ACOG 2016

WASHINGTON – The Centers for Disease Control and Prevention is recommending blood or urine testing for all pregnant women with possible Zika exposure through travel or because they live in an endemic area, regardless of whether they are symptomatic, Dr. Denise J. Jamieson said at the annual meeting of the American College of Obstetricians and Gynecologists.

Couples interested in conceiving who live in or have traveled to areas of active transmission should be alert for any signs of infection, no matter how slight; if they notice any, they should be tested for exposure before attempting conception, Dr. Jamieson, a medical officer with the CDC’s division of reproductive medicine, said in a video interview.

Unfortunately, she said at an update on the Zika situation, labs that process Zika blood and urine samples are backed up, and test results are being “unacceptably delayed.”

During a discussion period, some physicians in the audience complained of waiting up to 6 weeks for results. One said a local health department official told him that the CDC had a backlog of “a million tests.”

“We do not have a 1-million test backup,” Dr. Jamieson said. “But in some places there are still unacceptably long delays. This is not a test you can just check off on a form and send to a lab.”

Many of the tests are being funneled to the CDC’s Division of Vector-Borne Diseases in Ft. Collins, Colo.; that facility is experiencing a long turnaround time. Other samples are being handled in private labs with CDC contracts, but Dr. Jamieson said there’s an urgent need to expand the testing to many more commercial labs. There is no concrete plan for how or when this expansion will happen, however, she added.

Dr. Jamieson also discussed the CDC’s recommendation for managing pregnant women who have a positive serology or urine. These women should have serial ultrasounds every 3-4 weeks to track fetal brain development. Amniocentesis can positively confirm fetal exposure. A maternal-fetal medicine specialist should be on board if the fetus tests positive or if any concerning signs appear on imaging. Newborns can also be tested for exposure, as can placental and cord tissue.

On May 16, the World Health Organization released a comprehensive document describing a management algorithm for pregnant women who live in or travel to Zika-endemic areas.

Women who haven’t experienced signs and symptoms of an infection can proceed with routine care, and, if possible, an ultrasound before 18 weeks’ gestation and another at 28-30 weeks.

Women who have had signs of an infection should be tested for exposure. If negative, routine care with an early ultrasound and one at 28-30 weeks is indicated. If the results are positive, or if an early scan is concerning, patients should have a diagnostic ultrasound and amniocentesis, with referral to specialty care.

In the case of confirmed maternal exposure but normal early ultrasound, serial scans are indicated every month until delivery.

As a federal employee, Dr. Jamieson has no financial disclosures.

[email protected]

WASHINGTON – The Centers for Disease Control and Prevention is recommending blood or urine testing for all pregnant women with possible Zika exposure through travel or because they live in an endemic area, regardless of whether they are symptomatic, Dr. Denise J. Jamieson said at the annual meeting of the American College of Obstetricians and Gynecologists.

Couples interested in conceiving who live in or have traveled to areas of active transmission should be alert for any signs of infection, no matter how slight; if they notice any, they should be tested for exposure before attempting conception, Dr. Jamieson, a medical officer with the CDC’s division of reproductive medicine, said in a video interview.

Unfortunately, she said at an update on the Zika situation, labs that process Zika blood and urine samples are backed up, and test results are being “unacceptably delayed.”

During a discussion period, some physicians in the audience complained of waiting up to 6 weeks for results. One said a local health department official told him that the CDC had a backlog of “a million tests.”

“We do not have a 1-million test backup,” Dr. Jamieson said. “But in some places there are still unacceptably long delays. This is not a test you can just check off on a form and send to a lab.”

Many of the tests are being funneled to the CDC’s Division of Vector-Borne Diseases in Ft. Collins, Colo.; that facility is experiencing a long turnaround time. Other samples are being handled in private labs with CDC contracts, but Dr. Jamieson said there’s an urgent need to expand the testing to many more commercial labs. There is no concrete plan for how or when this expansion will happen, however, she added.

Dr. Jamieson also discussed the CDC’s recommendation for managing pregnant women who have a positive serology or urine. These women should have serial ultrasounds every 3-4 weeks to track fetal brain development. Amniocentesis can positively confirm fetal exposure. A maternal-fetal medicine specialist should be on board if the fetus tests positive or if any concerning signs appear on imaging. Newborns can also be tested for exposure, as can placental and cord tissue.

On May 16, the World Health Organization released a comprehensive document describing a management algorithm for pregnant women who live in or travel to Zika-endemic areas.

Women who haven’t experienced signs and symptoms of an infection can proceed with routine care, and, if possible, an ultrasound before 18 weeks’ gestation and another at 28-30 weeks.

Women who have had signs of an infection should be tested for exposure. If negative, routine care with an early ultrasound and one at 28-30 weeks is indicated. If the results are positive, or if an early scan is concerning, patients should have a diagnostic ultrasound and amniocentesis, with referral to specialty care.

In the case of confirmed maternal exposure but normal early ultrasound, serial scans are indicated every month until delivery.

As a federal employee, Dr. Jamieson has no financial disclosures.

[email protected]

WASHINGTON – The Centers for Disease Control and Prevention is recommending blood or urine testing for all pregnant women with possible Zika exposure through travel or because they live in an endemic area, regardless of whether they are symptomatic, Dr. Denise J. Jamieson said at the annual meeting of the American College of Obstetricians and Gynecologists.

Couples interested in conceiving who live in or have traveled to areas of active transmission should be alert for any signs of infection, no matter how slight; if they notice any, they should be tested for exposure before attempting conception, Dr. Jamieson, a medical officer with the CDC’s division of reproductive medicine, said in a video interview.

Unfortunately, she said at an update on the Zika situation, labs that process Zika blood and urine samples are backed up, and test results are being “unacceptably delayed.”

During a discussion period, some physicians in the audience complained of waiting up to 6 weeks for results. One said a local health department official told him that the CDC had a backlog of “a million tests.”

“We do not have a 1-million test backup,” Dr. Jamieson said. “But in some places there are still unacceptably long delays. This is not a test you can just check off on a form and send to a lab.”

Many of the tests are being funneled to the CDC’s Division of Vector-Borne Diseases in Ft. Collins, Colo.; that facility is experiencing a long turnaround time. Other samples are being handled in private labs with CDC contracts, but Dr. Jamieson said there’s an urgent need to expand the testing to many more commercial labs. There is no concrete plan for how or when this expansion will happen, however, she added.

Dr. Jamieson also discussed the CDC’s recommendation for managing pregnant women who have a positive serology or urine. These women should have serial ultrasounds every 3-4 weeks to track fetal brain development. Amniocentesis can positively confirm fetal exposure. A maternal-fetal medicine specialist should be on board if the fetus tests positive or if any concerning signs appear on imaging. Newborns can also be tested for exposure, as can placental and cord tissue.

On May 16, the World Health Organization released a comprehensive document describing a management algorithm for pregnant women who live in or travel to Zika-endemic areas.

Women who haven’t experienced signs and symptoms of an infection can proceed with routine care, and, if possible, an ultrasound before 18 weeks’ gestation and another at 28-30 weeks.

Women who have had signs of an infection should be tested for exposure. If negative, routine care with an early ultrasound and one at 28-30 weeks is indicated. If the results are positive, or if an early scan is concerning, patients should have a diagnostic ultrasound and amniocentesis, with referral to specialty care.

In the case of confirmed maternal exposure but normal early ultrasound, serial scans are indicated every month until delivery.

As a federal employee, Dr. Jamieson has no financial disclosures.

[email protected]

WASHINGTON – The postpartum readmission rate increased over a recent 8-year period from 1.72% to 2.16%, with readmitted patients more likely to be publicly insured and more likely to have multiple comorbidities, a multistate analysis shows.

The rise in readmissions from 2004 to 2011 “isn’t solely explained by the increasing cesarean rate,” and appears to be significantly influenced “by increasing maternal comorbidities,” said Dr. Mark A. Clapp, who reported preliminary findings at the annual meeting of the American College of Obstetricians and Gynecologists.

©SoberP/thinkstockphotos.com

Dr. Clapp and his coinvestigators analyzed postpartum readmissions occurring in the first 6 weeks after delivery in women in California, Florida, and New York – 3 states whose combined 1 million deliveries a year represent approximately a quarter of all deliveries in the United States. Of approximately 8 million deliveries identified over the study period, 6 million were eligible for analysis.

Medical and surgical readmission rates are used in various specialties as indicators of quality and linked to reimbursement, but “very little is known about readmissions in obstetrics,” he said.

The researchers identified deliveries and postpartum readmissions in state inpatient databases and compared maternal, pregnancy, and delivery characteristics of women who were readmitted with those who weren’t readmitted. This included both “primary” indications for readmissions and “associated diagnoses” listed for these patients.

The most common primary indication for readmission, they found, was wound infection or breakdown (15.5%), followed by hypertensive disease (9.3%), and psychiatric illness (7.7%). The most common associated diagnosis among readmitted patients was psychiatric disease, followed by hypertensive disease.

Women who were readmitted “were more likely to have comorbidities across the board,” said Dr. Clapp, a resident at Brigham and Women’s Hospital, Boston. The readmitted women had higher rates of all “associated diagnoses” listed in the state databases, from asthma and diabetes to obesity and thyroid disease, but the most significant differences were in the rates of hypertensive disease, psychiatric disease, and substance abuse.

Regarding mode of delivery, 37.2% of those who were readmitted had undergone a cesarean delivery versus 32.9% of those not readmitted. Patients who were readmitted also were more likely to have had a multiple gestation, preterm labor, or a placental abnormality.

The majority of readmitted patients in the retrospective cohort study were publicly insured: 54% versus 42%. Readmitted patients also were more likely to be older, with a mean age of 36 years, compared with 28 years in the non-readmitted group. They also were more likely to be black (19% of readmitted patients versus 14% of non-readmitted). Over 50% of readmissions occurred in the first week.

The impact of cesarean delivery on readmission risk needs further investigation, Dr. Clapp said, noting that cesarean delivery was an inconsistent predictor of readmission. In Florida, for instance, patients who had cesarean deliveries in 2011 were actually less likely to be readmitted than those who delivered vaginally.

Psychiatric comorbidities also need to be better understood, as does the “influence of increasing maternal comorbidities, which I suspect is driving the increase in readmissions, rather than the mode of delivery,” Dr. Clapp said.

“Hopefully, we can build a body of evidence to either support or refute the use of readmissions as a measure of quality in our field,” he said.

Dr. Clapp and his coauthors reported no relevant financial disclosures. The study was funded by an ACOG health policy grant.

WASHINGTON – The postpartum readmission rate increased over a recent 8-year period from 1.72% to 2.16%, with readmitted patients more likely to be publicly insured and more likely to have multiple comorbidities, a multistate analysis shows.

The rise in readmissions from 2004 to 2011 “isn’t solely explained by the increasing cesarean rate,” and appears to be significantly influenced “by increasing maternal comorbidities,” said Dr. Mark A. Clapp, who reported preliminary findings at the annual meeting of the American College of Obstetricians and Gynecologists.

©SoberP/thinkstockphotos.com

Dr. Clapp and his coinvestigators analyzed postpartum readmissions occurring in the first 6 weeks after delivery in women in California, Florida, and New York – 3 states whose combined 1 million deliveries a year represent approximately a quarter of all deliveries in the United States. Of approximately 8 million deliveries identified over the study period, 6 million were eligible for analysis.

Medical and surgical readmission rates are used in various specialties as indicators of quality and linked to reimbursement, but “very little is known about readmissions in obstetrics,” he said.

The researchers identified deliveries and postpartum readmissions in state inpatient databases and compared maternal, pregnancy, and delivery characteristics of women who were readmitted with those who weren’t readmitted. This included both “primary” indications for readmissions and “associated diagnoses” listed for these patients.

The most common primary indication for readmission, they found, was wound infection or breakdown (15.5%), followed by hypertensive disease (9.3%), and psychiatric illness (7.7%). The most common associated diagnosis among readmitted patients was psychiatric disease, followed by hypertensive disease.

Women who were readmitted “were more likely to have comorbidities across the board,” said Dr. Clapp, a resident at Brigham and Women’s Hospital, Boston. The readmitted women had higher rates of all “associated diagnoses” listed in the state databases, from asthma and diabetes to obesity and thyroid disease, but the most significant differences were in the rates of hypertensive disease, psychiatric disease, and substance abuse.

Regarding mode of delivery, 37.2% of those who were readmitted had undergone a cesarean delivery versus 32.9% of those not readmitted. Patients who were readmitted also were more likely to have had a multiple gestation, preterm labor, or a placental abnormality.

The majority of readmitted patients in the retrospective cohort study were publicly insured: 54% versus 42%. Readmitted patients also were more likely to be older, with a mean age of 36 years, compared with 28 years in the non-readmitted group. They also were more likely to be black (19% of readmitted patients versus 14% of non-readmitted). Over 50% of readmissions occurred in the first week.

The impact of cesarean delivery on readmission risk needs further investigation, Dr. Clapp said, noting that cesarean delivery was an inconsistent predictor of readmission. In Florida, for instance, patients who had cesarean deliveries in 2011 were actually less likely to be readmitted than those who delivered vaginally.

Psychiatric comorbidities also need to be better understood, as does the “influence of increasing maternal comorbidities, which I suspect is driving the increase in readmissions, rather than the mode of delivery,” Dr. Clapp said.

“Hopefully, we can build a body of evidence to either support or refute the use of readmissions as a measure of quality in our field,” he said.

Dr. Clapp and his coauthors reported no relevant financial disclosures. The study was funded by an ACOG health policy grant.

WASHINGTON – The postpartum readmission rate increased over a recent 8-year period from 1.72% to 2.16%, with readmitted patients more likely to be publicly insured and more likely to have multiple comorbidities, a multistate analysis shows.

The rise in readmissions from 2004 to 2011 “isn’t solely explained by the increasing cesarean rate,” and appears to be significantly influenced “by increasing maternal comorbidities,” said Dr. Mark A. Clapp, who reported preliminary findings at the annual meeting of the American College of Obstetricians and Gynecologists.

©SoberP/thinkstockphotos.com

Dr. Clapp and his coinvestigators analyzed postpartum readmissions occurring in the first 6 weeks after delivery in women in California, Florida, and New York – 3 states whose combined 1 million deliveries a year represent approximately a quarter of all deliveries in the United States. Of approximately 8 million deliveries identified over the study period, 6 million were eligible for analysis.

Medical and surgical readmission rates are used in various specialties as indicators of quality and linked to reimbursement, but “very little is known about readmissions in obstetrics,” he said.

The researchers identified deliveries and postpartum readmissions in state inpatient databases and compared maternal, pregnancy, and delivery characteristics of women who were readmitted with those who weren’t readmitted. This included both “primary” indications for readmissions and “associated diagnoses” listed for these patients.

The most common primary indication for readmission, they found, was wound infection or breakdown (15.5%), followed by hypertensive disease (9.3%), and psychiatric illness (7.7%). The most common associated diagnosis among readmitted patients was psychiatric disease, followed by hypertensive disease.

Women who were readmitted “were more likely to have comorbidities across the board,” said Dr. Clapp, a resident at Brigham and Women’s Hospital, Boston. The readmitted women had higher rates of all “associated diagnoses” listed in the state databases, from asthma and diabetes to obesity and thyroid disease, but the most significant differences were in the rates of hypertensive disease, psychiatric disease, and substance abuse.

Regarding mode of delivery, 37.2% of those who were readmitted had undergone a cesarean delivery versus 32.9% of those not readmitted. Patients who were readmitted also were more likely to have had a multiple gestation, preterm labor, or a placental abnormality.

The majority of readmitted patients in the retrospective cohort study were publicly insured: 54% versus 42%. Readmitted patients also were more likely to be older, with a mean age of 36 years, compared with 28 years in the non-readmitted group. They also were more likely to be black (19% of readmitted patients versus 14% of non-readmitted). Over 50% of readmissions occurred in the first week.

The impact of cesarean delivery on readmission risk needs further investigation, Dr. Clapp said, noting that cesarean delivery was an inconsistent predictor of readmission. In Florida, for instance, patients who had cesarean deliveries in 2011 were actually less likely to be readmitted than those who delivered vaginally.

Psychiatric comorbidities also need to be better understood, as does the “influence of increasing maternal comorbidities, which I suspect is driving the increase in readmissions, rather than the mode of delivery,” Dr. Clapp said.

“Hopefully, we can build a body of evidence to either support or refute the use of readmissions as a measure of quality in our field,” he said.

Dr. Clapp and his coauthors reported no relevant financial disclosures. The study was funded by an ACOG health policy grant.

WASHINGTON – Despite being approved by the Food and Drug Administration as a primary cervical cancer screening test starting at age 25, most medical societies recommend that the human papillomavirus (HPV) test be used as part of a cotesting strategy with cytology, and only among women age 30 years and older.

At the annual meeting of the American College of Obstetricians and Gynecologists, physicians debated whether the HPV test was ready to replace the pap smear as the standard primary screening test for cervical cancer.

Dr. Warner K. Huh, professor and director of gynecologic oncology at the University of Alabama at Birmingham, said in a video interview that the HPV test has already clearly been shown to be superior to cytology, which has a low sensitivity and is highly subjective. There also is a minimal difference between the sensitivity of HPV testing alone versus the combination of the HPV test and cytology, he added.

Although most physicians may not yet be ready to use the HPV test alone, Dr. Huh said that he sees the medical community gradually moving in that direction.

But Dr. George Sawaya, professor in obstetrics, gynecology, and reproductive sciences and epidemiology and biostatistics at the University of California, San Francisco, said in a video interview that he’s concerned that the use of the HPV test alone will result in women undergoing further testing – including cytology and colposcopy – and long-term monitoring. He added that any type of screening is valuable and that the key to decreasing cervical cancer cases and deaths is to reach those women who have never been screened.

[email protected]

On Twitter @maryellenny

WASHINGTON – Despite being approved by the Food and Drug Administration as a primary cervical cancer screening test starting at age 25, most medical societies recommend that the human papillomavirus (HPV) test be used as part of a cotesting strategy with cytology, and only among women age 30 years and older.

At the annual meeting of the American College of Obstetricians and Gynecologists, physicians debated whether the HPV test was ready to replace the pap smear as the standard primary screening test for cervical cancer.

Dr. Warner K. Huh, professor and director of gynecologic oncology at the University of Alabama at Birmingham, said in a video interview that the HPV test has already clearly been shown to be superior to cytology, which has a low sensitivity and is highly subjective. There also is a minimal difference between the sensitivity of HPV testing alone versus the combination of the HPV test and cytology, he added.

Although most physicians may not yet be ready to use the HPV test alone, Dr. Huh said that he sees the medical community gradually moving in that direction.

But Dr. George Sawaya, professor in obstetrics, gynecology, and reproductive sciences and epidemiology and biostatistics at the University of California, San Francisco, said in a video interview that he’s concerned that the use of the HPV test alone will result in women undergoing further testing – including cytology and colposcopy – and long-term monitoring. He added that any type of screening is valuable and that the key to decreasing cervical cancer cases and deaths is to reach those women who have never been screened.

[email protected]

On Twitter @maryellenny

WASHINGTON – Despite being approved by the Food and Drug Administration as a primary cervical cancer screening test starting at age 25, most medical societies recommend that the human papillomavirus (HPV) test be used as part of a cotesting strategy with cytology, and only among women age 30 years and older.

At the annual meeting of the American College of Obstetricians and Gynecologists, physicians debated whether the HPV test was ready to replace the pap smear as the standard primary screening test for cervical cancer.

Dr. Warner K. Huh, professor and director of gynecologic oncology at the University of Alabama at Birmingham, said in a video interview that the HPV test has already clearly been shown to be superior to cytology, which has a low sensitivity and is highly subjective. There also is a minimal difference between the sensitivity of HPV testing alone versus the combination of the HPV test and cytology, he added.

Although most physicians may not yet be ready to use the HPV test alone, Dr. Huh said that he sees the medical community gradually moving in that direction.

But Dr. George Sawaya, professor in obstetrics, gynecology, and reproductive sciences and epidemiology and biostatistics at the University of California, San Francisco, said in a video interview that he’s concerned that the use of the HPV test alone will result in women undergoing further testing – including cytology and colposcopy – and long-term monitoring. He added that any type of screening is valuable and that the key to decreasing cervical cancer cases and deaths is to reach those women who have never been screened.

[email protected]

On Twitter @maryellenny

WASHINGTON – Half of the pregnancy-associated hemorrhage deaths in Michigan were deemed preventable, and most of those occurred in women who received no fresh frozen plasma during their transfusion.

Only 3 women in the 46-case series received the generally accepted one-to-one ratio of fresh frozen plasma to packed red cells, Kathryn De La Rosa said at the annual meeting of the American College of Obstetricians and Gynecologists.

The data, gleaned from state records, were not detailed enough to show with absolute certainty that the failure to follow transfusion protocol was lethal, said Ms. De La Rosa, a medical student at the University of Michigan, Ann Arbor.

“I can’t say in good faith that this is why they died,” she said. “I don’t think we have the ability to say, if these women had gotten fresh frozen plasma, they would be here today. What this does show is that this is an area that needs improvement. It’s something we should be recognizing and dealing with.”

The study plumbed records of all pregnancy-associated deaths examined by the State of Michigan Maternal Mortality review committee from 1998 to 2011. Of these, 46 were due to hemorrhage. As part of the adjudication process, the board reviews each case and determines whether or not it was a preventable death; 23 were deemed preventable.

The most common cause of preventable hemorrhage death was postpartum hemorrhage, occurring in seven cases. Other causes included placental abruption, abortion-related, amniotic fluid embolism, antepartum hemorrhage, uterine rupture, ectopic rupture, preeclampsia, and sepsis.

Most of the women who succumbed to a preventable death were younger than 30 years (13); 7 were aged 30-34 years and the remainder were 35 years or older. There was no relationship between preventable death and race or mode of delivery, Ms. De La Rosa noted.

When she examined details of each patient’s transfusion protocol, it was immediately apparent that the protocol of a one-to-one or higher ratio of fresh frozen plasma to packed red cells was not being applied.

“These women got an average of 10 units of cells but not the proper ratio of fresh frozen plasma. In fact, 17 of our 23 preventable deaths didn’t get any fresh frozen plasma at all,” she said. “Only 3 of the 46 cases conformed to that protocol; of these, one death was considered preventable.”

She conducted a more in-depth analysis of the five postpartum hemorrhage cases that occurred in a hospital (two occurred outside a hospital). These women underwent a large variety of interventions, including uterotonics, oxytocin, bedside interventions like laceration repair, fundal massage and manual extraction of uterine contents, and surgery.

But there were concerns about the adequate application of best transfusion practices, Ms. De La Rosa said. None of the women were at a facility that used a massive transfusion protocol, and none were transfused aggressively with the proper plasma/red cell ratio.

Michigan has recently joined a national project to improve maternal health outcomes, including those related to hemorrhage, she said. The Alliance for Innovation on Maternal Health (AIM) is a partnership of organizations dedicated to reducing severe maternal morbidity by 100,000 events and maternal mortality by 1,000 deaths by 2018. Michigan’s goal is to cut maternal mortality in half by 2017.

In addition to obstetric hemorrhage, the group is developing other bundles on hypertension/preeclampsia, venous thromboembolism, and reduction of primary cesarean section.

Ms. De La Rosa reported having no financial disclosures.

[email protected]

On Twitter @Alz_Gal

WASHINGTON – Half of the pregnancy-associated hemorrhage deaths in Michigan were deemed preventable, and most of those occurred in women who received no fresh frozen plasma during their transfusion.

Only 3 women in the 46-case series received the generally accepted one-to-one ratio of fresh frozen plasma to packed red cells, Kathryn De La Rosa said at the annual meeting of the American College of Obstetricians and Gynecologists.

The data, gleaned from state records, were not detailed enough to show with absolute certainty that the failure to follow transfusion protocol was lethal, said Ms. De La Rosa, a medical student at the University of Michigan, Ann Arbor.

“I can’t say in good faith that this is why they died,” she said. “I don’t think we have the ability to say, if these women had gotten fresh frozen plasma, they would be here today. What this does show is that this is an area that needs improvement. It’s something we should be recognizing and dealing with.”

The study plumbed records of all pregnancy-associated deaths examined by the State of Michigan Maternal Mortality review committee from 1998 to 2011. Of these, 46 were due to hemorrhage. As part of the adjudication process, the board reviews each case and determines whether or not it was a preventable death; 23 were deemed preventable.

The most common cause of preventable hemorrhage death was postpartum hemorrhage, occurring in seven cases. Other causes included placental abruption, abortion-related, amniotic fluid embolism, antepartum hemorrhage, uterine rupture, ectopic rupture, preeclampsia, and sepsis.

Most of the women who succumbed to a preventable death were younger than 30 years (13); 7 were aged 30-34 years and the remainder were 35 years or older. There was no relationship between preventable death and race or mode of delivery, Ms. De La Rosa noted.

When she examined details of each patient’s transfusion protocol, it was immediately apparent that the protocol of a one-to-one or higher ratio of fresh frozen plasma to packed red cells was not being applied.

“These women got an average of 10 units of cells but not the proper ratio of fresh frozen plasma. In fact, 17 of our 23 preventable deaths didn’t get any fresh frozen plasma at all,” she said. “Only 3 of the 46 cases conformed to that protocol; of these, one death was considered preventable.”

She conducted a more in-depth analysis of the five postpartum hemorrhage cases that occurred in a hospital (two occurred outside a hospital). These women underwent a large variety of interventions, including uterotonics, oxytocin, bedside interventions like laceration repair, fundal massage and manual extraction of uterine contents, and surgery.

But there were concerns about the adequate application of best transfusion practices, Ms. De La Rosa said. None of the women were at a facility that used a massive transfusion protocol, and none were transfused aggressively with the proper plasma/red cell ratio.

Michigan has recently joined a national project to improve maternal health outcomes, including those related to hemorrhage, she said. The Alliance for Innovation on Maternal Health (AIM) is a partnership of organizations dedicated to reducing severe maternal morbidity by 100,000 events and maternal mortality by 1,000 deaths by 2018. Michigan’s goal is to cut maternal mortality in half by 2017.

In addition to obstetric hemorrhage, the group is developing other bundles on hypertension/preeclampsia, venous thromboembolism, and reduction of primary cesarean section.

Ms. De La Rosa reported having no financial disclosures.

[email protected]

On Twitter @Alz_Gal

WASHINGTON – Half of the pregnancy-associated hemorrhage deaths in Michigan were deemed preventable, and most of those occurred in women who received no fresh frozen plasma during their transfusion.

Only 3 women in the 46-case series received the generally accepted one-to-one ratio of fresh frozen plasma to packed red cells, Kathryn De La Rosa said at the annual meeting of the American College of Obstetricians and Gynecologists.

The data, gleaned from state records, were not detailed enough to show with absolute certainty that the failure to follow transfusion protocol was lethal, said Ms. De La Rosa, a medical student at the University of Michigan, Ann Arbor.

“I can’t say in good faith that this is why they died,” she said. “I don’t think we have the ability to say, if these women had gotten fresh frozen plasma, they would be here today. What this does show is that this is an area that needs improvement. It’s something we should be recognizing and dealing with.”

The study plumbed records of all pregnancy-associated deaths examined by the State of Michigan Maternal Mortality review committee from 1998 to 2011. Of these, 46 were due to hemorrhage. As part of the adjudication process, the board reviews each case and determines whether or not it was a preventable death; 23 were deemed preventable.

The most common cause of preventable hemorrhage death was postpartum hemorrhage, occurring in seven cases. Other causes included placental abruption, abortion-related, amniotic fluid embolism, antepartum hemorrhage, uterine rupture, ectopic rupture, preeclampsia, and sepsis.

Most of the women who succumbed to a preventable death were younger than 30 years (13); 7 were aged 30-34 years and the remainder were 35 years or older. There was no relationship between preventable death and race or mode of delivery, Ms. De La Rosa noted.

When she examined details of each patient’s transfusion protocol, it was immediately apparent that the protocol of a one-to-one or higher ratio of fresh frozen plasma to packed red cells was not being applied.

“These women got an average of 10 units of cells but not the proper ratio of fresh frozen plasma. In fact, 17 of our 23 preventable deaths didn’t get any fresh frozen plasma at all,” she said. “Only 3 of the 46 cases conformed to that protocol; of these, one death was considered preventable.”

She conducted a more in-depth analysis of the five postpartum hemorrhage cases that occurred in a hospital (two occurred outside a hospital). These women underwent a large variety of interventions, including uterotonics, oxytocin, bedside interventions like laceration repair, fundal massage and manual extraction of uterine contents, and surgery.

But there were concerns about the adequate application of best transfusion practices, Ms. De La Rosa said. None of the women were at a facility that used a massive transfusion protocol, and none were transfused aggressively with the proper plasma/red cell ratio.

Michigan has recently joined a national project to improve maternal health outcomes, including those related to hemorrhage, she said. The Alliance for Innovation on Maternal Health (AIM) is a partnership of organizations dedicated to reducing severe maternal morbidity by 100,000 events and maternal mortality by 1,000 deaths by 2018. Michigan’s goal is to cut maternal mortality in half by 2017.

In addition to obstetric hemorrhage, the group is developing other bundles on hypertension/preeclampsia, venous thromboembolism, and reduction of primary cesarean section.

Ms. De La Rosa reported having no financial disclosures.

[email protected]

On Twitter @Alz_Gal