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Clinical question

For patients undergoing any inpatient surgery, is the presence of new-onset perioperative atrial fibrillation associated with a greater long-term risk of ischemic stroke?

Bottom line

Perioperative atrial fibrillation (AF) is associated with an increased risk of ischemic stroke for patients who are hospitalized for surgery. (LOE = 2b)

Reference

Gialdini G, Nearing K, Bhave PD, et al. Perioperative atrial fibrillation and the long-term risk of ischemic stroke. JAMA 2014;312:616-622.

Study design

Cohort (retrospective)

Funding source

Government

Setting

Inpatient (any location)

Synopsis

New-onset perioperative AF is very common but its long-term association with ischemic stroke is unknown. Using administrative data, these investigators identified all adult patients who underwent inpatient surgery during a 4-year period. Patients with preexisiting AF and those with documented cerebrovascular disease were excluded. More than 1.7 million patients were included in the study, with a mean follow-up of 2 years.

Overall, perioperative AF was found in 1.4% of this population, more frequently following cardiac surgery than any other type of surgery (16% vs 0.78%; P < .001). Patients who experienced perioperative AF were also more likely to have high vascular comorbidities, such as hypertension, diabetes, and coronary artery disease. The incidence of ischemic stroke after discharge in the overall cohort was 0.81%.

After adjusting for potential confounders, including age, sex, race, and cardiovascular comorbidities, perioperative AF was independently associated with ischemic stroke both following noncardiac surgery (hazard ratio [HR] 2.0, 95% CI 1.7 - 2.3) and cardiac surgery (HR 1.3, 95% CI 1.1 - 1.6). A further analysis using a specific diagnostic code for cardioembolic stroke showed an even greater association between perioperative AF and this subset of stroke (noncardiac surgery: HR 4.9, 95% CI 3.5 - 6.7; cardiac surgery: HR 2.1, 95% CI 1.4 - 3.1).

Of note, sicker patients in this study may have had more intense cardiac monitoring following their surgeries, leading to an ascertainment bias that could overestimate the association between perioperative AF and stroke. However, a sensitivity analysis using a comorbidity index did not change the findings of the primary analysis.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

For patients undergoing any inpatient surgery, is the presence of new-onset perioperative atrial fibrillation associated with a greater long-term risk of ischemic stroke?

Bottom line

Perioperative atrial fibrillation (AF) is associated with an increased risk of ischemic stroke for patients who are hospitalized for surgery. (LOE = 2b)

Reference

Gialdini G, Nearing K, Bhave PD, et al. Perioperative atrial fibrillation and the long-term risk of ischemic stroke. JAMA 2014;312:616-622.

Study design

Cohort (retrospective)

Funding source

Government

Setting

Inpatient (any location)

Synopsis

New-onset perioperative AF is very common but its long-term association with ischemic stroke is unknown. Using administrative data, these investigators identified all adult patients who underwent inpatient surgery during a 4-year period. Patients with preexisiting AF and those with documented cerebrovascular disease were excluded. More than 1.7 million patients were included in the study, with a mean follow-up of 2 years.

Overall, perioperative AF was found in 1.4% of this population, more frequently following cardiac surgery than any other type of surgery (16% vs 0.78%; P < .001). Patients who experienced perioperative AF were also more likely to have high vascular comorbidities, such as hypertension, diabetes, and coronary artery disease. The incidence of ischemic stroke after discharge in the overall cohort was 0.81%.

After adjusting for potential confounders, including age, sex, race, and cardiovascular comorbidities, perioperative AF was independently associated with ischemic stroke both following noncardiac surgery (hazard ratio [HR] 2.0, 95% CI 1.7 - 2.3) and cardiac surgery (HR 1.3, 95% CI 1.1 - 1.6). A further analysis using a specific diagnostic code for cardioembolic stroke showed an even greater association between perioperative AF and this subset of stroke (noncardiac surgery: HR 4.9, 95% CI 3.5 - 6.7; cardiac surgery: HR 2.1, 95% CI 1.4 - 3.1).

Of note, sicker patients in this study may have had more intense cardiac monitoring following their surgeries, leading to an ascertainment bias that could overestimate the association between perioperative AF and stroke. However, a sensitivity analysis using a comorbidity index did not change the findings of the primary analysis.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

For patients undergoing any inpatient surgery, is the presence of new-onset perioperative atrial fibrillation associated with a greater long-term risk of ischemic stroke?

Bottom line

Perioperative atrial fibrillation (AF) is associated with an increased risk of ischemic stroke for patients who are hospitalized for surgery. (LOE = 2b)

Reference

Gialdini G, Nearing K, Bhave PD, et al. Perioperative atrial fibrillation and the long-term risk of ischemic stroke. JAMA 2014;312:616-622.

Study design

Cohort (retrospective)

Funding source

Government

Setting

Inpatient (any location)

Synopsis

New-onset perioperative AF is very common but its long-term association with ischemic stroke is unknown. Using administrative data, these investigators identified all adult patients who underwent inpatient surgery during a 4-year period. Patients with preexisiting AF and those with documented cerebrovascular disease were excluded. More than 1.7 million patients were included in the study, with a mean follow-up of 2 years.

Overall, perioperative AF was found in 1.4% of this population, more frequently following cardiac surgery than any other type of surgery (16% vs 0.78%; P < .001). Patients who experienced perioperative AF were also more likely to have high vascular comorbidities, such as hypertension, diabetes, and coronary artery disease. The incidence of ischemic stroke after discharge in the overall cohort was 0.81%.

After adjusting for potential confounders, including age, sex, race, and cardiovascular comorbidities, perioperative AF was independently associated with ischemic stroke both following noncardiac surgery (hazard ratio [HR] 2.0, 95% CI 1.7 - 2.3) and cardiac surgery (HR 1.3, 95% CI 1.1 - 1.6). A further analysis using a specific diagnostic code for cardioembolic stroke showed an even greater association between perioperative AF and this subset of stroke (noncardiac surgery: HR 4.9, 95% CI 3.5 - 6.7; cardiac surgery: HR 2.1, 95% CI 1.4 - 3.1).

Of note, sicker patients in this study may have had more intense cardiac monitoring following their surgeries, leading to an ascertainment bias that could overestimate the association between perioperative AF and stroke. However, a sensitivity analysis using a comorbidity index did not change the findings of the primary analysis.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does perioperative colchicine reduce postpericardiotomy syndrome following cardiac surgery?

Bottom line

The use of colchicine in the perioperative period decreases the incidence of postpericardiotomy syndrome after cardiac surgery with a number needed to treat (NNT) of 10. However, colchicine leads to adverse effects—specifically, gastrointestinal intolerance—and may not be tolerated during the vulnerable postoperative period. Findings in this study also suggest a role for colchicine in the prevention of postoperative atrial fibrillation, but this was not a primary outcome of this study and requires further investigation. (LOE = 1b)

Reference

Imazio M, Brucato A, Ferrazzi P, et al, for the COPPS-2 Investigators. Colchicine for prevention of postpericardiotomy syndrome and postoperative atrial fibrillation. JAMA 2014;312(10):1016-1023.

Study design

Randomized controlled trial (double-blinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Postpericardiotomy syndrome is a common complication after cardiac surgery and is defined by the presence of 2 of the following 5 criteria: fever without another cause, pleuritic chest pain, friction rub, new or worsening pericardial effusion, or pleural effusion with elevation in C-reactive protein levels.

To test the theory that perioperative colchicine can prevent postpericardiotomy syndrome, these investigators randomized 360 patients undergoing cardiac surgery to receive either colchicine at 0.5 mg twice daily (once daily for those who weighed less than 70 kg) or matching placebo. The study medication was started at 48 hours to 72 hours prior to surgery and continued for 1 month following surgery. Baseline characteristics of the 2 groups were similar, with two thirds of the patients undergoing either heart valve surgery or coronary artery bypass graft surgery.

The primary analysis was by intention to treat, but a prespecified on-treatment analysis was also performed. The overall study drug discontinuation rate for this trial was high (20%). Postpericardiotomy syndrome occurred less frequently in the colchicine group than in the placebo group at 3-month follow-up (19% vs 29%; absolute difference 10%; NNT = 10).

Additionally, although no significant difference was detected in the primary analysis, the on-treatment analysis did show a decrease in postoperative atrial fibrillation in the colchicine group (27% vs 41%; absolute difference 14%; NNT = 7). Adverse events were significantly greater in the colchicine group (20% vs 12%; number needed to treat to harm = 12), mainly due to increased gastrointestinal intolerance, but there was no difference between the 2 groups in the rate of study drug discontinuation.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does perioperative colchicine reduce postpericardiotomy syndrome following cardiac surgery?

Bottom line

The use of colchicine in the perioperative period decreases the incidence of postpericardiotomy syndrome after cardiac surgery with a number needed to treat (NNT) of 10. However, colchicine leads to adverse effects—specifically, gastrointestinal intolerance—and may not be tolerated during the vulnerable postoperative period. Findings in this study also suggest a role for colchicine in the prevention of postoperative atrial fibrillation, but this was not a primary outcome of this study and requires further investigation. (LOE = 1b)

Reference

Imazio M, Brucato A, Ferrazzi P, et al, for the COPPS-2 Investigators. Colchicine for prevention of postpericardiotomy syndrome and postoperative atrial fibrillation. JAMA 2014;312(10):1016-1023.

Study design

Randomized controlled trial (double-blinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Postpericardiotomy syndrome is a common complication after cardiac surgery and is defined by the presence of 2 of the following 5 criteria: fever without another cause, pleuritic chest pain, friction rub, new or worsening pericardial effusion, or pleural effusion with elevation in C-reactive protein levels.

To test the theory that perioperative colchicine can prevent postpericardiotomy syndrome, these investigators randomized 360 patients undergoing cardiac surgery to receive either colchicine at 0.5 mg twice daily (once daily for those who weighed less than 70 kg) or matching placebo. The study medication was started at 48 hours to 72 hours prior to surgery and continued for 1 month following surgery. Baseline characteristics of the 2 groups were similar, with two thirds of the patients undergoing either heart valve surgery or coronary artery bypass graft surgery.

The primary analysis was by intention to treat, but a prespecified on-treatment analysis was also performed. The overall study drug discontinuation rate for this trial was high (20%). Postpericardiotomy syndrome occurred less frequently in the colchicine group than in the placebo group at 3-month follow-up (19% vs 29%; absolute difference 10%; NNT = 10).

Additionally, although no significant difference was detected in the primary analysis, the on-treatment analysis did show a decrease in postoperative atrial fibrillation in the colchicine group (27% vs 41%; absolute difference 14%; NNT = 7). Adverse events were significantly greater in the colchicine group (20% vs 12%; number needed to treat to harm = 12), mainly due to increased gastrointestinal intolerance, but there was no difference between the 2 groups in the rate of study drug discontinuation.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Clinical question

Does perioperative colchicine reduce postpericardiotomy syndrome following cardiac surgery?

Bottom line

The use of colchicine in the perioperative period decreases the incidence of postpericardiotomy syndrome after cardiac surgery with a number needed to treat (NNT) of 10. However, colchicine leads to adverse effects—specifically, gastrointestinal intolerance—and may not be tolerated during the vulnerable postoperative period. Findings in this study also suggest a role for colchicine in the prevention of postoperative atrial fibrillation, but this was not a primary outcome of this study and requires further investigation. (LOE = 1b)

Reference

Imazio M, Brucato A, Ferrazzi P, et al, for the COPPS-2 Investigators. Colchicine for prevention of postpericardiotomy syndrome and postoperative atrial fibrillation. JAMA 2014;312(10):1016-1023.

Study design

Randomized controlled trial (double-blinded)

Funding source

Government

Allocation

Concealed

Setting

Inpatient (any location) with outpatient follow-up

Synopsis

Postpericardiotomy syndrome is a common complication after cardiac surgery and is defined by the presence of 2 of the following 5 criteria: fever without another cause, pleuritic chest pain, friction rub, new or worsening pericardial effusion, or pleural effusion with elevation in C-reactive protein levels.

To test the theory that perioperative colchicine can prevent postpericardiotomy syndrome, these investigators randomized 360 patients undergoing cardiac surgery to receive either colchicine at 0.5 mg twice daily (once daily for those who weighed less than 70 kg) or matching placebo. The study medication was started at 48 hours to 72 hours prior to surgery and continued for 1 month following surgery. Baseline characteristics of the 2 groups were similar, with two thirds of the patients undergoing either heart valve surgery or coronary artery bypass graft surgery.

The primary analysis was by intention to treat, but a prespecified on-treatment analysis was also performed. The overall study drug discontinuation rate for this trial was high (20%). Postpericardiotomy syndrome occurred less frequently in the colchicine group than in the placebo group at 3-month follow-up (19% vs 29%; absolute difference 10%; NNT = 10).

Additionally, although no significant difference was detected in the primary analysis, the on-treatment analysis did show a decrease in postoperative atrial fibrillation in the colchicine group (27% vs 41%; absolute difference 14%; NNT = 7). Adverse events were significantly greater in the colchicine group (20% vs 12%; number needed to treat to harm = 12), mainly due to increased gastrointestinal intolerance, but there was no difference between the 2 groups in the rate of study drug discontinuation.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

Hands-on workshop helps hospitalists gain confidence in fundamentals, learn to teach physical exam skills better

Hands-on workshop helps hospitalists gain confidence in fundamentals, learn to teach physical exam skills better

Hands-on workshop helps hospitalists gain confidence in fundamentals, learn to teach physical exam skills better

Dr. Ramiro Jervis and Dr. Umesh Gidwani urge hospitalists to experiment with checklists during the 7th annual Hospital Medicine Symposium in New York City.

Dr. Ramiro Jervis and Dr. Umesh Gidwani urge hospitalists to experiment with checklists during the 7th annual Hospital Medicine Symposium in New York City.

Dr. Ramiro Jervis and Dr. Umesh Gidwani urge hospitalists to experiment with checklists during the 7th annual Hospital Medicine Symposium in New York City.

As SHM's glycemic control lead mentor and a hospitalist at the University of New Mexico in Albuquerque, Kendall Rogers, MD, CPE, FACP, SFHM, offers advice to hospitalists when working as part of a quality team in achieving glycemic control.

As SHM's glycemic control lead mentor and a hospitalist at the University of New Mexico in Albuquerque, Kendall Rogers, MD, CPE, FACP, SFHM, offers advice to hospitalists when working as part of a quality team in achieving glycemic control.

As SHM's glycemic control lead mentor and a hospitalist at the University of New Mexico in Albuquerque, Kendall Rogers, MD, CPE, FACP, SFHM, offers advice to hospitalists when working as part of a quality team in achieving glycemic control.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Listen now to excerpts of our interview with Dr. Zelop, a board certified maternal-fetal medicine specialist and director of perinatal ultrasound and research at Valley Hospital in Ridgewood, N.J.

Listen now to excerpts of our interview with Dr. Zelop, a board certified maternal-fetal medicine specialist and director of perinatal ultrasound and research at Valley Hospital in Ridgewood, N.J.

Listen now to excerpts of our interview with Dr. Zelop, a board certified maternal-fetal medicine specialist and director of perinatal ultrasound and research at Valley Hospital in Ridgewood, N.J.

Although new medications to manage and treat hyperglycemia and diabetes continuously appear on the market, national guidelines and position statements consistently refer to insulin as the treatment of choice in the inpatient hospital setting.

“When patients are admitted to the hospital, our standard is to switch from the outpatient regimen [wide variety of medications] to the inpatient regimen—insulin,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston.

For critically ill patients in ICUs or during the peri-operative period, intravenous infusion of insulin is preferred. Most general medicine and surgery patients are managed with subcutaneous insulin.

“Using a basal bolus regimen starting at a total daily dose of 0.3-0.5 unit/kg is sufficient for most patients,” says Guillermo Umpierrez, MD, CDE, FCAE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the board of directors for the American Diabetes Association; however, for most general medicine and surgical patients who have low oral intake or are NPO, a recent trial reported that the administration of basal insulin alone plus correction doses with rapid-acting insulin analogs before meals is as good as a basal bolus regimen. A regimen should be tweaked throughout the inpatient’s stay with an aim to reach the goal of minimal or no hypoglycemia.¹

Planning for a discharge regimen should start early in the hospital stay, Dr. Szumita says, and should be based on several factors:

1. The patient’s Hb1c;
2. The prior regimen and how it was performing;
3. The patient’s wishes; and
4. Collaboration with outpatient providers.

At discharge, it is critical that patients be clear about what medications they should be on post-discharge and that they follow-up with outpatient providers in a timely manner. TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169-2174.

Although new medications to manage and treat hyperglycemia and diabetes continuously appear on the market, national guidelines and position statements consistently refer to insulin as the treatment of choice in the inpatient hospital setting.

“When patients are admitted to the hospital, our standard is to switch from the outpatient regimen [wide variety of medications] to the inpatient regimen—insulin,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston.

For critically ill patients in ICUs or during the peri-operative period, intravenous infusion of insulin is preferred. Most general medicine and surgery patients are managed with subcutaneous insulin.

“Using a basal bolus regimen starting at a total daily dose of 0.3-0.5 unit/kg is sufficient for most patients,” says Guillermo Umpierrez, MD, CDE, FCAE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the board of directors for the American Diabetes Association; however, for most general medicine and surgical patients who have low oral intake or are NPO, a recent trial reported that the administration of basal insulin alone plus correction doses with rapid-acting insulin analogs before meals is as good as a basal bolus regimen. A regimen should be tweaked throughout the inpatient’s stay with an aim to reach the goal of minimal or no hypoglycemia.¹

Planning for a discharge regimen should start early in the hospital stay, Dr. Szumita says, and should be based on several factors:

1. The patient’s Hb1c;
2. The prior regimen and how it was performing;
3. The patient’s wishes; and
4. Collaboration with outpatient providers.

At discharge, it is critical that patients be clear about what medications they should be on post-discharge and that they follow-up with outpatient providers in a timely manner. TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169-2174.

Although new medications to manage and treat hyperglycemia and diabetes continuously appear on the market, national guidelines and position statements consistently refer to insulin as the treatment of choice in the inpatient hospital setting.

“When patients are admitted to the hospital, our standard is to switch from the outpatient regimen [wide variety of medications] to the inpatient regimen—insulin,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston.

For critically ill patients in ICUs or during the peri-operative period, intravenous infusion of insulin is preferred. Most general medicine and surgery patients are managed with subcutaneous insulin.

“Using a basal bolus regimen starting at a total daily dose of 0.3-0.5 unit/kg is sufficient for most patients,” says Guillermo Umpierrez, MD, CDE, FCAE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the board of directors for the American Diabetes Association; however, for most general medicine and surgical patients who have low oral intake or are NPO, a recent trial reported that the administration of basal insulin alone plus correction doses with rapid-acting insulin analogs before meals is as good as a basal bolus regimen. A regimen should be tweaked throughout the inpatient’s stay with an aim to reach the goal of minimal or no hypoglycemia.¹

Planning for a discharge regimen should start early in the hospital stay, Dr. Szumita says, and should be based on several factors:

1. The patient’s Hb1c;
2. The prior regimen and how it was performing;
3. The patient’s wishes; and
4. Collaboration with outpatient providers.

At discharge, it is critical that patients be clear about what medications they should be on post-discharge and that they follow-up with outpatient providers in a timely manner. TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169-2174.

Twenty years ago, pregnant women rarely appeared in the hospital for reasons other than delivery. Two trends responsible for that shift are advanced maternal age and rising rates of obesity, defined as a body mass index of >30.

The birth rate for women ages 35-44 has continued to rise, and that has brought new challenges to treating pregnancy, many of which result in hospital visits.¹

OB/GYN hospitalist Robert Olson, MD, SFHM, has witnessed the winds of change firsthand. “Older patients are more likely to have medical conditions such as hypertension and diabetes, as well as the unusual medical problems such as status post heart attack, status post heart transplant, status post chemotherapy for cancer, as well as being on medications for chronic disease,” says Dr. Olson, who practices in Bellingham, Wash., and is the founding president of the Society of OB/GYN Hospitalists.

According to the National Health and Nutrition Examination Survey, more than one third of U.S. women are obese and more than half of all pregnant women are overweight or obese and therefore prone to complications that send them to the hospital, including gestational diabetes, hypertension, and preeclampsia.³

As an inpatient, obese pregnant women present their own challenges, including increased risk of thromboembolism. When treating this type of patient, remember pneumatic compression devices are recommended if the patient will be immobile for any length of time.⁴

Click here to listen to Dr. Carolyn Zelop discuss cardiovascular emergencies in pregnant patients.

Clinicians might also have significant difficulty intubating the overweight mother-to-be. Whether for cesarean section, other surgical procedures, or an acute medical crisis, physicians must approach intubation with caution as a result of excessive adipose tissue, obscured landmarks, difficulty positioning, and edema, as well as progesterone-induced relaxation of the sphincter between the esophagus and stomach.⁵ It is vital to make use of your most experienced staff when intubating this special needs patient. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Martin JA, Hamilton BE, Ventura SJ, et al. National Vital Statistics Reports: Volume 62, Number 1. June 28, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed October 6, 2014.
2. Olson, Robert. Founding president, Society of OB/GYN Hospitalists; OB/GYN hospitalist, PeaceHealth St. Joseph Medical Center, Bellingham, Wash. E-mail interview. November 13, 2013.
3. Leddy MA, Power ML, Schulkin J. The impact of maternal obesity on maternal and fetal health. Rev Obstet Gynecol. 2008;1(4):170-178.
4. ACOG committee opinion number 549. Obstet Gynecol. 2013;121(1):213-217.
5. Zelop, Carolyn M. Director, perinatal ultrasound and research, Valley Hospital, Ridgewood, N.J. Telephone interview. October 30, 2013.

Twenty years ago, pregnant women rarely appeared in the hospital for reasons other than delivery. Two trends responsible for that shift are advanced maternal age and rising rates of obesity, defined as a body mass index of >30.

The birth rate for women ages 35-44 has continued to rise, and that has brought new challenges to treating pregnancy, many of which result in hospital visits.¹

OB/GYN hospitalist Robert Olson, MD, SFHM, has witnessed the winds of change firsthand. “Older patients are more likely to have medical conditions such as hypertension and diabetes, as well as the unusual medical problems such as status post heart attack, status post heart transplant, status post chemotherapy for cancer, as well as being on medications for chronic disease,” says Dr. Olson, who practices in Bellingham, Wash., and is the founding president of the Society of OB/GYN Hospitalists.

According to the National Health and Nutrition Examination Survey, more than one third of U.S. women are obese and more than half of all pregnant women are overweight or obese and therefore prone to complications that send them to the hospital, including gestational diabetes, hypertension, and preeclampsia.³

As an inpatient, obese pregnant women present their own challenges, including increased risk of thromboembolism. When treating this type of patient, remember pneumatic compression devices are recommended if the patient will be immobile for any length of time.⁴

Click here to listen to Dr. Carolyn Zelop discuss cardiovascular emergencies in pregnant patients.

Clinicians might also have significant difficulty intubating the overweight mother-to-be. Whether for cesarean section, other surgical procedures, or an acute medical crisis, physicians must approach intubation with caution as a result of excessive adipose tissue, obscured landmarks, difficulty positioning, and edema, as well as progesterone-induced relaxation of the sphincter between the esophagus and stomach.⁵ It is vital to make use of your most experienced staff when intubating this special needs patient. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Martin JA, Hamilton BE, Ventura SJ, et al. National Vital Statistics Reports: Volume 62, Number 1. June 28, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed October 6, 2014.
2. Olson, Robert. Founding president, Society of OB/GYN Hospitalists; OB/GYN hospitalist, PeaceHealth St. Joseph Medical Center, Bellingham, Wash. E-mail interview. November 13, 2013.
3. Leddy MA, Power ML, Schulkin J. The impact of maternal obesity on maternal and fetal health. Rev Obstet Gynecol. 2008;1(4):170-178.
4. ACOG committee opinion number 549. Obstet Gynecol. 2013;121(1):213-217.
5. Zelop, Carolyn M. Director, perinatal ultrasound and research, Valley Hospital, Ridgewood, N.J. Telephone interview. October 30, 2013.

Twenty years ago, pregnant women rarely appeared in the hospital for reasons other than delivery. Two trends responsible for that shift are advanced maternal age and rising rates of obesity, defined as a body mass index of >30.

The birth rate for women ages 35-44 has continued to rise, and that has brought new challenges to treating pregnancy, many of which result in hospital visits.¹

OB/GYN hospitalist Robert Olson, MD, SFHM, has witnessed the winds of change firsthand. “Older patients are more likely to have medical conditions such as hypertension and diabetes, as well as the unusual medical problems such as status post heart attack, status post heart transplant, status post chemotherapy for cancer, as well as being on medications for chronic disease,” says Dr. Olson, who practices in Bellingham, Wash., and is the founding president of the Society of OB/GYN Hospitalists.

According to the National Health and Nutrition Examination Survey, more than one third of U.S. women are obese and more than half of all pregnant women are overweight or obese and therefore prone to complications that send them to the hospital, including gestational diabetes, hypertension, and preeclampsia.³

As an inpatient, obese pregnant women present their own challenges, including increased risk of thromboembolism. When treating this type of patient, remember pneumatic compression devices are recommended if the patient will be immobile for any length of time.⁴

Click here to listen to Dr. Carolyn Zelop discuss cardiovascular emergencies in pregnant patients.

Clinicians might also have significant difficulty intubating the overweight mother-to-be. Whether for cesarean section, other surgical procedures, or an acute medical crisis, physicians must approach intubation with caution as a result of excessive adipose tissue, obscured landmarks, difficulty positioning, and edema, as well as progesterone-induced relaxation of the sphincter between the esophagus and stomach.⁵ It is vital to make use of your most experienced staff when intubating this special needs patient. TH

Maybelle Cowan-Lincoln is a freelance writer in New Jersey.

References

1. Martin JA, Hamilton BE, Ventura SJ, et al. National Vital Statistics Reports: Volume 62, Number 1. June 28, 2013. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_01.pdf. Accessed October 6, 2014.
2. Olson, Robert. Founding president, Society of OB/GYN Hospitalists; OB/GYN hospitalist, PeaceHealth St. Joseph Medical Center, Bellingham, Wash. E-mail interview. November 13, 2013.
3. Leddy MA, Power ML, Schulkin J. The impact of maternal obesity on maternal and fetal health. Rev Obstet Gynecol. 2008;1(4):170-178.
4. ACOG committee opinion number 549. Obstet Gynecol. 2013;121(1):213-217.
5. Zelop, Carolyn M. Director, perinatal ultrasound and research, Valley Hospital, Ridgewood, N.J. Telephone interview. October 30, 2013.

Hospital Medicine 2013 offers expert speakers, 90 educational offerings, and networking with the best and brightest hospital medicine has to offer.

Hospital Medicine 2013 offers expert speakers, 90 educational offerings, and networking with the best and brightest hospital medicine has to offer.

Hospital Medicine 2013 offers expert speakers, 90 educational offerings, and networking with the best and brightest hospital medicine has to offer.