American journal of obstetrics and gynecology
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Am. J. Obstet. Gynecol. · Dec 2016
The "virtual" obstetrical intensive care unit: providing critical care for contemporary obstetrics in nontraditional locations.
Management of the critically ill pregnant patient presents a clinical dilemma in which there are sparse objective data to determine the optimal setting for provision of high-quality care to these patients. This clinical scenario will continue to present a challenge for providers as the chronic illness and comorbid conditions continue to become more commonly encountered in the obstetric population. Various care models exist across a broad spectrum of facilities that are characterized by differing levels of resources; however, no studies have identified which model provides the highest level of care and patient safety while maintaining a reasonable degree of cost-effectiveness. ⋯ We propose a model in which a virtual intensive care unit team composed of preselected specialists from multiple disciplines (maternal-fetal medicine, neonatology, obstetric anesthesiology, cardiology, pulmonology, etc) participate in the provision of individualized, precontemplated care that is readily adapted to the specific patient's clinical needs, regardless of setting. With this team-based approach, an environment of trust and familiarity is fostered among team members and well thought-out patient care plans are developed through routine prebrief discussions regarding individual clinical care for parturients anticipated to required critical care services. Incorporating debriefings between team members following these intricate cases will allow for the continued evolution of care as the medical needs of this patient population change as well.
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Am. J. Obstet. Gynecol. · Nov 2016
Observational StudyPrevalence of positive screening test for cognitive impairment among elderly urogynecologic patients.
Impaired cognition has been correlated with adverse postoperative outcomes, such as an increased incidence of delirium, a longer length of hospital stay, and higher 6 month mortality. The incidence of cognitive impairment in the elderly is high. Per the Centers for Disease Control and Prevention, 1 in 8 adults aged 60 years and older deal with memory loss and confusion, and less than 20% inform their health care providers. Most studies in the elderly or cognitively impaired have been conducted at Veterans Administration hospitals, in which the majority of patients are male. As the female patient population ages, it is increasingly important to describe the prevalence of cognitive impairment in this specific population as well as identify and manage risk factors for cognitive decline in the ambulatory and perioperative setting. ⋯ In our study population positive screening for cognitive impairment, as measured by validated questionnaires, was prevalent among women aged >75 years. Screening for potential cognitive impairment in an ambulatory urogynecology population is feasible and useful in clinical practice. Our subjects were interested in cognitive screening because a third of them self-reported early cognitive changes. These tools are effective in screening for previously unrecognized impaired cognition, a definitive diagnosis, and hence treatment requires additional evaluation. Future studies could evaluate which screening tools for cognitive impairment would be most helpful in assessing patients prior to surgery in an effort to further decrease perioperative morbidity in elderly woman.
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Am. J. Obstet. Gynecol. · Nov 2016
Randomized Controlled Trial Multicenter StudyNonresponse to 17-alpha hydroxyprogesterone caproate for recurrent spontaneous preterm birth prevention: clinical prediction and generation of a risk scoring system.
Spontaneous preterm birth remains a leading cause of neonatal morbidity and mortality among nonanomalous neonates in the United States. Spontaneous preterm birth tends to recur at similar gestational ages. Intramuscular 17-alpha hydroxyprogesterone caproate reduces the risk of recurrent spontaneous preterm birth. Unfortunately, one-third of high-risk women will have a recurrent spontaneous preterm birth despite 17-alpha hydroxyprogesterone caproate therapy; the reasons for this variability in response are unknown. ⋯ Several clinical characteristics define women at risk for recurrent preterm birth at a similar gestational age despite 17-alpha hydroxyprogesterone caproate therapy and can be used to generate a clinical risk predictor score. These data should be refined and confirmed in other cohorts, and women at high risk for nonresponse should be targets for novel therapeutic intervention studies.
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Am. J. Obstet. Gynecol. · Nov 2016
Comparative StudyComparison of robotic and other minimally invasive routes of hysterectomy for benign indications.
Despite a lack of evidence showing improved clinical outcomes with robotic-assisted hysterectomy over other minimally invasive routes for benign indications, this route has increased in popularity over the last decade. ⋯ Robotic-assisted laparoscopy does not decrease major morbidity following hysterectomy for benign indications when compared to other minimally invasive routes. While superficial surgical site infection and blood transfusion rates were statistically lower in the robotic-assisted group, in the absence of substantial reductions in clinically and financially burdensome complications, it will be challenging to find a scenario in which robotic-assisted hysterectomy is clinically superior and cost-effective.
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Am. J. Obstet. Gynecol. · Nov 2016
A prospective assessment of pelvic infection risk following same-day sexually transmitted infection testing and levonorgestrel intrauterine system placement.
Misperceptions persist that intrauterine device placement is related to pelvic infections and Chlamydia and gonorrhea testing results are needed prior to placement. ⋯ Conducting Chlamydia and gonorrhea testing on the same day as intrauterine system placement is associated with a low risk of pelvic infection (0.2%). Over the first 2 years of intrauterine system use, infections are infrequent and not temporally related to intrauterine system placement. Pelvic infection can be successfully treated in most women with outpatient antibiotics and typically does not require intrauterine system removal. Women without clinical evidence of active infection can have intrauterine system placement and sexually transmitted infection screening, if indicated, on the same day.