Objectives:To determine the association between medications intake in early pregnancy and variation in the fetal fraction (FF) in pregnant women undergoing cell-free DNA (cfDNA) testing. Methods:We performed a retrospective cohort study of women (n = 1051) undergoing cfDNA testing at an academic center. The exposed group included women taking medications (n = 400; 38.1%), while the nonexposed group consisted of women taking no medications (n = 651; 61.9%). Our primary outcome was FF. We performed univariate and multivariate analyses as appropriate. Results:The FFs were 8.8% (6.6-12.1), 8.7% (6.3-11.6), and 7.7% (5.1-9.3) among women taking 0, 1, and two or more medications, respectively (P < 0.01). Using multivariable linear mixed effects model, the mean FF was significantly lower among those taking two or more medications compared with the nonexposed group. FF was directly correlated with gestational age at the time of cfDNA testing and inversely correlated with maternal obesity. Exposure to metformin was associated with 1.8% (0.2-3.4) lower mean FF when compared with the nonexposed group (P = 0.02). Obesity and intake of two or more medications were associated with higher hazard ratio of having a low FF less than 4%.Conclusions: Exposure to metformin or two or more medications was associated with decreased FF, and obesity is associated with delay in achieving adequate FF percentage. These findings should be considered while counseling patients on test limitations.
Carbon monoxide (CO) is a small molecule poison released as a product of incomplete combustion. Carbon monoxide binds hemoglobin, reducing oxygen delivery. This effect is exacerbated in the burned pregnant patient by fetal hemoglobin that binds CO 2.5- to 3-fold stronger than maternal hemoglobin. With no signature clinical symptom, diagnosis depends on patient injury history, elevated carboxyhemoglobin levels, and alterations in mental status. The standard of care for treatment of CO intoxication is 100% normobaric oxygen, which decreases the half-life of CO in the bloodstream from 5 hours to 1 hour. Hyperbaric oxygen (HBO2) is a useful adjunct to rapidly reduce the half-life of CO to 20 minutes and the incidence of delayed neurologic sequelae. Because of the slow disassociation of CO from hemoglobin in the fetus, there is a far stronger indication for HBO2 in the burned pregnant patient than in other burn patient populations.Cyanide intoxication is often a comorbid disease with CO in inhalation injury from an enclosed fire, but may be the predominant toxin. It acts synergistically with CO to effectively lower the lethal doses of both cyanide and CO. Diagnosis is best made in the presence of high lactate levels, carboxyhemoglobin concentrations greater than 10%, injury history of smoke inhalation from an enclosed fire, and alterations in consciousness. While treatment with hydroxocobalamin is the standard of care and has the effect of reducing concomitant CO toxicity, data indicate cyanide may also be displaced by HBO2.Carbon monoxide and cyanide poisoning presents potential complications impacting care. This review addresses the mechanism of action, presentation, diagnosis, and treatment of CO and cyanide poisonings in the burned pregnant patient and the use of HBO2 therapy.
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In healthy term pregnancy, the heart operates in the ascending portion of the Starling's curve, rendering it fluid responsive.
To lessen the liability, a surgeon using transvaginal mesh should inform patients of potential complications associated with the products and document informed consent in their medical records.
INTRODUCTION: Coaching and debriefing after simulated exercises are both well-established approaches to enhancing education and personal performance. Coaching may also have an important role in training interdisciplinary teams for obstetric emergencies. We sought to understand factors which create an optimal environment for coaching interdisciplinary obstetric rapid-response teams. METHODS: An interdisciplinary simulation drill was conducted for our institution's obstetric rapid-response team. The individuals leading the debriefing session were varied by discipline, and participants' responses in a post-simulation survey were analyzed to determine if receiving feedback from a person from one's own discipline is important to satisfaction with the assessment process. Participants were asked to rank their satisfaction with feedback on a numerical scale (1-10, 10=best). We also posed questions regarding acceptance of video recording and playback in a group setting. RESULTS: There was no difference among obstetricians (n=3), anesthesiologists (n=3), or nurses (n=8) regarding feedback received from a representative of their own discipline versus a representative from a different discipline. The majority believed that recording the simulation and playing it back during the team debrief would be helpful. None of the participants indicated that recording the simulation and playing it back during the debrief would deter them from participating. CONCLUSION: Our pilot exercise indicates that participants respond equally to feedback given by a representative of their own discipline as to feedback given by a representative of a different discipline. Interdisciplinary coaching for rapid-response team simulations was well-accepted. The addition of a video recording appears to be a welcome addition to the debrief process.
INTRODUCTION: Appropriate documentation is an important component of quality health care. In academic medical centers, most documentation is done by residents. Given the scope of topics for resident education, a formal curriculum for documentation is often non-existent. Poor documentation has important consequences, including financial loss and compromise of quality indices. We sought to determine if instructing residents in basic coding principles improved the rate of appropriate documentation for early-term deliveries. METHODS: Residents were given a one-hour lecture focused on inpatient documentation, with a section on documenting appropriate justification for early-term deliveries. Subsequent documentation over a one-week period by each of the second- and third-year residents in attendance (n=7) was reviewed, and the rate of appropriate documentation for early-term deliveries was compared to similar documentation prior to the intervention for the same residents. This was compared to documentation by second- and third-year residents who did not attend the lecture (n=9). RESULTS: There were 153 total encounters analyzed. 29 were for patients who underwent early-term delivery. Of the pre-intervention early-term deliveries, the reasons for delivery in 8/13 (61.5%) were incorrectly documented. Of the post-intervention early-term deliveries, the reasons for delivery in 6/16 (37.5%) were incorrectly documented. 5/6 (83.3%) of the post-intervention early-term deliveries which were incorrectly documented were by residents who had not attended the lecture. CONCLUSION: Teaching residents coding and formal documentation is a valuable intervention. These simple interventions stand to make a significant impact on both financial and quality indices. These interventions will also serve to better prepare trainees for their transition into practice.
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