III.

Pregnancy causes anatomic and physiologic changes in the gastrointestinal tract. Pregnant women with intestinal disease such as Crohn disease or ulcerative colitis pose a management challenge in clinical diagnosis, radiologic evaluation, and treatment secondary to potential risk to the fetus. Heightened physician awareness on possible etiologies such as appendicitis, diverticulitis, and rarely colorectal cancer is required for rapid diagnosis and treatment to improve maternal/fetal outcome. A multidisciplinary approach to evaluation is a necessity because radiologic procedures and treatment medications commonly used in nonpregnant patients may have a potential harmful effect on the fetus. The authors review several gastrointestinal conditions encountered during pregnancy and address presentation, diagnosis, and treatment of each condition.

Variation in practice patterns for offering and performing maternal-fetal surgery for myelomeningocele repair exists among centers. Ongoing evaluation of inclusion and exclusion criteria as well as operative techniques is warranted to ensure continued safety, effectiveness, and beneficence.

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Objective To describe our hospital's experience following expectant management of previable preterm prelabor rupture of membranes (pPPROM). Study Design Retrospective review of neonatal survival and maternal and neonatal outcomes of pPPROM cases between 2012 and 2019 at a tertiary referral center in South Central Louisiana. Regression analyses were performed to identify predictors of neonatal survival. Results Of 81 cases of pPPROM prior to 23 weeks gestational age (WGA), 23 survived to neonatal intensive care unit discharge (28.3%) with gestational age at rupture ranging from 180/7 to 226/7 WGA. Increased latency (adjusted odds ratio [aOR] = 1.30, 95% confidence interval [CI] = 1.11, 1.52) and increased gestational age at rupture (aOR = 1.62, 95% CI = 1.19, 2.21) increased the probability of neonatal survival. Antibiotics prior to delivery were associated with increased latency duration (adjusted hazard ratio = 0.55, 95% CI = 0.42, 0.74). Conclusion Neonatal survival rate following pPPROM was 28.3%. Later gestational age at membrane rupture and increased latency periods are associated with increased neonatal survivability. Antibiotic administration following pPPROM increased latency duration.

This article compares the maneuvers used to relieve shoulder dystocia (SD) at three centers and discerns risk factors for brachial plexus injury (BPI) following SD. Retrospectively SD managed at three tertiary centers was identified and charts reviewed. Unconditional logistic regression was used to identify risk factors for BPI. SD was encountered in 2% of vaginal deliveries (624/29,591), and BPI followed impacted shoulders in 6% (38/624). The rate of SD among the three institutes varied significantly (1.5%, 2%, 0.8% of vaginal births; P < 0.0001). The use of the McRoberts' maneuver to relieve SD differed significantly by center (98%, 80%, 90%; P < 0.0001) as did the use of suprapubic pressure (83%, 66%, 54%; P < 0.0001). The rate of BPI per case of SD (10%, 3%, 5%) was significantly different at the three centers ( P = 0.009). A multivariate predictive model indicates that among those with and without concomitant fractures, there is a significantly increased risk of BPI if three or more maneuvers are used rather than two or fewer. In conclusion, not only does the rate of SD and BPI following it occur at significantly different rates, the management differs too. Compared with two maneuvers or fewer, there is an increased risk of BPI if three or more maneuvers are used to relieve SD.

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Context. Medicaid populations have low rates of advance care planning (ACP). Potential policy interventions include financial incentives.Objective. To test the effectiveness of patient plus provider financial incentive compared with provider financial incentive alone for increasing ACP discussions among Medicaid patients.Methods. Between April 2014 and July 2015, we conducted two sequential assessor-blinded pragmatic randomized trials in a health plan that pays primary care providers (PCPs) $100 to discuss ACP: 1) a parallel cluster trial ( provider-delivered patient incentive) and 2) an individual-level trial (mail-delivered patient incentive). Control and intervention arms included encouragement to complete ACP, instructions for using an online ACP tool, and (in the intervention arm) $50 for completing the online ACP tool and a small probability of $1000 (i.e., lottery) for discussing ACP with their PCP. The primary outcome was provider-reported ACP discussion within three months.Results. In the provider-delivered patient incentive study, 38 PCPs were randomized to the intervention (n ¼ 18) or control (n ¼ 20) and given 10 patient packets each to distribute. Using an intention-to-treat analysis, there were 27 of 180 ACP discussions (15%) in the intervention group and 5 of 200 (2.5%) in the control group (P ¼ .0391). In the mail-delivered patient incentive study, there were 5 of 187 ACP discussions (2.7%) in the intervention group and 5 of 189 (2.6%) in the control group (P ¼ .99).Conclusion. ACP rates were low despite an existing provider financial incentive. Adding a provider-delivered patient financial incentive, but not a mail-delivered patient incentive, modestly increased ACP discussions. PCP encouragement combined with a patient incentive may be more powerful than either encouragement or incentive alone. J Pain Symptom Manage 2017;-:-e-. Ó