Objective The study aimed to evaluate the impact of obesity on the management and outcomes of postpartum hemorrhage. Study Design We conducted a retrospective cohort study of women who delivered at a tertiary care center between February 1, 2013 and January 31, 2014 and experienced a postpartum hemorrhage. Charts were reviewed for clinical and sociodemographic data, and women were excluded if the medical record was incomplete. Hemorrhage-related severe morbidity indicators included blood transfusion, shock, renal failure, transfusion-related lung injury, cardiac arrest, and use of interventional radiology procedures. Obese (body mass index [BMI] ≥ 30 kg/m2) and nonobese women were compared. Data were analyzed using Chi-square, Student's t-test, Mann–Whitney U test, and linear regression where appropriate. The p-value <0.05 was significant. Results Of 9,890 deliveries, 2.6% (n = 262) were complicated by hemorrhage. Obese women were more likely to deliver by cesarean section (55.5 vs. 39.8%, p = 0.016), undergo a cesarean after labor (31.1 vs. 12.2%, p = 0.001), and have a higher quantitative blood loss (1,313 vs. 1,056 mL, p = 0.003). Both groups were equally likely to receive carboprost, methylergonovine, and misoprostol, but obese women were more likely to receive any uterotonic agent (95.7 vs. 88.9%, p = 0.007) and be moved to the operating room (32.3 vs. 20.4, p = 0.04). There was no difference in the use of intrauterine pressure balloon tamponade, interventional radiology, or decision to proceed with hysterectomy. The two groups were similar in time to stabilization. There was no difference in the need for blood transfusion. Obese women required more units of blood transfused (2.2 ± 2 vs. 2 ± 5 units, p = 0.023), were more likely to have any hemorrhage-related severe morbidity (34.1 vs. 25%, p = 0.016), and more than one hemorrhage related morbidity (17.1 vs. 7.9, p = 0.02). After controlling for confounding variables, quantitative blood loss, and not BMI was predictive of the need for transfusion. Conclusion Despite similar management, obese women were more likely to have severe morbidity and need more units of blood transfused. Key Points
Objectives: Systemic lupus erythematosus (SLE) is a chronic illness that often affects women of reproductive age. The objectives of this article are to review the impact of SLE on pregnancy and current management strategies, including commonly used therapies. Methods: We conducted a review of available literature on the clinical course of SLE, diagnosis, management and pregnancy complications. Results: SLE has a variable clinical course characterized by flares and periods of remission and can present unique challenges in the management of obstetric patients. Pregnancy in patients with SLE is associated with multiple risks, including fetal loss, preterm birth, fetal growth restriction, and hypertensive disease. With advancements in disease treatment, many women have favorable pregnancy outcomes, but appropriate preconception counseling and disease management remain important tools in reducing complications. Conclusion: Given the implications SLE can have on women of reproductive age and in pregnancy, understanding the disease course and management is important in order to optimize pregnancy outcomes.
OBJECTIVE: We sought to evaluate the impact of obesity on the management and outcomes of postpartum hemorrhage. STUDY DESIGN: We conducted a retrospective cohort study including all women who delivered at a tertiary center during 2/1/2013-12/31/ 2014. Medical charts were reviewed for clinical and sociodemographic data. Hemorrhage related severe morbidity indicators included blood transfusion, shock, acute renal failure, transfusion related lung injury, cardiac arrest and use of interventional radiology procedures. Obese (BMI30kg/m 2) and nonobese women were compared. The data was analyzed using chi-square, student t-test, Mann Whitney U test, and logistic regression where appropriate. P < 0.05 was significant. RESULTS: There were 9,890 deliveries and 2.9% (n¼287) were complicated by obstetric hemorrhage. The sample population of obese and non-obese women did not differ in race, ethnicity or insurance status. The obese women with hemorrhage were more likely to have a macrosomic infant (18.6 vs. 8.9%, p¼0.03), have delivered by cesarean section, (71% vs 29%, p¼0.008), undergo a cesarean section after labor (30.4% vs 11.9%, p¼0.001), and have a higher quantitative blood loss (1281 vs 1042 ml, p¼.01). Both groups were equally likely to receive carboprost, methylergonovine and misoprostol but obese women were more likely to need >2 doses of uterotonic agents (66% vs. 34%, p¼0.04). There was no difference in the decision to proceed to the operating room (11.8 % vs 20.5%, p¼0.39), Bakri balloon (11.8% and 7.7%, p¼0.72), use of interventional radiology (5.8% vs 6.5%, p¼0.99), or the decision to proceed with hysterectomy (8% vs 5.2%, p¼0.57). The two groups were similar in the time to first treatment and time to stabilization, and there was no difference in the need for blood transfusion (29.2 vs 24.7, p¼.47) or number of units of blood transfused (2.2 vs. 2.1 units, p¼.25). Obese women were equally likely to experience a severe morbidity (50.5% vs 41%, p¼0.34), but more likely to experience more than one severe morbidity (28.4% vs 10.3%, p¼0.03). After controlling for confounding variables, time to stabilization (hr.) [or 1.06 (95%CI 1.006-1.13)], and admission hemoglobin [aOR 0.63 (95%CI 0.49-0.84] neither obesity nor management were predictive of severe morbidity. CONCLUSION: Compared to normal weight women, obese women with postpartum hemorrhage required more doses of uterotonic agents and had more severe morbidity despite similar management.
OBJECTIVE: To evaluate the impact of implementation of a maternal early warning system on the outcome of critically ill women. STUDY DESIGN: This retrospective cohort study included pregnant women who delivered at a tertiary referral center from June 2016-June 2019. The maternal early warning system (MEWS) was implemented and embedded in the electronic medical record. Protocols for use were launched after education for all medical staff. The following maternal parameters were scored: heart rate, respiratory rate, systolic blood pressure, temperature, oxygen saturation and altered mental status. Recommendations for patient evaluation and transfer to an intensive care unit were included in the protocol. Medical charts of all women who met criteria for admission to the intensive care unit were reviewed, and two time intervals were used to analyze the effect of MEWS: an 18-month baseline period (Time 1) and an 18 month MEWS study period (Time 2). Outcomes of interest were CDC severe maternal morbidity, length of stay, readmission and death. Data were analyzed using chi square, Mann-Whitney U test, and linear regression. P< .05 was significant. RESULTS: Of the 17, 959 deliveries during the study period, 0.82% resulted in an ICU admission (n¼148). The most frequent causes of an unplanned ICU admission were hemodynamic instability related to postpartum hemorrhage (32.6%), sepsis (25.8%), cardiovascular disease (11.4%) and respiratory morbidity (22%). There were no maternal deaths among the ICU admissions. Of the infants, 7.6% were stillborn and 1.5% experienced a neonatal death. The women admitted to the ICU in Time 1 vs Time 2 were similar in race, ethnicity, and age. White women had a shorter length of stay in Time 2 compared to black women but the difference did not persist after controlling for severe morbidity. The protocol implementation was associated with a longer time between the first abnormal MEWS score and ICU admission. CONCLUSION: A standard protocol using vital signs as a maternal early warning system was associated with an increased time until ICU admission and was not associated with improved outcomes.
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