The Experts below are selected from a list of 360 Experts worldwide ranked by ideXlab platform
Robert M Silver - One of the best experts on this subject based on the ideXlab platform.
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long term Maternal Morbidity associated with repeat cesarean delivery
American Journal of Obstetrics and Gynecology, 2011Co-Authors: Erin A S Clark, Robert M SilverAbstract:Concern regarding the association between cesarean delivery and long-term Maternal Morbidity is growing as the rate of cesarean delivery continues to increase. Observational evidence suggests that the risk of Morbidity increases with increasing number of cesarean deliveries. The dominant Maternal risk in subsequent pregnancies is placenta accreta spectrum disorder and its associated complications. A history of multiple cesarean deliveries is the major risk factor for this condition. Pregnancies following cesarean delivery also have increased risk for other types of abnormal placentation, reduced fetal growth, preterm birth, and possibly stillbirth. Chronic Maternal morbidities associated with cesarean delivery include pelvic pain and adhesions. Adverse reproductive effects may include decreased fertility and increased risk of spontaneous abortion and ectopic pregnancy. Clinicians and patients need to be aware of the long-term risks associated with cesarean delivery so that they can be considered when determining the method of delivery for first and subsequent births.
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Maternal Morbidity in cases of placenta accreta managed by a multidisciplinary care team compared with standard obstetric care
Obstetrics & Gynecology, 2011Co-Authors: Alexandra G Eller, Michele A Bennett, Margarita Sharshiner, Carol Masheter, Andrew P Soisson, Mark K Dodson, Robert M SilverAbstract:OBJECTIVE:To compare Maternal Morbidity in cases of placenta accreta managed by a multidisciplinary care team with similar cases managed by standard obstetric care.METHODS:This was a retrospective cohort study of all cases of placenta accreta identified in the State of Utah from 1996 to 2008. Cases
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Maternal Morbidity associated with multiple repeat cesarean deliveries
Obstetrics & Gynecology, 2006Co-Authors: Robert M Silver, Kenneth J Leveno, Steve N Caritis, Mark B Landon, Dwight J Rouse, Catherine Y Spong, Elizabeth Thom, Atef H Moawad, Margaret Harper, Ronald J WapnerAbstract:OBJECTIVE: Although repeat cesarean deliveries often are associated with serious Morbidity, they account for only a portion of abdominal deliveries and are overlooked when evaluating Morbidity. Our objective was to estimate the magnitude of increased Maternal Morbidity associated with increasing number of cesarean deliveries. METHODS: Prospective observational cohort of 30,132 women who had cesarean delivery without labor in 19 academic centers over 4 years (1999–2002). RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452 fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks of placenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, the need for postoperative ventilation, intensive care unit admission, hysterectomy, and blood transfusion requiring 4 or more units, and the duration of operative time and hospital stay significantly increased with increasing number of cesarean deliveries. Placenta accreta was present in 15 (0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) women undergoing their first, second, third, fourth, fifth, and sixth or more cesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%) first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%) fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 women with previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67% for first, second, third, fourth, and fifth or more repeat cesarean deliveries, respectively. CONCLUSION: Because serious Maternal Morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery. (Obstet Gynecol 2006;107:1226–32) LEVEL OF EVIDENCE: II-2
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the mfmu cesaraean section registry Maternal Morbidity associated with multiple repeat cesarean delivery
American Journal of Obstetrics and Gynecology, 2004Co-Authors: Robert M SilverAbstract:36 37 THE MFMU CESARAEAN SECTION REGISTRY: Maternal Morbidity ASSOCIATED WITH MULTIPLE REPEAT CESAREAN DELIVERY ROBERT M. SILVER, MFMU Network, NICHD, Bethesda, Maryland OBJECTIVE: There has been a substantial increase in the rate of cesarean delivery (CD) over the past decade, including primary elective cases. In part, this has been justified by the relative safety of CD in modern obstetrics. Although multiple repeat CD often are associated with serious Morbidity they account for only a portion of abdominal deliveries and are overlooked when evaluating Morbidity. Our objective was to estimate whether Morbidity is higher with increasing numbers of CD. STUDY DESIGN: Prospective observational cohort of 30,132 women with CD without labor in 19 academic centers over 4 years (1999–2002). RESULTS: The risk of accreta, accreta with previa, and hysterectomy increased with increasing numbers of CD (Table; all P ! .001), as did the risk of blood transfusion of 4 or more units (P ! .001). In the 143 women with accreta, the risk of cystotomy, but not other co-Morbidity, increased with increasing number of CD (P ! .001). CONCLUSION: Serious Maternal Morbidity increases with increasing numbers of CD. Thus, the number of intended pregnancies should be factored into consideration of elective cesarean or VBAC attempts. This large series confirms the high risk of accreta in women with previa and 2 or more prior CD. However, the risk of accreta in women with previa and 1 prior CD is less than previously reported. () accretas in women with previas; Hyst – hysterectomy).
Sarah J Kilpatrick - One of the best experts on this subject based on the ideXlab platform.
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confirmed severe Maternal Morbidity is associated with high rate of preterm delivery
Obstetric Anesthesia Digest, 2017Co-Authors: Sarah J Kilpatrick, Anisha Abreo, Naomi Greene, Jeffrey B Gould, Elliott K MainAbstract:Background Because severe Maternal Morbidity (SMM) is increasing in the United States, affecting up to 50,000 women per year, there was a recent call to review all mothers with SMM to better understand their Morbidity and improve outcomes. Administrative screening methods for SMM have recently been shown to have low positive predictive value for true SMM after chart review. To ultimately reduce Maternal Morbidity and mortality we must better understand risk factors, and preventability issues about true SMM such that interventions could be designed to improve care. Objective Our objective was to determine risk factors associated with true SMM identified from California delivery admissions, including the relationship between SMM and preterm delivery. Study Design In this retrospective cohort study, SMM cases were screened for using International Classification of Diseases, Ninth Revision codes for severe illness and procedures, prolonged postpartum length of stay, intensive care unit admission, and transfusion from all deliveries in 16 hospitals from July 2012 through June 2013. Charts of screen-positive cases were reviewed and true SMM diagnosed based on expert panel agreement. Underlying disease diagnosis was determined. Women with true-positive SMM were compared to SMM-negative women for the following variables: Maternal age, ethnicity, gestational age at delivery, prior cesarean delivery, and multiple gestation. Results In all, 491 women had true SMM and 66,977 women did not have SMM for a 0.7% rate of true SMM. Compared to SMM-negative women, SMM cases were significantly more likely to be age >35 years (33.6 vs 23.8%; P P P P P P Conclusion An extremely high proportion of women with severe Morbidity (42.5%) delivered preterm with 17.8% delivering
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opportunities for improvement in care among women with severe Maternal Morbidity
American Journal of Obstetrics and Gynecology, 2016Co-Authors: John A Ozimek, Rhonda M Eddins, Naomi Greene, Daniela Karagyozyan, Sujane E Pak, Melissa S Wong, Mark I Zakowski, Sarah J KilpatrickAbstract:Background Severe Maternal Morbidity is increasing in the United States and has been estimated to occur in up to 1.3% of all deliveries. A standardized, multidisciplinary approach has been recommended to identify and review cases of severe Maternal Morbidity to identify opportunities for improvement in Maternal care. Objective The aims of our study were to apply newly described gold standard guidelines to identify true severe Maternal Morbidity and to utilize a recently recommended multidisciplinary approach to determine the incidence of and characterize opportunities for improvement in care. Study Design We conducted a retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from Jan. 1, 2012, through June 30, 2014. Electronic medical records were screened for severe Maternal Morbidity using the following criteria: International Classification of Diseases, Ninth Revision codes for severe illness identified by the Centers for Disease Control and Prevention; prolonged length of stay; intensive care unit admission; transfusion of ≥4 U of packed red blood cells; or hospital readmission within 30 days of discharge. A multidisciplinary team conducted in-depth review of each medical record that screened positive for severe Maternal Morbidity to determine if true severe Maternal Morbidity occurred. Each true case of severe Maternal Morbidity was presented to a multidisciplinary committee to determine a consensus opinion about the Morbidity and if opportunities for improvement in care existed. Opportunity for improvement was described as strong, possible, or none. The incidence of opportunity for improvement was determined and categorized as system, provider, and/or patient. Morbidity was classified by primary cause, organ system, and underlying medical condition. Results There were 16,323 deliveries of which 386 (2%) screened positive for severe Maternal Morbidity. Following review of each case, true severe Maternal Morbidity was present in 150 (0.9%) deliveries. We determined by multidisciplinary committee review that there was opportunity for improvement in care in 66 (44%) cases. The 2 most common underlying causes of severe Maternal Morbidity were hemorrhage (71.3%) and preeclampsia/eclampsia (10.7%). In cases with opportunity for improvement in care, provider factors were present in 78.8%, followed by patient (28.8%) and system (13.6%) factors. Conclusion We demonstrated the feasibility of a recently recommended review process of severe Maternal Morbidity at a large, academic medical center. We demonstrated that opportunity for improvement in care exists in 44% of cases and that the majority of these cases had contributing provider factors.
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impact of fertility treatment on severe Maternal Morbidity
Fertility and Sterility, 2016Co-Authors: Erica T Wang, Sarah J Kilpatrick, John A Ozimek, Naomi Greene, Lauren Ramos, Nina Vyas, Margareta D PisarskaAbstract:Objective To determine if fertility treatment is associated with increased risk of severe Maternal Morbidity (SMM) compared with spontaneous pregnancies. Design Retrospective cohort study. Setting Academic medical center. Patient(s) In 2012, 6,543 women delivered live births >20 weeks gestation at our center. Women were categorized based on mode of conception: in vitro fertilization (IVF), non-IVF fertility treatment (NIFT), or spontaneous pregnancies. Intervention(s) None. Main Outcome Measure(s) The main outcome was presence of true SMM, such as eclampsia, respiratory failure, and peripartum hysterectomy. Deliveries were screened with the use of: 1) International Classification of Diseases 9 codes; 2) prolonged postpartum stay; 3) Maternal intensive care unit admissions, and 4) blood transfusion. The charts of women meeting the screening criteria were reviewed to identify true SMM based on a previously validated method, recognizing that medical record review is the criterion standard. Result(s) Of the 6,543 deliveries, 246 (3.8%) were IVF conceptions and 109 (1.7%) NIFT conceptions. Sixty-nine cases of true SMM were identified (1.1%). In multivariate analyses, any fertility treatment (IVF + NIFT) was associated with increased risk of SMM compared with spontaneous conceptions. In a subset analysis of singletons only, the association between any fertility treatment (IVF + NIFT) and SMM was not statistically significant. Conclusion(s) Overall, fertility treatment increased risk for SMM events. Given the limited sample size, the negative finding with singleton gestations is inconclusive. Larger multicenter studies with accurate documentation of fertility treatment and SMM cases are needed to further clarify the risk associated with singletons.
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severe Maternal Morbidity in a large cohort of women with acute severe intrapartum hypertension
American Journal of Obstetrics and Gynecology, 2016Co-Authors: Sarah J Kilpatrick, Anisha Abreo, Kathryn Melsop, Naomi Greene, Nancy Peterson, Larry Shields, Elliott K MainAbstract:Background Hypertensive diseases of pregnancy are associated with severe Maternal Morbidity and remain common causes of Maternal death. Recently, national guidelines have become available to aid in recognition and management of hypertension in pregnancy to reduce Morbidity and mortality. The increased Morbidity related to hypertensive disorders of pregnancy is presumed to be associated with the development of severe hypertension. However, there are few data on specific treatment or severe Maternal Morbidity in women with acute severe intrapartum hypertension as opposed to severe preeclampsia. Objective The study aimed to characterize Maternal Morbidity associated with women with acute severe intrapartum hypertension, and to determine whether there was an association between various first-line antihypertensive agents and posttreatment blood pressure. Study Design This retrospective cohort study of women delivering between July 2012 and August 2014 at 15 hospitals participating in the California Maternal Quality Care Collaborative compared women with severe intrapartum hypertension (systolic blood pressure >160 mm Hg or diastolic blood pressure >105 mm Hg) to women without severe hypertension. Hospital Patient Discharge Data and State of California Birth Certificate Data were used. Severe Maternal Morbidity using the Centers for Disease Control and Prevention criteria based on International Classification of Diseases–9 codes was compared between groups. The efficacy of different antihypertensive medications in meeting the 1-hour posttreatment goal was determined. Statistical methods included distribution appropriate univariate analyses and multivariate logistic regression. Results There were 2252 women with acute severe intrapartum hypertension and 93,650 women without severe hypertension. Severe Maternal Morbidity was significantly more frequent in the women with severe hypertension (8.8%) compared to the control women (2.3%) ( P P = .90 for systolic and .42 for diastolic). There was no difference in severe Maternal Morbidity between women treated (8.6%) and women not treated (9.5%) ( P = .56). Antihypertensive treatment rates were significantly higher in hospitals with a level IV neonatal intensive care unit (85.8%) compared to a level III neonatal intensive care unit (80.2%) ( P P P P P = .001). Severe intrapartum hypertension remained untreated in 17% of women. Conclusion Women with acute severe intrapartum hypertension had a significantly higher risk of severe Maternal Morbidity compared to women without severe hypertension. Significantly lower antihypertensive treatment rates and higher severe Maternal Morbidity rates were seen in lower–delivery volume hospitals.
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standardized severe Maternal Morbidity review rationale and process
Obstetrics & Gynecology, 2014Co-Authors: Sarah J Kilpatrick, William M Callaghan, Cynthia J Berg, Peter S Bernstein, Debra Bingham, Ana Delgado, Karen Harris, Susan Lanni, Jeanne Mahoney, Elliot MainAbstract:Severe Maternal Morbidity and mortality have been rising in the United States. To begin a national effort to reduce Morbidity, a specific call to identify all pregnant and postpartum women experiencing admission to an intensive care unit or receipt of 4 or more units of blood for routine review has been made. While advocating for review of these cases, no specific guidance for the review process was provided. Therefore, the aim of this expert opinion is to present guidelines for a standardized severe Maternal Morbidity interdisciplinary review process to identify systems, professional, and facility factors that can be ameliorated, with the overall goal of improving institutional obstetric safety and reducing severe Morbidity and mortality among pregnant and recently pregnant women. This opinion was developed by a multidisciplinary working group that included general obstetrician-gynecologists, Maternal-fetal medicine subspecialists, certified nurse-midwives, and registered nurses all with experience in Maternal mortality reviews. A process for standardized review of severe Maternal Morbidity addressing committee organization, review process, medical record abstraction and assessment, review culture, data management, review timing, and review confidentiality is presented. Reference is made to a sample severe Maternal Morbidity abstraction and assessment form.
William M Callaghan - One of the best experts on this subject based on the ideXlab platform.
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trends in severe Maternal Morbidity after assisted reproductive technology in the united states 2008 2012
Obstetrics & Gynecology, 2016Co-Authors: Angela S Martin, Dmitry M. Kissin, Denise J. Jamieson, William M Callaghan, Michael Monsour, Sheree L. BouletAbstract:OBJECTIVE:To examine trends in severe Maternal Morbidity from 2008 to 2012 in delivery and postpartum hospitalizations among pregnancies conceived with or without assisted reproductive technology (ART).METHODS:In this retrospective cohort study, deliveries were identified in the 2008–2012 Truven Hea
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standardized severe Maternal Morbidity review rationale and process
Obstetrics & Gynecology, 2014Co-Authors: Sarah J Kilpatrick, William M Callaghan, Cynthia J Berg, Peter S Bernstein, Debra Bingham, Ana Delgado, Karen Harris, Susan Lanni, Jeanne Mahoney, Elliot MainAbstract:Severe Maternal Morbidity and mortality have been rising in the United States. To begin a national effort to reduce Morbidity, a specific call to identify all pregnant and postpartum women experiencing admission to an intensive care unit or receipt of 4 or more units of blood for routine review has been made. While advocating for review of these cases, no specific guidance for the review process was provided. Therefore, the aim of this expert opinion is to present guidelines for a standardized severe Maternal Morbidity interdisciplinary review process to identify systems, professional, and facility factors that can be ameliorated, with the overall goal of improving institutional obstetric safety and reducing severe Morbidity and mortality among pregnant and recently pregnant women. This opinion was developed by a multidisciplinary working group that included general obstetrician-gynecologists, Maternal-fetal medicine subspecialists, certified nurse-midwives, and registered nurses all with experience in Maternal mortality reviews. A process for standardized review of severe Maternal Morbidity addressing committee organization, review process, medical record abstraction and assessment, review culture, data management, review timing, and review confidentiality is presented. Reference is made to a sample severe Maternal Morbidity abstraction and assessment form.
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racial and ethnic disparities in severe Maternal Morbidity a multistate analysis 2008 2010
American Journal of Obstetrics and Gynecology, 2014Co-Authors: Andreea A Creanga, Brian T Bateman, Elena V Kuklina, William M CallaghanAbstract:Objective The purpose of this study was to examine racial and ethnic disparities in severe Maternal Morbidity during delivery hospitalizations in the United States. Study Design We identified delivery hospitalizations from 2008-2010 in State Inpatient Databases from 7 states. We used International Classification of Diseases, 9th Revision , codes to create severe Maternal Morbidity indicators during delivery hospitalizations. We calculated the rates of severe Maternal Morbidity that were measured with and without blood transfusion for 5 racial/ethnic groups: non-Hispanic white, non-Hispanic black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women. Poisson regression models were fitted to explore the associations between race/ethnicity and severe Maternal Morbidity after we controlled for potential confounders. Results Overall, severe Maternal Morbidity rates that were measured with and without blood transfusion were 150.7 and 64.3 per 10,000 delivery hospitalizations, respectively. Non-Hispanic black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women had 2.1, 1.3, 1.2, and 1.7 times (all P Conclusion Severe Maternal Morbidity disproportionally affects racial/ethnic minority women, especially non-Hispanic black women. There is a need for a systematic review of severe Maternal morbidities at the facility, state, and national levels to guide the development of quality improvement interventions to reduce the racial/ethnic disparities in severe Maternal Morbidity.
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facility based identification of women with severe Maternal Morbidity it is time to start
Obstetrics & Gynecology, 2014Co-Authors: William M Callaghan, Sarah J Kilpatrick, Elliott K Main, William A Grobman, Mary DaltonAbstract:Although Maternal deaths have been the traditional indicator of Maternal health, these events are the "tip of the iceberg" in that there are many women who have significant complications of pregnancy, labor, and delivery. Identifying women who experience severe Maternal Morbidity and reviewing their care can provide critical information to inform quality improvement in obstetrics. In this commentary, we review methods to identify women who experienced severe complications of pregnancy. We propose a simple validated approach based on transfusion of four or more units of blood products, admission to an intensive care unit, or both as a starting point for identification and review of severe Maternal Morbidity in health care settings for the purpose of understanding successes and failures in systems of care.
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severe Maternal Morbidity among delivery and postpartum hospitalizations in the united states
Obstetrics & Gynecology, 2012Co-Authors: William M Callaghan, Andreea A Creanga, Elena V KuklinaAbstract:OBJECTIVES: To propose a new standard for monitoring severe Maternal Morbidity, update previous estimates of severe Maternal Morbidity during both delivery and postpartum hospitalizations, and estimate trends in these events in the United States between 1998 and 2009. METHODS: Delivery and postpartum hospitalizations were identified in the Nationwide Inpatient Sample for the period 1998–2009. International Classification of Diseases, 9 th Revision codes indicating severe complications were used to identify hospitalizations with severe Maternal Morbidity and related in-hospital mortality. Trends were reported using 2-year increments of data. RESULTS: Severe Morbidity rates for delivery and postpartum hospitalizations for the 2008–2009 period were 129 and 29, respectively, for every 10,000 delivery hospitalizations. Compared with the 1998–1999 period, severe Maternal Morbidity increased by 75% and 114% for delivery and postpartum hospitalizations, respectively. We found increasing rates of blood transfusion, acute renal failure, shock, acute myocardial infarction, respiratory distress syndrome, aneurysms, and cardiac surgery during delivery hospitalizations. Moreover, during the study period, rates of postpartum hospitalization with 13 of the 25 severe complications examined more than doubled, and the overall mortality during postpartum hospitalizations increased by 66% (P,.05). CONCLUSIONS: Severe Maternal Morbidity currently affects approximately 52,000 women during their delivery hospitalizations and, based on current trends, this burden is expected to increase. Clinical review of identified cases of severe Maternal Morbidity can provide an opportunity to identify points of intervention for quality improvement in Maternal care.
Elliott K Main - One of the best experts on this subject based on the ideXlab platform.
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an expanded obstetric coMorbidity scoring system for predicting severe Maternal Morbidity
Obstetrics & Gynecology, 2020Co-Authors: Stephanie A Leonard, Chris J Kennedy, Suzan L Carmichael, Deirdre J Lyell, Elliott K MainAbstract:Objective To develop and validate an expanded obstetric coMorbidity score for predicting severe Maternal Morbidity that can be applied consistently across contemporary U.S. patient discharge data sets. Methods Discharge data from birth hospitalizations in California during 2016-2017 were used to develop the score. The outcomes were severe Maternal Morbidity, defined using the Centers for Disease Control and Prevention index, and nontransfusion severe Maternal Morbidity (excluding cases where transfusion was the only indicator of severe Maternal Morbidity). We selected 27 potential patient-level risk factors for severe Maternal Morbidity, identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used a targeted causal inference approach integrated with machine learning to rank the risk factors based on adjusted risk ratios (aRRs). We used these results to assign scores to each coMorbidity, which sum to a single numeric score. We validated the score in California and national data sets and compared the performance to that of a previously developed obstetric coMorbidity index. Results Among 919,546 births, the rates of severe Maternal Morbidity and nontransfusion severe Maternal Morbidity were 168 and 74 per 10,000 births, respectively. The highest risk coMorbidity was placenta accreta spectrum (aRR of 30.5 for severe Maternal Morbidity and 54.7 for nontransfusion severe Maternal Morbidity) and the lowest was gestational diabetes mellitus (aRR of 1.06 for severe Maternal Morbidity and 1.12 for nontransfusion severe Maternal Morbidity). Normalized scores based on the aRR were developed for each coMorbidity, which ranged from 1 to 59 points for severe Maternal Morbidity and from 1 to 36 points for nontransfusion severe Maternal Morbidity. The overall performance of the expanded coMorbidity scores was good (C-statistics were 0.78 for severe Maternal Morbidity and 0.84 for nontransfusion severe Maternal Morbidity in California data and 0.82 and 0.87, respectively, in national data) and improved on prior coMorbidity indices developed for obstetric populations. Calibration plots showed good concordance between predicted and actual risks of the outcomes. Conclusion We developed and validated an expanded obstetric coMorbidity score to improve comparisons of severe Maternal Morbidity rates across patient populations with different coMorbidity case mixes.
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racial and ethnic disparities in severe Maternal Morbidity prevalence and trends
Annals of Epidemiology, 2019Co-Authors: Stephanie A Leonard, Elliott K Main, Karen A Scott, Jochen Profit, Suzan L CarmichaelAbstract:Abstract Purpose Racial/ethnic disparities in severe Maternal Morbidity (SMM) are substantial, but little is known about whether these disparities are changing over time or the role of Maternal and obstetric factors. Methods We examined disparities in SMM prevalence and trends using linked birth certificate and delivery discharge records from Californian births during 1997–2014 (n = 8,252,025). Results The prevalence of SMM was highest in non-Hispanic (NH) Black women (1.63%), lowest in NH White women (0.84%), and increased from 1997 to 2014 by approximately 170% in each racial/ethnic group. The magnitude of SMM disparities remained consistent over time. Compared with NH White women, the adjusted risk of SMM was higher in women who identified as Hispanic (RR 1.14; 95% CI 1.12, 1.16), Asian/Pacific Islander (RR 1.23; 95% CI 1.20, 1.26), NH Black (RR 1.27; 95% CI 1.23, 1.31), and American Indian/Alaska Native (RR 1.29; 95% CI 1.15, 1.44), accounting for comorbidities, anemia, cesarean birth, and other Maternal characteristics. Conclusions The prevalence of SMM varied considerably by race/ethnicity but increased at similarly high rates among all racial/ethnic groups. Comorbidities, cesarean birth, and other factors did not fully explain the disparities in SMM, which remained persistent over time.
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confirmed severe Maternal Morbidity is associated with high rate of preterm delivery
Obstetric Anesthesia Digest, 2017Co-Authors: Sarah J Kilpatrick, Anisha Abreo, Naomi Greene, Jeffrey B Gould, Elliott K MainAbstract:Background Because severe Maternal Morbidity (SMM) is increasing in the United States, affecting up to 50,000 women per year, there was a recent call to review all mothers with SMM to better understand their Morbidity and improve outcomes. Administrative screening methods for SMM have recently been shown to have low positive predictive value for true SMM after chart review. To ultimately reduce Maternal Morbidity and mortality we must better understand risk factors, and preventability issues about true SMM such that interventions could be designed to improve care. Objective Our objective was to determine risk factors associated with true SMM identified from California delivery admissions, including the relationship between SMM and preterm delivery. Study Design In this retrospective cohort study, SMM cases were screened for using International Classification of Diseases, Ninth Revision codes for severe illness and procedures, prolonged postpartum length of stay, intensive care unit admission, and transfusion from all deliveries in 16 hospitals from July 2012 through June 2013. Charts of screen-positive cases were reviewed and true SMM diagnosed based on expert panel agreement. Underlying disease diagnosis was determined. Women with true-positive SMM were compared to SMM-negative women for the following variables: Maternal age, ethnicity, gestational age at delivery, prior cesarean delivery, and multiple gestation. Results In all, 491 women had true SMM and 66,977 women did not have SMM for a 0.7% rate of true SMM. Compared to SMM-negative women, SMM cases were significantly more likely to be age >35 years (33.6 vs 23.8%; P P P P P P Conclusion An extremely high proportion of women with severe Morbidity (42.5%) delivered preterm with 17.8% delivering
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reduction of severe Maternal Morbidity from hemorrhage using a state perinatal quality collaborative
American Journal of Obstetrics and Gynecology, 2017Co-Authors: Elliott K Main, Anisha Abreo, Valerie Cape, Julie Vasher, Amanda Woods, Andrew Carpenter, Jeffrey B GouldAbstract:Background Obstetric hemorrhage is the leading cause of severe Maternal Morbidity and of preventable Maternal mortality in the United States. The California Maternal Quality Care Collaborative developed a comprehensive quality improvement tool kit for hemorrhage based on the national patient safety bundle for obstetric hemorrhage and noted promising results in pilot implementation projects. Objective We sought to determine whether these safety tools can be scaled up to reduce severe Maternal Morbidity in women with obstetric hemorrhage using a large Maternal quality collaborative. Study Design We report on 99 collaborative hospitals (256,541 annual births) using a before-and-after model with 48 noncollaborative comparison hospitals (81,089 annual births) used to detect any systemic trends. Both groups participated in the California Maternal Data Center providing baseline and rapid-cycle data. Baseline period was the 48 months from January 2011 through December 2014. The collaborative started in January 2015 and the postintervention period was the 6 months from October 2015 through March 2016. We modified the Institute for Healthcare Improvement collaborative model for achieving breakthrough improvement to include the mentor model whereby 20 pairs of nurse and physician mentors experienced in quality improvement gave additional support to small groups of 6-8 hospitals. The national hemorrhage safety bundle served as the template for quality improvement action. The main outcome measurement was the composite Centers for Disease Control and Prevention severe Maternal Morbidity measure, for both the target population of women with hemorrhage and the overall delivery population. The rate of adoption of bundle elements was used as an indicator of hospital engagement and intensity. Results Compared to baseline period, women with hemorrhage in collaborative hospitals experienced a 20.8% reduction in severe Maternal Morbidity while women in comparison hospitals had a 1.2% reduction ( P Conclusion We used an innovative collaborative quality improvement approach (mentor model) to scale up implementation of the national hemorrhage bundle. Participation in the collaborative was strongly associated with reductions in severe Maternal Morbidity among hemorrhage patients. Women in hospitals in their second collaborative had an even greater reduction in Morbidity than those approaching the bundle for the first time, reinforcing the concept that quality improvement is a long-term and cumulative process.
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severe Maternal Morbidity in a large cohort of women with acute severe intrapartum hypertension
American Journal of Obstetrics and Gynecology, 2016Co-Authors: Sarah J Kilpatrick, Anisha Abreo, Kathryn Melsop, Naomi Greene, Nancy Peterson, Larry Shields, Elliott K MainAbstract:Background Hypertensive diseases of pregnancy are associated with severe Maternal Morbidity and remain common causes of Maternal death. Recently, national guidelines have become available to aid in recognition and management of hypertension in pregnancy to reduce Morbidity and mortality. The increased Morbidity related to hypertensive disorders of pregnancy is presumed to be associated with the development of severe hypertension. However, there are few data on specific treatment or severe Maternal Morbidity in women with acute severe intrapartum hypertension as opposed to severe preeclampsia. Objective The study aimed to characterize Maternal Morbidity associated with women with acute severe intrapartum hypertension, and to determine whether there was an association between various first-line antihypertensive agents and posttreatment blood pressure. Study Design This retrospective cohort study of women delivering between July 2012 and August 2014 at 15 hospitals participating in the California Maternal Quality Care Collaborative compared women with severe intrapartum hypertension (systolic blood pressure >160 mm Hg or diastolic blood pressure >105 mm Hg) to women without severe hypertension. Hospital Patient Discharge Data and State of California Birth Certificate Data were used. Severe Maternal Morbidity using the Centers for Disease Control and Prevention criteria based on International Classification of Diseases–9 codes was compared between groups. The efficacy of different antihypertensive medications in meeting the 1-hour posttreatment goal was determined. Statistical methods included distribution appropriate univariate analyses and multivariate logistic regression. Results There were 2252 women with acute severe intrapartum hypertension and 93,650 women without severe hypertension. Severe Maternal Morbidity was significantly more frequent in the women with severe hypertension (8.8%) compared to the control women (2.3%) ( P P = .90 for systolic and .42 for diastolic). There was no difference in severe Maternal Morbidity between women treated (8.6%) and women not treated (9.5%) ( P = .56). Antihypertensive treatment rates were significantly higher in hospitals with a level IV neonatal intensive care unit (85.8%) compared to a level III neonatal intensive care unit (80.2%) ( P P P P P = .001). Severe intrapartum hypertension remained untreated in 17% of women. Conclusion Women with acute severe intrapartum hypertension had a significantly higher risk of severe Maternal Morbidity compared to women without severe hypertension. Significantly lower antihypertensive treatment rates and higher severe Maternal Morbidity rates were seen in lower–delivery volume hospitals.
Catherine Deneuxtharaux - One of the best experts on this subject based on the ideXlab platform.
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risk factors and high risk subgroups of severe acute Maternal Morbidity in twin pregnancy a population based study
PLOS ONE, 2020Co-Authors: Diane Korb, Francois Goffinet, Thomas Schmitz, Aurelien Seco, Catherine DeneuxtharauxAbstract:Objective To determine risk factors of severe acute Maternal Morbidity in women with twin pregnancies and identify subgroups at high risk. Methods In a prospective, population-based study of twin deliveries, the JUMODA cohort, all women with twin pregnancies at or after 22 weeks of gestation were recruited in 176 French hospitals. Severe acute Maternal Morbidity was a composite criterion. We determined its risk factors by multilevel multivariate Poisson regression modeling and identified high-risk subgroups by classification and regression tree (CART) analysis, in two steps: first considering only characteristics known at the beginning of pregnancy and then adding factors arising during its course. Results Among the 8,823 women with twin pregnancies, 542 (6.1%, 95% confidence interval (CI) 5.6–6.6) developed severe acute Maternal Morbidity. Risk factors for severe Maternal Morbidity identified at the beginning of pregnancy were Maternal birth in sub-Saharan Africa (adjusted relative risk (aRR) 1.6, 95% CI 1.1–2.3), preexisting insulin-treated diabetes (aRR 2.2, 95% CI 1.1–4.4), nulliparity (aRR 1.6, 95% CI 1.3–2.0), IVF with autologous oocytes (aRR, 1.3, 95% CI, 1.0–1.6), and oocyte donation (aRR 2.0, 95% CI 1.4–2.8); CART analysis identified nulliparous women with oocyte donation as the subgroup at highest risk (SAMM rate: 14.7%, 95% CI, 10.3–19.1). At the end of pregnancy, additional risk factors identified were placenta praevia (aRR 3.5, 95% CI 2.3–5.3), non-severe preeclampsia (aRR 2.5, 95% CI 1.9–3.2), and macrosomia for either twin (aRR 1.7, 95% CI 1.3–2.1); CART analysis identified women with both oocyte donation and non-severe preeclampsia (SAMM rate: 28.9%, 95% CI, 19.9–37.9) and sub-Saharan nulliparous women with non-severe preeclampsia (SAMM rate: 26.9%, 95% CI, 9.9–43.9) as the two subgroups at highest risk. Conclusion In woman with twin pregnancy, rates of severe acute Maternal Morbidity vary between subgroups from 4.6% to 14.7% and from 3.8% to 28.9% at the beginning and at the end of pregnancy respectively, depending on the combined presence of risk factors.
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risk of severe Maternal Morbidity associated with cesarean delivery and the role of Maternal age a population based propensity score analysis
Canadian Medical Association Journal, 2019Co-Authors: Diane Korb, Francois Goffinet, Aurelien Seco, S Chevret, Catherine DeneuxtharauxAbstract:BACKGROUND: Short-term Maternal complications of cesarean delivery remain uncertain because of confounding by indication. Our objective was to assess whether cesarean delivery is associated with severe acute intra- or postpartum Maternal Morbidity compared with vaginal delivery, overall and according to the timing of the cesarean. METHODS: We performed a case–control analysis using data from EPIMOMS, a prospective population-based study of deliveries at 22 gestation weeks or later from 6 regions of France in 2012–2013. Cases of intra- or postpartum severe acute Maternal Morbidity that were not a result of a condition present before delivery were compared with controls randomly selected in a 1/50 ratio. Associations between delivery modes and severe acute Maternal Morbidity were estimated in a propensity score–matched sample. RESULTS: Among 182 300 deliveries, we identified 1444 cases and 3464 controls. The proportion of cesarean delivery was significantly higher among cases than controls (36.0% v. 18.2%). In the propensity score–matched analysis, cesarean deliveries were significantly associated with a higher risk of severe acute Maternal Morbidity (adjusted odds ratio [OR] 1.8, 95% confidence interval [CI] 1.5–2.2). This association increased with Maternal age and was particularly marked for women aged 35 years or older (adjusted OR 2.9, 95% CI 1.9–4.4). This increased risk was significant for cesarean deliveries during labour in women of all age groups and for those before labour only in women aged 35 years or older (adjusted OR 5.1, 95% CI 2.3–11.0). INTERPRETATION: Cesarean delivery is associated with a higher risk of severe acute Maternal Morbidity than vaginal delivery, particularly in women aged 35 years and older. Clinical decisions regarding delivery mode should account for this excess risk accordingly.