摘要:

Objective:To study the quality of obstetric care in relation to rising cesarean rates, a Task Force was formed in New York state by the Department of Health and ACOG District II. The Task Force also included the Organization of Obstetric, Gynecologic, and Neonatal Nurses and the Hospital Association of New York State. The goals were to enhance hospitals' in-house review processes, standardize terminology, and improve the quality of care. A premise of the program was that if quality of care improved, cesarean rates would fall.Methods:A Dictionary of Terms was developed to standardize clinical and diagnostic terminology. A two-tiered review process was instituted, using internal and external hospital reviews. A format for in-house review of obstetric care was developed and recommended to hospitals. External reviews were conducted at 24 hospitals during 1989-1990. Review teams, composed of obstetrician-gynecologists and obstetric nurses in active obstetric practice, assessed obstetric facilities, staffing, medical care, and the in-house review process. Contacts continued with the hospitals after site visits to follow up on implementation of recommendations. General recommendations to improve care, based on the overall program experience, were distributed to hospitals and physicians as part of educational efforts to improve quality of care.Results:The state cesarean rate reversed. Statistics for 1989 and 1990 showed a stronger downward trend in reviewed hospitals than in non-reviewed hospitals. A survey of reviewed hospitals reported a positive response to the review process.Conclusion:A successful quality assurance program can be jointly developed by a state regulatory agency and a medical specialty society.

ISSN:0029-7844    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Objective:To assess the impact of current smoking intervention efforts and to target future efforts by describing the relationships between maternal smoking, smoking cessation, and source of prenatal care.Methods:We used population-based data from 6319 mothers who delivered live-born infants during 1988 and 1989 in Maine, Michigan, Oklahoma, and West Virginia. The number of women sampled per state ranged from 1490-2659; state-specific response rates ranged from 66-84%. Analysis weights adjusted for selection probability and non-response.Results:The prevalences of maternal smoking before, during, and after pregnancy among women receiving publicly funded prenatal care were 2.3-3.4 times the comparable prevalences among privately insured women receiving prenatal care from private providers. Although many smokers reduced or quit smoking during pregnancy, most resumed or increased their smoking to nearly pre-pregnancy levels by 3-6 months postpartum.Conclusion:Interventions should target the very high levels of smoking among the 27% of women receiving publicly funded prenatal care. However, from a population perspective, the greatest potential for reduction in smoking is among patients of private providers, who care for 61% of pre-pregnancy smokers.

ISSN:0029-7844    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Objective:To determine whether early-gestation vaginal bleeding and elevated maternal serum alpha-fetoprotein (MSAFP) are independent risk factors for adverse infant outcomes.Methods:We conducted a cohort study of 201 women with an elevated MSAFP (at least 2.0 multiples of the median [MOM]) and a second-trimester ultrasound evaluation at Swedish Hospital Medical Center between January 1989 and March 1991, and 211 women with MSAFP levels below 2.0 MOM who had also undergone ultrasound evaluations during the same period.Results:Stratified analyses demonstrated that earlygestation bleeding and elevated MSAFP were independent risk factors for the delivery of both preterm and low birth weight infants. Compared with women with no history of early-gestation bleeding or elevated MSAFP, women with early-gestation bleeding alone had a relative risk (RR) of preterm delivery of 4.3 (95% confidence interval [CI] 1.5- 12.1); non-bleeders with elevated MSAFP had an RR of 4.6 (95% CI 1.9-10.9). A combined history of early-gestation bleeding and elevated MSAFP was associated with an almost sixfold increased risk of preterm delivery (RR 5.8; 95% CI 2.2-15.6). Analyses restricted to women with normal-appearing placentas by second-trimester ultrasound evaluations yielded similar results.Conclusion:These findings support an earlier report documenting the independence of early-gestation bleeding and elevated MSAFP as predictors of adverse infant outcomes.

ISSN:0029-7844    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Objective:To compare the efficacy of structured questionnaire screening and prenatal urine toxicology for the detection of substance use by pregnant women, and to describe substance use patterns in a group of women presenting to a university-based obstetric clinic.Methods:All patients presenting to our obstetric clinic for their first prenatal visit were evaluated for evidence of current use of alcohol or any illicit substances. Nursing personnel administered an extensive questionnaire, which included detailed questions about past and current substance use patterns. Urine samples were examined by a commercial laboratory for alcohol and a number of illicit substances. Current users were defined as those who admitted use within the past 30 days or who had positive urine toxicology.Results:Fifty-eight of 302 patients (19.2%) were identified as current users of alcohol or illicit substances. Only 17 of 41 women (41.5%) with toxicologic evidence of recent use admitted to current use. Only 17 of 34 (50.0%) admitting to current use had toxicology positive for any substance. Patients with a history of multiple past substance use were significantly more likely to have positive urine toxicology than those without such a history (26.1 versus 7.4%; P<.005). Among current users, multiple substance use (34.5%) and cigarette smoking (52%) were common.Conclusion:A screening combination of structured questionnaire and universal urine toxicology identifies more current users than either technique alone, and neither is clearly superior to the other. A history of multiple substance use may be an important indicator of current use.

ISSN:0029-7844    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Objective:To assess the influence of several maternal and neonatal variables on the recurrence of gestational diabetes mellitus.Methods:A retrospective review was conducted on 90 of our patients whose index pregnancy was complicated by gestational diabetes mellitus and whose subsequent pregnancy was also managed at our institution.Results:Forty-seven women (52%) had a recurrence of gestational diabetes mellitus in their subsequent pregnancy. These 47 women had an increased body mass index (BMI) (32.8 ± 8.2 versus 28.9 ± 7.2 kg/m2;P<.03) and more large for gestational age (LGA) neonates (38 versus 14%P<.05) and more of them required insulin during their index pregnancy (38 versus 19%P<.05) than did those who did not have a recurrence of gestational diabetes mellitus. Women who developed a recurrence of gestational diabetes mellitus also had higher fasting (P<.05), 1-hour, 2-hour, and total glucose tolerance test values (Ps .01) during their index pregnancy.Conclusion:Women with a history of gestational diabetes mellitus who have a BMI greater than 35 kg/m2, whose previous newborn was LGA, and who required insulin during their previous pregnancy are at increased risk for recurrence of gestational diabetes mellitus.

ISSN:0029-7844    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Objective:To determine whether the addition of broadspectrum antimicrobial therapy to traditional expectant management improves pregnancy outcome in patients with premature rupture of membranes (PROM) remote from term.Methods:Patients with preterm PROM before 34 weeks' gestation who were not in labor and had no signs of infection or fetal distress were randomized to one of two study groups: 1) expectant management alone and 2) expectant management plus antimicrobial therapy. Women in the latter group received intravenous ampicillin, gentamicin, and clindamycin for 24 hours, followed by amoxicillin plus clavulanic acid orally for 7 days. Other than antibiotic use, management of the two groups was identical.Results:Significantly more women (P<.01) treated with antibiotics (20 of 48,42%) remained undelivered 7 days after admission compared with those managed expectantly without antibiotics (seven of 46, 15%). In addition, more neonates in the group managed with antibiotics were admitted to the routine nursery (nine of 48 versus two of 45;P=.03). However, there was no difference between the groups in the frequency of serious maternal or neonatal morbidity.Conclusion:The addition of broad-spectrum antimicrobial therapy to traditional expectant management of pregnancy complicated by preterm PROM may increase the number of gestations undelivered 7 days after admission. It may also decrease the proportion of infants, admitted to special care nurseries. Whether these effects result in significant short- or long-term maternal or neonatal benefit remains to be determined.

ISSN:0029-7844    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Objective:To determine whether approximate entropy (ApEn), a new statistic of regularity, when applied to fetal heart rate (FHR) data antepartum or in labor, would offer an advantage over standard statistics of variation in predicting outcome.Methods:A large data base of antepartum FHR records collected in clinical practice over 10 years was available. Two data sets in labor were stored on disk in small computers interfaced to fetal monitors on-line. Outcomes were assessed using blood gas values on delivery and Apgar scores.Results:Antepartum, when the most favorable form of ApEn was used on 769 good-quality FHR records, the correlation with measurement of short-term variation was high. This was especially true when the fetal pulse interval variation fell below the normal range (less than 6 milliseconds short-term; r=0.93) and in 20 other records with sinusoidal variation (r=0.96). Approximate entropy varied with fetal sleep cycles and took longer to calculate than FHR variation. During the last hour of labor, in 319 records, there was no significant correlation between umbilical artery base deficit values on delivery and ApEn measurement. In 871 additional good-quality records of fetuses with normal outcome, the mean (± standard error [SE]) ApEn (0.95 ± 0.005) was significantly greater than in 22 records (0.88 ± 0.028) from fetuses with abnormal outcome (umbilical artery base deficit more than 12 mmol/L and Apgar score of 3 or less at 1 minute). However, consideration of the frequency distributions of these measurements showed that ApEn did not discriminate between normal and abnormal outcomes. The SD of fetal pulse intervals rose in labor whereas ApEn values fell, confirming that this new statistic of regularity differs from standard statistics of variation.Conclusion:Approximate entropy offered no advantage over measurement of short-term FHR variation antepartum, and neither measurement predicted outcome in labor.

ISSN:0029-7844    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Objective:The amniotic fluid (AF) index has been shown to be a useful tool in the area of antepartum surveillance. An intrapartum AF index less than or equal to 5.0 has been shown to have predictive value with respect to increased perinatal morbidity. This study was designed to determine whether the distribution of the AF within the AF index is related to perinatal outcome.Methods:Patients presenting for labor and delivery had an AF index determined and were divided into two groups. Patients with greater than 50% of their AF distributed in the upper quadrants were placed in the “upper-greater” group. The remaining patients were placed in the “lower-greater” group. The distribution data were compared with the following variables: meconium staining, 1- or 5-minute Apgar score of less than 7, persistent variable decelerations in the first stage of labor, late decelerations, neonatal intensive care unit admission, cesarean delivery for fetal distress, and umbilical arterial and venous pH less than 7.20.Results:A total of 218 patients were evaluated, 125 in the upper-greater group and 93 in the lower-greater group. The upper-greater group had a greater incidence of meconium staining (32.8 versus 9.7%; P<.0001), 1-minute Apgar score of less than 7 (12.0 versus 2.2%; P<.007), variable decelerations (53.6 versus 19.4%; P<.00001), late decelerations (16.0 versus 0%; P<.0001), cesarean delivery for fetal distress (7.2 versus 0%; P<.008), umbilical arterial pH less than 7.20 (29.6 versus 8.9%; P<.0105), and umbilical venous pH less than 7.20 (8.9 versus 0%; P<.0398). These results were maintained regardless of the overall AF index.Conclusion:The distribution of the fluid within the AF index is predictive of perinatal outcome. In addition, the presence of a high negative predictive value for all of the perinatal indices studied enhances the value of this technique as a potential screening tool. Application of these results could provide additional guidelines in defining the intrapartum management and therapy of patients presenting for labor and delivery.

ISSN:0029-7844    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Objective:To test the hypothesis that among patients with a low amniotic fluid (AF) index, those who have a large cord-containing AF pocket will have a lower risk for adverse perinatal outcome than women with a small cord-containing pocket.Methods:Gravidas with an antepartum AF index no greater than 5 cm were studied prospectively. The vertical diameter of the single largest cord-containing pocket, which was excluded from the calculation of the AF index, was measured. Women with rupture of the membranes, multiple gestation, or fetal anomalies were excluded.Results:Fifty-one women with gestational ages of 35-43 weeks were analyzed. Among 35 who had a cord-containing pocket of no more than 5 cm, eight (23%) had fetal distress necessitating operative delivery and eight neonates had cord arterial pH below 7.20. None of these complications occurred in the 16 women who had a cord-containing pocket above 5 cm (P<.05). The mean AF index (2.9 versus 2.8 cm) was not significantly different between the groups.Conclusion:Among women with a low AF index, a cord-containing pocket above 5 cm identifies a subgroup of women at lower perinatal risk compared with those with a smaller cord-containing pocket. The need for intervention may be reduced in women with a cord-containing pocket greater than 5 cm.

ISSN:0029-7844    

出版商:OVID    

年代:1992

数据来源: OVID

摘要:

Objective:The clinical significance of sonographically detected hyperechoic fetal bowel has not been fully established. This report describes the natural history, pregnancy outcome, and associated features of 30 cases of prenatally diagnosed hyperechoic fetal bowel.Methods:Fetal bowel of similar or greater echogenicity than surrounding bone was considered hyperechoic. Fetuses so diagnosed were compared with matched controls and with our general obstetric population to determine the relative frequencies of cystic fibrosis, perinatal death, fetal growth retardation, and fetal trisomies.Results:The incidence of hyperechoic fetal bowel during the study period was 0.2% (30 of 12,776 fetuses). Four of the 30 fetuses (13.3%) with hyperechoic bowel were found to have cystic fibrosis, as compared with one in 2200 (0.05%) in the general population. Hyperechoic fetal bowel was also associated with increased risks for perinatal death (16.7%, versus 3.8% in matched controls and 1.9% in the general obstetric population) and fetal growth retardation (23.3% versus 1.9% and 5%, respectively). One fetus with hyperechoic bowel had trisomy 18, an incidence of cytogenetic abnormalities of 3.3%. This was not significantly greater than observed in our general obstetric population (1.2%) (P>.25).Conclusions:The sonographic finding of hyperechoic fetal bowel is associated with an increased risk for cystic fibrosis, perinatal death, and growth retardation. The risk of fetal trisomy in cases of isolated hyperechoic bowel appears small. When detected, hyperechoic bowel should prompt a complete and careful fetal anatomical survey, consideration of parental carrier testing for cystic fibrosis, and serial sonographic assessment of fetal growth, with cytogenetic testing reserved for cases demonstrating other structural malformations.

ISSN:0029-7844    

出版商:OVID    

年代:1992

数据来源: OVID