahjoub M, Sakhri J, Beletaifa D, Jazia KB. [Transfusion strategy for patients with severe postpartum hemorrhage: a retrospective study of 47 cases]. Pan Afr Med J 2017; 25:169. [PMID: 28292131 PMCID: PMC5326027 DOI: 10.11604/pamj.2016.25.169.7095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/12/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Postpartum haemorrhage is the leading cause of maternal morbidity and mortality worldwide. It requires a multidisciplinary approach. Transfusion strategy is essential, playing a key role in maternal prognosis. This study aims to determine FFP/RBC ratio (plasma frais congelé/concentrés de globules rouges; fresh frozen plasma/red blood cells) during the treatment of serious postpartum haemorrhages. METHODS We conducted a retrospective study at a Maternity Referral Center (level III) in eastern Tunisia over a period of 4 years (2009-2012). All parturients admitted due to severe postpartum bleeding requiring transfusion of more than 4 Units of RBC during the first 3 hours or of more than 10 Units of RBC during the first 24 hours of treatment were included in the study. RESULTS 47 parturients were enrolled in our study. The diagnosis of PPH was made on the basis of vaginal bleeding in 28 cases and following cesarean section in 19 cases. Preoperative hemoglobin level was of 6.3 g/dl. Transfusion ratio (FFP/RBC) was 1/0.7. CONCLUSION During tratment transfusion ratio was greater than that indicated in the existing guidelines stating an early and massive administration of FFP with a FFP/RBC ratio ranging between 1/2 and 1/1. Fibrinogen (Fbg) and tranexamic acid should be administered as early as possible. The use of recombinant activated factor VII (rFVIIa) should remain the ultimate treatment option.
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Affiliation(s)
- Hosni Khouadja
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie; Unité de Recherche UR12SP32, CHU Farhat Hached, Sousse, Tunisie
| | - Wissem Rouissi
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie
| | - Mohamed Mahjoub
- Service d'Hygiène Hospitalière. Centre Hospitalo-Universitaire Farhat Hached Sousse, Tunisie
| | - Jaballah Sakhri
- Unité de Recherche UR12SP32, CHU Farhat Hached, Sousse, Tunisie
| | - Dhafer Beletaifa
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie
| | - Khaled Ben Jazia
- Service Anesthésie Réanimation chirurgicale, Centre Hospitalo-Universitaire Farhat Hached Sousse-Tunisie
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Skurnik G, Roche AT, Stuart JJ, Rich-Edwards J, Tsigas E, Levkoff SE, Seely EW. Improving the postpartum care of women with a recent history of preeclampsia: a focus group study. Hypertens Pregnancy 2016; 35:371-81. [PMID: 27043861 DOI: 10.3109/10641955.2016.1154967] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Women with prior preeclampsia are at increased risk of cardiovascular disease (CVD). This study investigated barriers and facilitators toward learning about this link and engaging in lifestyle modifications to reduce this risk. METHODS Four focus groups were held with 14 women within 6 months of a preeclamptic pregnancy. RESULTS Participants were unaware of the link between preeclampsia and CVD, suggested improvements to provider-patient communication, and discussed the benefits of social support and online tracking (weight, blood pressure) in making lifestyle modifications. CONCLUSIONS Solutions offered may improve efforts to modify lifestyle and communication between providers and women about this link.
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Affiliation(s)
- Geraldine Skurnik
- a Department of Medicine, Division of Endocrinology, Brigham and Women's Hospital, Boston , MA, USA; Harvard Medical School , Boston , MA , USA
| | - Andrea Teresa Roche
- a Department of Medicine, Division of Endocrinology, Brigham and Women's Hospital, Boston , MA, USA; Harvard Medical School , Boston , MA , USA
| | - Jennifer J Stuart
- b Connors Center for Women's Health and Gender Biology , Division of Women's Health, Brigham and Women's Hospital , Boston , MA , USA.,c Department of Epidemiology , Harvard T.H. Chan School of Public Health , Boston , MA , USA
| | - Janet Rich-Edwards
- b Connors Center for Women's Health and Gender Biology , Division of Women's Health, Brigham and Women's Hospital , Boston , MA , USA.,c Department of Epidemiology , Harvard T.H. Chan School of Public Health , Boston , MA , USA
| | - Eleni Tsigas
- d The Preeclampsia Foundation , Melbourne , FL , USA
| | - Sue E Levkoff
- e College of Social Work, University of South Carolina , Columbia , SC , USA
| | - Ellen W Seely
- a Department of Medicine, Division of Endocrinology, Brigham and Women's Hospital, Boston , MA, USA; Harvard Medical School , Boston , MA , USA
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Leme Galvão LP, Menezes FE, Mendonca C, Barreto I, Alvim-Pereira C, Alvim-Pereira F, Gurgel R. Analysis of association of clinical aspects and IL1B tagSNPs with severe preeclampsia. Hypertens Pregnancy 2016; 35:112-22. [PMID: 26909468 DOI: 10.3109/10641955.2015.1116554] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study investigates the association between IL1B genotypes using a tag SNP (single polymorphism) approach, maternal and environmental factors in Brazilian women with severe preeclampsia. METHODS A case-control study with a total of 456 patients (169 preeclamptic women and 287 controls) was conducted in the two reference maternity hospitals of Sergipe state, Northeast Brazil. A questionnaire was administered and DNA was extracted to genotype the population for four tag SNPs of the IL1Beta: rs 1143643, rs 1143633, rs 1143634 and rs 1143630. Haplotype association analysis and p-values were calculated using the THESIAS test. Odds ratio (OR) estimation, confidence interval (CI) and multivariate logistic regression were performed. RESULTS High pregestational body mass index (pre-BMI), first gestation, cesarean section, more than six medical visits, low level of consciousness on admission and TC and TT genotype in rs1143630 of IL1Beta showed association with the preeclamptic group in univariate analysis. After multivariate logistic regression pre-BMI, first gestation and low level of consciousness on admission remained associated. CONCLUSION We identified an association between clinical variables and preeclampsia. Univariate analysis suggested that inflammatory process-related genes, such as IL1B, may be involved and should be targeted in further studies. The identification of the genetic background involved in preeclampsia host response modulation is mandatory in order to understand the preeclampsia process.
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Affiliation(s)
| | - Filipe Emanuel Menezes
- a Department of Medicine , Federal University of Sergipe , Farolândia , Aracaju , Brazil
| | - Caio Mendonca
- a Department of Medicine , Federal University of Sergipe , Farolândia , Aracaju , Brazil
| | - Ikaro Barreto
- a Department of Medicine , Federal University of Sergipe , Farolândia , Aracaju , Brazil
| | - Claudia Alvim-Pereira
- a Department of Medicine , Federal University of Sergipe , Farolândia , Aracaju , Brazil
| | - Fabiano Alvim-Pereira
- a Department of Medicine , Federal University of Sergipe , Farolândia , Aracaju , Brazil
| | - Ricardo Gurgel
- a Department of Medicine , Federal University of Sergipe , Farolândia , Aracaju , Brazil
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Bergenhenegouwen L, Ensing S, Ravelli ACJ, Schaaf J, Kok M, Mol BW. Subsequent pregnancy outcome after preterm breech delivery, a population based cohort study. J Matern Fetal Neonatal Med 2015; 29:2540-4. [PMID: 26553533 DOI: 10.3109/14767058.2015.1094050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The objective of this study is to investigate the effect of the mode of delivery in women with preterm breech presentation on neonatal and maternal outcome in the subsequent pregnancy. METHODS Nationwide population-based cohort study in the Netherlands of women with a preterm breech delivery and a subsequent delivery in the years 1999-2007. We compared planned caesarean section versus planned vaginal delivery for perinatal outcomes in both pregnancies. RESULTS We identified 1543 women in the study period, of whom 259 (17%) women had a planned caesarean section and 1284 (83%) women had a planned vaginal delivery in the first pregnancy. In the subsequent pregnancy, perinatal mortality was 1.1% (3/259) for women with a planned caesarean section in the first pregnancy and 0.5% (6/1284) for women with a planned vaginal delivery in the first pregnancy (aOR 1.8; 95% CI 0.31-10.1). Composite adverse neonatal outcome was 2.3% (6/259) versus 1.5% (19/1284), (aOR 1.5; 95% CI 0.55-4.2). The average risk of perinatal mortality over two pregnancies was 1.9% (10/518) for planned caesarean section and 2.0% (51/2568) for planned vaginal delivery, (OR 0.98; 95% CI 0.49-1.9). CONCLUSION In women with a preterm breech delivery, planned caesarean section does not reduce perinatal mortality, perinatal morbidity, or maternal morbidity rate over the course of two pregnancies.
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Affiliation(s)
| | - Sabine Ensing
- b Department of Obstetrics and Gynaecology and.,c Department of Medical Informatics , Amsterdam Medical Centre, Amsterdam, The Netherlands , and
| | - Anita C J Ravelli
- c Department of Medical Informatics , Amsterdam Medical Centre, Amsterdam, The Netherlands , and
| | | | | | - Ben-Willem Mol
- d The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide , Australia
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Stevens DU, Smits MP, Bulten J, Spaanderman MEA, van Vugt JMG, Al-Nasiry S. Prevalence of hypertensive disorders in women after preeclamptic pregnancy associated with decidual vasculopathy. Hypertens Pregnancy 2015; 34:332-41. [PMID: 25954825 DOI: 10.3109/10641955.2015.1034803] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE A subgroup of preeclamptic women has spiral artery lesions termed decidual vasculopathy (DV) which relate to worse clinical outcome. We aimed to determine whether a history of preeclampsia (PE) with DV is associated with adverse overall and future pregnancy outcome, including increased recurrence risk of hypertensive diseases of pregnancy. METHODS Via posted survey women with PE and DV (DV positive) in the index pregnancy were compared to those without the lesions (DV negative) on overall and future pregnancy outcome. RESULTS DV positive cases showed a higher incidence of chronic hypertension both preconceptionally and at time of survey, adjusted odds ratio 4.8 (2.0-11.9). The DV positive group had a higher overall incidence of pregnancies with gestational hypertension (22% vs 13%, p = 0.04), preterm birth (59% vs 45%, p = 0.02) and a lower birth weight centile (30 vs 39, p = 0.02). There was no difference in outcome of future pregnancies, irrespective of the use of prophylactic aspirin. CONCLUSION Women with DV-associated PE have a higher overall incidence of adverse obstetric outcome and of chronic hypertension, indicating an underlying vascular pathology, putting them at risk for pregnancy and cardiovascular complications. These women constitute a target group for counseling, monitoring and possibly lifestyle or pharmacological interventions.
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Kostopanagiotou G, Kalimeris K, Pandazi A, Salamalekis G, Chrelias C, Matsota P. The role of the post-anaesthesia care unit in the management of high-risk obstetric patients. Arch Med Sci 2011; 7:123-6. [PMID: 22291744 PMCID: PMC3258694 DOI: 10.5114/aoms.2011.20616] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Revised: 04/25/2010] [Accepted: 06/18/2010] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION High-risk obstetric patients in the immediate postpartum period are frequently admitted to the intensive care unit, but the necessity of this practice has recently been doubted. Herein we describe the efficiency of utilizing the post-anaesthesia care unit (PACU) as an intermediate intensive care facility for those patients. MATERIAL AND METHODS We retrospectively described the reasons for admission, duration of stay, the anaesthetic used, main interventions and outcome for all obstetric admissions in the PACU during a period of 4 years in a university hospital. RESULTS During the 4-year period 47 women were admitted to the PACU after delivery. The frequency of admission to the PACU was 15.3 per 1000 deliveries, while obstetric cases represented 4.4 per 1000 admissions to the PACU. The majority represented caesarean sections (81%). The main reasons for admission to the PACU were haemorrhage (49%), cardiovascular problems (19%) and preeclampsia/eclampsia (17%). Mean length of stay in the PACU was 14.5 ±11.6 h, being significantly less in women having received epidural anaesthesia (8.2 ±5.6 h) compared to those who delivered with general anaesthesia (19.0 ±13.6 h, p < 0.05). General anaesthesia was used in 85% of cases in which emergency delivery was indicated, but only in 27% of cases without emergency indications for delivery (p < 0.01). No death or admission to the intensive care unit occurred during the study period. CONCLUSIONS The PACU can offer an intermediate intensive care facility for high-risk obstetric patients, thus reducing unnecessary admissions to the intensive care unit.
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Affiliation(s)
- Georgia Kostopanagiotou
- 2 Department of Anaesthesiology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
| | - Konstantinos Kalimeris
- 2 Department of Anaesthesiology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
| | - Aggeliki Pandazi
- 2 Department of Anaesthesiology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
| | - George Salamalekis
- 3 Department of Obstetrics and Gynaecology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
| | - Charalampos Chrelias
- 3 Department of Obstetrics and Gynaecology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
| | - Paraskevi Matsota
- 2 Department of Anaesthesiology, University of Athens School of Medicine, Attikon Hospital, Athens, Greece
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Chilongozi D, Wang L, Brown L, Taha T, Valentine M, Emel L, Sinkala M, Kafulafula G, Noor RA, Read JS, Brown ER, Goldenberg RL, Hoffman I; HIVNET 024 Study Team. Morbidity and mortality among a cohort of human immunodeficiency virus type 1-infected and uninfected pregnant women and their infants from Malawi, Zambia, and Tanzania. Pediatr Infect Dis J 2008; 27:808-14. [PMID: 18679152 DOI: 10.1097/INF.0b013e31817109a4] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Morbidity and mortality patterns among pregnant women and their infants (before antiretroviral therapy was widely available) determines HIV-1 diagnostic, monitoring, and care interventions. METHODS Data from mothers and their infants enrolled in a trial of antibiotics to reduce mother-to-child-transmission of HIV-1 at 4 sub-Saharan African sites were analyzed. Women were enrolled during pregnancy and follow-up continued until the infants reached 12 months of age. We describe maternal and infant morbidity and mortality in a cohort of HIV-1-infected and HIV-1-uninfected mothers. Maternal and infant factors associated with mortality risk in the infants were assessed using Cox proportional hazard modeling. RESULTS Among 2292 HIV-1-infected mothers, 166 (7.2%) had a serious adverse event (SAE) and 42 (1.8%) died, whereas no deaths occurred among the 331 HIV-1 uninfected mothers. Four hundred twenty-four (17.8%) of 2383 infants had an SAE and 349 (16.4%) died before the end of follow-up. Infants with early HIV-1 infection (birth to 4-6 weeks) had the highest mortality. Among infants born to HIV-1-infected women, maternal morbidity and mortality (P = 0.0001), baseline CD4 count (P = 0.0002), and baseline plasma HIV-1 RNA concentration (P < 0.0001) were significant predictors of infant mortality in multivariate analyses. CONCLUSIONS The high mortality among infants with early HIV-1 infection supports access to HIV-1 diagnostics and appropriate early treatment for all infants of HIV-1-infected mothers. The significant association between stage of maternal HIV-1 infection and infant mortality supports routine CD4 counts at the time of prenatal HIV-1 testing.
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