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In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.Venous thromboembolism (VTE) accounts for a significant proportion of pregnancy-related mortality. In response to a series of VTEs at our institution and in accordance with mounting medical evidence for increased assessment, we implemented a universal, standardized obstetric VTE risk assessment process during antepartum and postpartum admissions and corresponding pharmacological thromboprophylaxis, which extends into the postdischarge period to prevent pregnancy-associated VTE in our urban, safety-net population.This quality improvement (QI) project used the Institute for Healthcare Improvement's model for improvement. We analyzed data from chart audits, patient and pharmacy outreach, and electronic reports using statistical process control charts. A review of 407 charts showed an increase in the proportion of patients undergoing documented risk assessment from 0% to 80% (average of 61%) from July 2015 to June 2016. The average risk assessment rate increased from 61% to 98% from July 2016 through March 2021 after the screening was integrated into the electronic health record (EHR). Rate of receipt of recommended thromboprophylaxis during admission increased from an average of 85% before EHR integration to 94% after integration. The proportion of high-risk patients receiving prescriptions upon discharge increased from 7% before EHR integration to 94% after integration. We interviewed 117 patients by telephone, of whom 74% continued the medications at home.An interprofessional team can achieve high rates of obstetric inpatient VTE risk assessment, pharmacological thromboprophylaxis initiation, and outpatient continuation using QI methodology.

Identify factors associated with the need for pharmacologic therapy (PT) among opioid exposed newborn (OENs). Retrospective analysis of a statewide database of OENs from 2017 through 2019. Multivariable mixed-effects logistic regression modeled the association of maternal characteristics, infant characteristics, and family engagement practices on the receipt of PT. Of 2098 OENs, 44.8% required PT for NOWS. Higher odds of PT were associated with in-utero exposure to medication treatment for opioid use disorder (MOUD) and non-prescribed opioids in addition to MOUD; nicotine, benzodiazepines, SSRIs; male; out-born infants and mother’s ineligibility to provide breast-milk. Lower odds were associated with increasing birth year, skin-to-skin (STS) care, and rooming-in. Male, out-born infants exposed to MOUD with additional non-prescribed opioids, nicotine, benzodiazepines and SSSRIs with mothers ineligible to provide breast-milk were more likely to require PT, while modifiable care practices including STS care, and rooming-in decreased the likelihood of PT.

BackgroundThe rate of induction of labor in the U.S. has risen from 9.6% in 1990 to 25.7% in 2018, including 31.7% of first-time births. Recent studies that have examined inductions have been small qualitative studies or relied on either medical records or administrative data. This study examines induction from the perspective of those women who experienced it, with a particular focus on the prevalence and predictors of inductions for nonmedical indications, women’s experience of pressure to induce labor and the relationship between the attempt to medically initiate labor and cesarean section.MethodsStudy data are drawn from the 2119 respondents to theListening to Mothers in Californiasurvey who were planning to have a vaginal birth in 2016. Mothers were asked if there had been an attempt to medically initiate labor, if it actually started labor, if they felt pressured to have the induction, if they had a cesarean and the reason for the induction. Reasons for induction were classified as either medically indicated or elective.ResultsAlmost half (47%) of our respondents indicated an attempt was made to medically induce their labor, and 71% of those attempts initiated labor. More than a third of the attempts (37%) were elective. Attempted induction overall was most strongly associated with giving birth at 41+ weeks (aOR 3.28; 95% C.I. 2.21–4.87). Elective inductions were more likely among multiparous mothers and in pregnancies at 39 or 40 weeks. The perception of being pressured to have labor induced was related to higher levels of education, maternal preference for less medical intervention in birth, having an obstetrician compared to a midwife and gestational ages of 41+ weeks. Cesarean birth was more likely in the case of overall induction (aOR 1.51; 95% C.I. 1.11–2.07) and especially following a failed attempt at labor induction (aOR 4.50; 95% C.I. 2.93–6.90).ConclusionClinicians counselling mothers concerning the need for labor induction should be aware of mothers’ perceptions about birth and engage in true shared decision making in order to avoid the maternal perception of being pressured into labor induction.

Cesarean rates and maternal morbidity increase with the duration of the second stage of labor. We studied the effect of hourly evaluation and documentation during the second stage of labor on maternal and fetal outcomes. We performed a retrospective cohort study of all women who delivered at our urban, tertiary care hospital and underwent a second stage of greater than 60 min between 1 June 2016 and 31 May 2019. There were 1498 patients with complete data. Four hundred forty patients had hourly evaluation and documentation throughout the second stage and 1058 did not. We performed t-tests, Chi-squared, and regression analyses to compare cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage and blood transfusion rates, and fetal outcomes. We performed regression analyses to evaluate for independent effect of this intervention on each outcome. Patients with hourly evaluation and documentation had a decreased likelihood of cesarean delivery (8.2% vs. 20.3%, p < .001), shorter second-stage of labor (98.1 min vs. 177.5 min, p < .001), decreased quantitative blood loss (514.4 mL vs. 667.7 mL, p < .001), and hemorrhage rate (12.5% vs. 19.9%, p < .001). Hourly evaluation was associated with decreased transfusion rates (3.2% vs. 5.6%, p = .05) but was not related to the number of units transfused. Regression analyses confirmed the impact of hourly documentation when potential confounders were included. These differences in outcomes were also noted when evaluation was performed and documented within every 75 min. Hourly second-stage evaluation and documentation did not affect other maternal or infant morbidities. Hourly evaluation and documentation in the second stage was associated with decreased cesarean delivery rate, second-stage duration, quantitative blood loss, hemorrhage, and transfusion.

BackgroundMost women who have had previous caesareans are eligible to have labour after caesarean (LAC), but only 11.9% do so. Studies show the majority of women have already decided about future mode of birth (FMOB) before a subsequent pregnancy. Hence, providing women with LAC counselling soon after birth may help women plan for future pregnancies. Prior to our intervention, our hospital had no method of ensuring that women received LAC counselling after caesarean section. The purpose of this QI initiative was to assess whether formal LAC documentation on labour and delivery (L&D) improves rates of LAC counselling post partum.MethodsOur three-part intervention included: (1) surgeon’s assessment of LAC feasibility in the operative note, (2) written LAC education for women in discharge paperwork and (3) documentation of LAC counselling in the discharge summary. We implemented these changes on L&D in January 2019. We conducted phone surveys of 40 women after caesarean preintervention and postintervention. Surveys included questions regarding three primary outcomes: whether or not they had received LAC counselling either in the hospital or at a postpartum visit, and whether or not they would pursue LAC as FMOB. Surveys also assessed two secondary outcomes: (1) women’s understanding of the indications for surgery and (2) their involvement in the decision process. We used a χ2 analysis to assess primary outcomes and a Fisher’s exact test to assess secondary outcomes. We also surveyed providers about the culture of LAC counselling at our hospital.ResultsAfter our intervention, there was a significant difference between the number of women reporting LAC postpartum counselling (30.77% vs 53.8%, p=0.04). There was also a significant difference in the number of women feeling involved in the decision-making process (68% vs 95%, p=0.03). Providers reported improved knowledge/confidence around LAC counselling (58%–100%). Providers universally stated that LAC counselling has become more ingrained in the culture on L&D.ConclusionsDocumentation of LAC counselling improved the consistency with which providers incorporated LAC counselling into postpartum care. Addressing FMOB at the time of pLTCS and documenting that counselling may be an effective first step in empowering women to pursue LAC in future pregnancies.

Objective Our objective was to describe patient-, provider-, and health systems-level factors associated with likelihood of obtaining guideline-recommended follow-up to prevent or mitigate early-onset type 2 diabetes after a birth complicated by gestational diabetes mellitus (GDM). Methods This study presents a retrospective cohort analysis of de-identified demographic and health care system characteristics, and clinical claims data for 12,622 women with GDM who were continuously enrolled in a large, national U.S. health plan from January 31, 2006, to September 30, 2012. Data were obtained from the OptumLabs Data Warehouse. We extracted 1) known predictors of follow-up (age, race, education, comorbidities, GDM severity); 2) novel factors that had potential as predictors (prepregnancy use of preventive measures and primary care, delivery hospital size); and 3) outcome variables (glucose testing within 1 and 3 years and primary care visit within 3 years after delivery). Results Asian ethnicity, higher education, GDM severity, and delivery in a larger hospital predicted greater likelihood of post-GDM follow-up. Women with a prepregnancy primary care visit of any type were two to three times more likely to receive postpartum glucose testing and primary care at 1 year, and 3.5 times more likely to have obtained testing and primary care at 3 years after delivery. Conclusions A history of use of primary care services before a pregnancy complicated by GDM seems to enhance the likelihood of postdelivery surveillance and preventive care, and thus reduce the risk of undetected early-onset type 2 diabetes. An emphasis on promoting early primary care connections for women in their early reproductive years, in addition to its overall value, is a promising strategy for ensuring follow-up testing and care for women after complicated pregnancies that forewarn risk for later chronic illness. Health systems should focus on models of care that connect primary and reproductive/maternity care before, during, and long after pregnancies occur.

Objectives Complications of pregnancy such as gestational diabetes mellitus (GDM) forewarn future chronic illness and disability, and demonstrate the need for a life course approach to prevention. Our study had two aims: (1) to elucidate how experiences reported by patients and providers converge to facilitate or impede follow-up care after GDM, and (2) to elicit recommendations for system-level changes to enhance prevention across key care transitions. Methods We conducted in-depth interviews with 30 GDM patients and 29 providers of maternity, specialty and primary care in an urban safety hospital network, and used a three-tiered thematic analysis to interpret their narratives. Results Findings reveal that a 'perfect storm' gathers on the path to prevention across stages of care. At diagnosis, patients feel profound anxiety about the debilitating effects of type 2 diabetes mellitus in their communities, providers choose reassurance over risk communication, and both focus primarily on the birth of a healthy baby. Providers report that clinical teams often lack coordination, and confuse patients with a barrage of often-inconsistent advice. In the postpartum period, providers juggle competing clinical priorities and mothers juggle overwhelming demands; for both, the recommended 2-h oral glucose tolerance test is too arduous for women and providers to do as prescribed. Finally, the transition from maternity to primary care is complicated by communication barriers between clinicians and patients, and between maternity and primary care providers. Conclusions for Practice Respondents propose systems innovations to open communication between provider specialties in order to bridge the chasm between reproductive care and life course prevention.

Objectives. To examine the extent to which differences in medication for opioid use disorder (MOUD) in pregnancy and infant neonatal opioid withdrawal syndrome (NOWS) outcomes are associated with maternal race/ethnicity. Methods. We performed a secondary analysis of a statewide quality improvement database of opioid-exposed deliveries from January 2017 to April 2019 from 24 hospitals in Massachusetts. We used multivariable mixed-effects logistic regression to model the association between maternal race/ethnicity (non-Hispanic White, non-Hispanic Black, or Hispanic) and prenatal receipt of MOUD, NOWS severity, early intervention referral, and biological parental custody at discharge. Results. Among 1710 deliveries to women with opioid use disorder, 89.3% (n = 1527) were non-Hispanic White. In adjusted models, non-Hispanic Black women (AOR = 0.34; 95% confidence interval [CI] = 0.18, 0.66) and Hispanic women (AOR = 0.43; 95% CI = 0.27, 0.68) were less likely to receive MOUD during pregnancy compared with non-Hispanic White women. We found no statistically significant associations between maternal race/ethnicity and infant outcomes. Conclusions. We identified significant racial/ethnic differences in MOUD prenatal receipt that persisted in adjusted models. Research should focus on the perspectives and treatment experiences of non-Hispanic Black and Hispanic women to ensure equitable care for all mother–infant dyads.

Objective To implement a standardized universal substance use screening process in an outpatient prenatal clinic at an urban tertiary care hospital. Methods Using a quality-improvement framework that involved process modeling, stakeholder analyses, and plan-do-study-act cycles, we implemented universal substance use screening for prenatal patients using a modified 5Ps screening tool (Parents, Peers, Partner, Past, Present). Implementation included an operational workflow based on the SBIRT (Screening, Brief Intervention, Referral to Treatment) model. The primary outcome measure was percentage of patients who were screened for substance use, with a goal of 90% screened. Secondary outcome measures were percentage who screened positive and percentage of the time a positive screen resulted in documentation of a brief intervention by a health care practitioner. Results Over a 19-month implementation period, 733 patient encounters were sampled. A substance use screen was completed in 618 (84%). We exceeded our goal of screening 90% of eligible patients for the final 6 months of data collection. Of the 618 completed screens, 124 (20%) screened positive. Health care practitioner documentation of brief interventions for patients with a positive screen reached 80% in the final phase of implementation, but then declined to 50% by the completion of the study period. Conclusion A sustainable and generalizable process to carry out substance use screening within a large prenatal practice is feasible, and assisted with identification of patients not known to be at risk. Further efforts are needed to evaluate how to sustain health care practitioner documentation of intervention in response to positive screens.

Objective The study aimed to compare the quantitative blood loss (QBL) and hemorrhage-related outcomes of pregnant women with and without a coronavirus disease 2019 (COVID-19) diagnosis. Study Design This retrospective cohort study of all live deliveries at Boston Medical Center between April 1, 2020 and July 22, 2020 compares the outcomes of pregnant women with a laboratory-confirmed COVID-19 positive diagnosis and pregnant women without COVID-19. The primary outcomes are QBL and obstetric hemorrhage. The secondary outcomes analyzed were a maternal composite outcome that consisted of obstetric hemorrhage, telemetry-level (intermediate care unit) or intensive care unit, transfusion, length of stay greater than 5 days, or intraamniotic infection, and individual components of the maternal composite outcome. Groups were compared using Student's t-test, Chi-squared tests, or Fisher's exact. Logistic regression was used to adjust for confounding variables. Results Of 813 women who delivered a live infant between April 1 and July 22, 2020, 53 women were diagnosed with COVID-19 on admission to the hospital. Women with a COVID-19 diagnosis at their time of delivery were significantly more likely to identify as a race other than white (p = 0.01), to deliver preterm (p = 0.05), to be diagnosed with preeclampsia with severe features (p Conclusion Pregnant women with COVID-19 diagnosis do not have increased risk for obstetric hemorrhage, increased QBL or risk of maternal morbidity compared with pregnant women without a COVID-19 diagnosis. Further research is needed to describe the impact of a COVID-19 diagnosis on maternal hematologic physiology and pregnancy outcomes. Key Points

Background The prevention of venous thromboembolism (VTE) is a high priority in aesthetic surgery. Abdominoplasty is the aesthetic procedure most commonly associated with VTE, yet the mechanisms for the development of VTE associated with this procedure are unclear. Objectives The purpose of this study was to analyze the incidence and predictors of VTE in patients undergoing abdominoplasty procedures in outpatient surgery centers using data from the Internet Based Quality Assurance Program (IBQAP). Methods IBQAP data from 2001 to 2011 were queried retrospectively to identify abdominoplasty cases and VTE cases. Patient- and procedure-specific variables were analyzed to identify potential predictors of VTE in abdominoplasty. Results Among all outpatient aesthetic surgery cases entered from 2001 to 2011, 414 resulted in VTE, representing a VTE incidence of 0.02%. Of these, 240 (58%) occurred in abdominoplasty cases. Predictors of VTE were age greater than 40 years and BMI greater than 25 kg/m2. Patient sex, duration of anesthesia and surgery, type of anesthesia, type of additional procedure, and number of procedures did not appear to influence the risk of VTE. Importantly, 95.5% of the VTEs identified for this study occurred in patients whose Caprini risk assessment model score was between 2 and 8, which would not be an indication for chemoprophylaxis according to current recommendations. Conclusions Many factors must be considered when determining the true incidence of VTE in abdominoplasty. Research is needed to discover the reason abdominoplasty carries a greater risk compared with other aesthetic surgery procedures so that appropriate steps can be taken to prevent its occurrence and improve the safety of the procedure.

BACKGROUND. Low vitamin D status in pregnancy was proposed as a risk factor of preeclampsia. METHODS. We assessed the effect of vitamin D supplementation (4,400 vs. 400 IU/day), initiated early in pregnancy (10–18 weeks), on the development of preeclampsia. The effects of serum vitamin D (25-hydroxyvitamin D [25OHD]) levels on preeclampsia incidence at trial entry and in the third trimester (32–38 weeks) were studied. We also conducted a nested case-control study of 157 women to investigate peripheral blood vitamin D–associated gene expression profiles at 10 to 18 weeks in 47 participants who developed preeclampsia. RESULTS. Of 881 women randomized, outcome data were available for 816, with 67 (8.2%) developing preeclampsia. There was no significant difference between treatment (N = 408) or control (N = 408) groups in the incidence of preeclampsia (8.08% vs. 8.33%, respectively; relative risk: 0.97; 95% CI, 0.61–1.53). However, in a cohort analysis and after adjustment for confounders, a significant effect of sufficient vitamin D status (25OHD ≥30 ng/ml) was observed in both early and late pregnancy compared with insufficient levels (25OHD

This survey study assesses patients’ self-reported communication experiences with their maternity care clinicians and examines the association of these experiences with women’s reports of feeling pressure to have interventions during delivery.

Study Objective Same Day Discharge (SDD) after minimally invasive gynecologic surgery (MIGS) is an evidence-based safe alternative to inpatient hospital admission for appropriately selected patients. Many institutions have implemented SDD protocols after minimally invasive surgery with excellent outcomes. However, as there is clear disparity in access to minimally invasive surgery in safety net hospitals, we hypothesize a similar disparity in SDD. Our goals were 1) to implement a SDD pathway for patients undergoing MIGS at an urban, safety-net hospital and 2) to track outcomes following pathway implementation. Design A multidisciplinary SDD pathway was launched on December 3, 2018. A pilot study was conducted from December 1, 2017 until February 28, 2018. Setting N/A Patients or Participants Patients undergoing either total laparoscopic hysterectomy or laparoscopic myomectomy were eligible. Interventions N/A Measurements and Main Results Prior to SDD implementation, 46 patients were pre-screened; 40 (86.9%) were medically eligible for SDD. Accounting for social determinants of health, 34 (73.9%) would be eligible. 25 (54%) stated that they would feel comfortable going home on the same day, while 21 (46%) would not. The most common reasons for wanting to stay overnight were: anxiety (n=7), unsure of sufficient home care (n=4), fear of anesthetic reaction (n=5), fear of pain (n=3), and unsure of safety to go home (n=3). Specific materials were later developed to educate patients about the safety of SDD. Between SDD implementation and March 31st, 2019, 56 patients underwent MIGS, of whom 42 were eligible for SDD. 12 total patients were discharged home safely the same day without any adverse events or readmissions. Conclusion SDD is a safe alternative to inpatient admission without increasing adverse events or post-operative readmissions. We aim to use a screening tool and educational materials to identify eligible patients. We believe this will improve patient outcomes through shorter hospital stay and quicker return to baseline function.

Background A major contributor to the increase in cesarean deliveries over recent decades is the decline in vaginal births after cesarean (VBAC). Racial and ethnic disparities in other perinatal outcomes are widely recognized, but few studies have been directed toward racial/ethnic differences in VBAC rates. Methods We used the population-based Massachusetts Pregnancy to Early Life (PELL) database to investigate racial/ethnic differences in rates of VBAC for Massachusetts residents with one prior cesarean from 1998 to 2008. Results The overall VBAC rate was 17.3 percent. After adjusting for demographic, behavioral, and medical risk factors, non-Hispanic Asian mothers had a greater likelihood of VBAC than non-Hispanic white mothers (adjusted risk ratio 1.31 [95% CI 1.23–1.39]). No other racial/ethnic group was significantly different from non-Hispanic whites in adjusted analyses. The likelihood of VBAC also decreased with increasing maternal age. Discussion Non-Hispanic Asian women are significantly more likely to have VBAC than non-Hispanic white women. Efforts to reduce cesarean delivery rates in the United States should address these disparities. Future research should investigate factors underlying these differences to ensure that all women have access to appropriate maternity care services.

This study investigates the effect of severity of gestational diabetes (GDM) on likelihood of post-delivery glucose testing and early onset Type 2 diabetes (T2DM). We asked if clinical focus on relative risk (RR), i.e. greater probability of T2DM onset in a higher-severity group, contributes to missed opportunities for prevention among women with lower-severity GDM. A sample of 12,622 continuously-insured women with GDM (2006–2015) was drawn from a large national dataset (OptumLabs® Data Warehouse) and followed for 3-years post-delivery. Higher-severity GDM was defined as addition of hypoglycemic therapy to standard of care for GDM. We found that women with higher-severity (n = 2627) were twice as likely as lower-severity women (n = 9995) to obtain glucose testing post-delivery. Moreover, 357 (13.6%) of the higher-severity women developed T2DM by year-3 vs. 600 (6.0%) lower-severity women. In an analysis of the population attributable fraction (PAF), defined as the contribution of excess risk to population prevalence, lower-severity women contributed more cases to diabetes rates than higher-risk women (PAF 79% vs. 21%), despite an increased RR in the higher-severity group (13.6% vs. 6.0%, RR 2.26, 95%CI 2.00, 2.56). Projecting out to the 327,950 U.S. deliveries in 2014, we estimate that 9277 higher-severity women (13.6%) and 15,584 lower-severity women (6.0%), will have developed T2DM by 2018. These data demonstrate that lower-severity GDM contributes substantially to the diabetes epidemic. Greater awareness of clinical and cost implications of gaps in follow-up for lower-severity GDM may strengthen the likelihood of post-delivery testing and primary care referral, and thus reinforce the path to prevention.

Objective Gestational diabetes mellitus (GDM) is a known harbinger of future type 2 diabetes mellitus (T2DM), hypertension, and cardiac disease. This population-based study was designed to identify gaps in follow-up care relevant to prevention of T2DM in a continuously insured sample of women diagnosed with GDM. Research design and methods We analyzed data spanning 2005–2015 from OptumLabs Data Warehouse, a comprehensive, longitudinal, real-world data asset with deidentified lives across claims and clinical information, to describe patterns of preventive care after GDM. Women with GDM were followed, from 1 year preconception through 3 years postdelivery to identify individual and healthcare systems characteristics, and report on GDM-related outcomes: postpartum glucose testing, transition to primary care for monitoring, GDM recurrence, and T2DM onset. Results Among 12 622 women with GDM, we found low rates of glucose monitoring in the recommended postpartum period (5.8%), at 1 year (21.8%), and at 3 years (51%). A minority had contact with primary care postdelivery (5.7% at 6 months, 13.2% at 1 year, 40.5% at 3 years). Despite increased population risk (GDM recurrence in 52.2% of repeat pregnancies, T2DM onset within 3 years in 7.6% of the sample), 70.1% of GDM-diagnosed women had neither glucose testing nor a primary care visit at 1 year and 32.7% had neither at 3 years. Conclusions We found low rates of glucose testing and transition to primary care in this group of continuously insured women with GDM. Despite continuous insurance coverage, many women with a pregnancy complication that portends risk for future chronic illness fail to obtain follow-up testing and may have difficulty navigating between clinician specialties. Results point to a need for action to close the gap between obstetrics and primary care to ensure receipt of preventive monitoring as recommended by both the American Diabetes Association and the American Congress of Obstetricians and Gynecologists.

Background Maternal asthma, uncontrolled asthma, and low vitamin D levels during pregnancy have been individually linked to increased risk of preeclampsia. Objective To investigate the association of history of physician-diagnosed asthma and uncontrolled asthma status during pregnancy with the risk of preeclampsia and the effects of early pregnancy vitamin D concentrations on this relationship. Methods A total of 816 subjects with available pregnancy outcome data and risk factors of interest were analyzed. A group of experienced obstetricians and gynecologists from 3 study centers validated the preeclampsia diagnoses. Vitamin D was measured using the DiaSorin method at 10 to 18 weeks of gestation. The Pregnancy-Asthma Control Test was used to assess asthma control during pregnancy. Criterion-based stepwise variable selection algorithm was applied to investigate the relationships of risk factors of interest (history of asthma diagnosis, uncontrolled asthma during pregnancy, and vitamin D) to preeclampsia. Results The incidence of preeclampsia was not related to the presence of asthma diagnosis (8.9% with vs 7.4% without). The adjusted odds of preeclampsia controlled for maternal serum 25-hydroxyvitamin D (25OHD) concentrations was higher for women with a higher proportion of uncontrolled asthma months per visit during pregnancy (adjusted odds ratio, 3.55; 95% CI, 1.15-13.0). Adjusting for asthma control status during pregnancy, an additional decrease in the associated preeclampsia risk by 7% was observed for a 10-unit (ng/mL) increase in early pregnancy 25OHD levels (adjusted odds ratio10-unit, 0.60; 95% CI, 0.43-0.82) as compared with the previous risk estimate of preeclampsia associated with low maternal 25OHD unadjusted for asthma control status. Conclusions Uncontrolled asthma during pregnancy is associated with an increased risk of preeclampsia. Early pregnancy 25OHD contributes to the association of uncontrolled asthma status with preeclampsia.

Background: Our study assessed the follow-up of gestational diabetes mellitus (GDM) in the postpartum period among a racially and ethnically diverse group of women receiving care in a major urban medical center. Methods: We conducted cross-sectional analysis of clinical and administrative data on women aged 18–44 years who gave birth at Boston Medical Center (BMC) between 2003 and 2009, had GDM, and used BMC for regular care. We calculated the rate of glucose testing by 70 days and by 180 days after delivery and used logistic regression to assess the predictors of testing. Results: By 6 months postpartum, only 23.4% of GDM-affected women received any kind of glucose test. Among these, over half had been completed by 10 weeks but only 29% were the recommended oral glucose tolerance test (OGTT). After accounting for sociodemographic and health service factors, women aged ≤35 years of age and women with a family practice provider were significantly less likely to be tested than their counterparts (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.32, 0.83 and OR 0.36; 95% CI 0.19, 0.71 respectively). Women who attended a primary care visit within 180 days after birth had three times higher odds of being tested than those without such a visit (OR 3.10; 95% CI 1.97, 4.87). Conclusions: Despite widely disseminated clinical guidelines, postpartum glucose testing rates are exceedingly low, marking a critical missed opportunity to launch preventive care for women at high risk of type 2 DM. Failed follow-up of GDM by providers of prenatal and postpartum care also reflects a broader systems failure: the absence of a well-supported transition from pregnancy care to ongoing primary care for women.

This article summarizes current information on the risk and the assessment of risks for deep venous thrombosis (DVT) resulting from plastic surgery procedures. Risk assessment is the foundation for recommended methods of prevention of DVT and, in turn, possible pulmonary emboli. If prevention fails, treatment of DVT is required to avoid the major complication of pulmonary emboli. The significant risk of DVT and pulmonary emboli after an abdominoplasty is confirmed in this article.

Objectives Gestational diabetes mellitus (GDM) greatly increases the risk of developing diabetes in the decade after delivery, but few women receive appropriately timed postpartum glucose testing (PPGT) or a referral to primary care (PC) for continued monitoring. This qualitative study was designed to identify barriers and facilitators to testing and referral from patient and providers' perspectives. Methods We interviewed patients and clinicians in depth about knowledge, values, priorities, challenges, and recommendations for increasing PPGT rates and PC linkage. Interviews were coded with NVIVO data analysis software, and analyzed using an implementation science framework. Results Women reported motivation to address GDM for the health of the fetus. Most women did not anticipate future diabetes for themselves, and focused on delivery outcomes rather than future health risks. Patients sought and received reassurance from clinicians, and were unlikely to discuss early onset following GDM or preventive measures. PPGT barriers described by patients included provider not mentioning the test or setting it up, transportation difficulties, work responsibilities, fatigue, concerns about fasting while breastfeeding, and timing of the test after discharge from obstetrics, and no referral to PC for follow-up. Practitioners described limited communication among multiple care providers during pregnancy and delivery, systems issues, and separation of obstetrics from PC. Conclusions Patients' barriers to PPGT included low motivation for self-care, structural obstacles, and competing priorities. Providers reported the need to balance risk with reassurance, and identified systems failures related to test timing, limitations of electronic medical record systems (EMR), lack of referrals to PC, and inadequate communication between specialties. Prevention of early onset has great potential for medical cost savings and improvements in quality of life.

In reviewing outcomes that are associated with the implementation of a series of labor and delivery patient safety efforts from 2004-2009, we requested data on the number of related professional liability claims that were reserved by our insurance companies that are established with the specific objective of financing risks that emanate from their parent group or groups. While we restructured the manner in which we give care, required training modules, and provided simulations to our providers, our legal risk continued to be monitored independently and in parallel. Retrospective review of the number of cases for which money was held in reserve for claims demonstrated a 20% decrease per year, which was adjusted for delivery volume, over this time period. We believe that the improved care that resulted from our safety projects has led to this decreased legal risk.

Despite the many benefits of ambulatory surgery, there remain inherent risks associated with any surgical care environment that have the potential to jeopardize patient safety. This practice advisory provides an overview of the preoperative steps that should be completed to ensure appropriate patient selection for ambulatory surgery settings. In conjunction, this advisory identifies several physiologic stresses commonly associated with surgical procedures, in addition to potential postoperative recovery problems, and provides recommendations for how best to minimize these complications.

Maintaining patient safety in the operating room is a major concern of surgeons, hospitals and surgical facilities. Circumventing preventable complications is essential, and pressure to avoid these complications in cosmetic surgery is increasing. Traditionally, nursing and anesthesia staff have managed patient positioning and safety issues in the operating room. As the number of office-based procedures in the plastic surgeon's practice increases, understanding and implementing patient safety guidelines by the plastic surgeon is of increasing importance. A review of the Joint Commission's Universal Protocol highlights requirements set forth to prevent perioperative complications. In the present paper, the importance of implementing these guidelines into the cosmetic surgery practice is reviewed. Key aspects of patient safety in the operating room are outlined, including patient positioning, ocular protection and other issues essential for minimization of postoperative morbidity. Additionally, as the demand for body contouring surgery in the cosmetic practice continues to increase, special attention to safety considerations specific to the obese and massive weight loss patients is mandatory. After review of the present paper, the reader should be able to introduce the Joint Commission's Universal Protocol into their daily practice. The reader will understand key aspects of patient positioning, airway management and ocular protection in cosmetic surgery. Finally, the reader will have a better understanding of the perioperative care of unique populations including the morbidly obese, massive weight loss patients and the elderly. Attention to detail in these aspects of patient safety can help avoid unnecessary complication and significantly improve the patient's experience and surgical outcome.

Learning objectives After studying this article, the participant should be able to: 1. Adequately evaluate a patient preoperatively for liposuction. 2. Formulate a surgical treatment plan to safely perform liposuction. 3. Postoperatively diagnose immediate, early, and late complications and formulate a treatment plan for the complications. 4. Classify the anesthesia status of a potential liposuction patient and select the appropriate type of anesthetics to be used. 5. Understand large-volume liposuction and the added risks inherent in this type of liposuction procedure. Summary The purpose of this liposuction article is to provide a broad overview of the procedure, currently one of the most common operations performed by plastic surgeons. The important medical history that must be obtained, including comorbidities and conditions that increase the risk of deep venous thrombosis, is discussed. Specifics of the physical examination are highlighted. Anesthesia for liposuction is an extremely important factor for the success and safety of the procedure. The anesthetic agents and the wetting solutions used in liposuction are explained to promote safety and good results. A surgical treatment plan for a successful outcome, including the types of lipoplasty, is presented. Outcomes of the procedures, including potential complications, are covered. The rare complication of intestinal or organ perforation from the cannula is discussed to increase the surgeon's level of awareness of the problem and its avoidance. Deep venous thrombosis, associated with pulmonary embolism and death, is the most frequent serious complication of liposuction. This and other sequelae of liposuction are discussed so that the surgeon can evaluate his or her surgical outcomes to improve the results and promote patient safety.

Background The United States has recently experienced increases in both its rate of obesity and its cesarean rate. Our objective was to use a new item measuring prepregnancy body mass index (BMI) on the U.S. Standard Certificate of Live Birth to examine at a population level the relationship between maternal obesity and primary cesarean delivery for women at otherwise low risk for cesarean delivery. Methods By 2012, 38 states with 86 percent of United States births had adopted the U.S. Standard Certificate. The sample was limited to the 2,233,144 women who had a singleton, vertex, term (37–41 weeks) birth in 2012 and no prior cesarean. We modeled the likelihood of a primary cesarean by BMI category, controlling for maternal socio-demographic and medical characteristics. Results Overall, 46.4 percent of otherwise low-risk mothers had a prepregnancy BMI in the overweight (25.1%) or obese (21.3%) categories, with the obese category distributed as follows: obese I (BMI 30.0–34.9, 12.4%); obese II (BMI 35.0–39.9, 5.5%); and obese III (BMI 40+, 3.5%). Obesity rates were highest among American Indian and Alaska Native (32.5%) and non-Hispanic black mothers (30.5%). After adjustment for demographic and medical risks, the adjusted risk ratios (95% confidence intervals) of cesarean for low-risk primiparas were: 1.61 (1.60–1.63) for obese I, 1.86 (1.83–1.88) for obese II, and 2.21 (2.18–2.25) for obese III mothers compared with mothers in the normal weight category. Discussion A relationship between prepregnancy obesity and primary cesarean delivery among relatively low-risk mothers remained even after controlling for social and medical risk factors.

ObjectiveTo characterize the prevalence of and factors associated with clinicians' prenatal suspicion of a large baby; and to determine whether communicating fetal size concerns to patients was associated with labor and delivery interventions and outcomes.MethodsWe examined data from women without a prior cesarean who responded to Listening to Mothers III, a nationally representative survey of women who had given birth between July 2011 and June 2012 (n = 1960). We estimated the effect of having a suspected large baby (SLB) on the odds of six labor and delivery outcomes.ResultsNearly one-third (31.2%) of women were told by their maternity care providers that their babies might be getting "quite large"; however, only 9.9% delivered a baby weighing ≥4000 g (19.7% among mothers with SLBs, 5.5% without). Women with SLBs had increased adjusted odds of medically-induced labor (AOR 1.9; 95% CI 1.4-2.6), attempted self-induced labor (AOR 1.9; 95% CI 1.4-2.7), and use of epidural analgesics (AOR 2.0; 95% CI 1.4-2.9). No differences were noted for overall cesarean rates, although women with SLBs were more likely to ask for (AOR 4.6; 95% CI 2.8-7.6) and have planned (AOR 1.8; 95% CI 1.0-4.5) cesarean deliveries. These associations were not affected by adjustment for gestational age and birthweight.Conclusions for practiceOnly one in five US women who were told that their babies might be getting quite large actually delivered infants weighing ≥4000 g. However, the suspicion of a large baby was associated with an increase in perinatal interventions, regardless of actual fetal size.

Assessing the quality of care delivered in office-based outpatient surgery centers is difficult because formerly there was no central data collection system. The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), in its ongoing effort to assess and improve patient care, has developed an Internet-based quality improvement and peer review program to analyze outcomes for surgery centers it accredits. Reporting is mandatory for all surgeons operating in AAAASF-accredited facilities. Each surgeon must report all unanticipated sequelae and at least six random cases reviewed by an accepted peer review group biannually. A total of 411,670 procedures were analyzed during a 2-year period (from 2001 to 2002). There were 2597 sequelae reported during this period. The most common sequela was hematoma formation following breast augmentation. Infection occurred in 388 cases. Deep vein thrombosis, pulmonary embolism, and intraoperative cardiac arrhythmias were found to occur in a frequency consistent with previous reports. Significant complications (hematoma, hypertensive episode, wound infection, sepsis, and hypotension) were infrequent. A total of 1378 significant sequelae were reported for 411,670 procedures. This calculates to one unanticipated sequela in 299 procedures (an incidence of 0.33 percent). Seven deaths were reported. A death occurred in one in 58,810 procedures (0.0017 percent). The overall risk of death was comparable whether the procedure was performed in an AAAASF-accredited office surgery facility or a hospital surgery facility. This study documents an excellent safety record for surgical procedures performed in accredited office surgery facilities by board-certified surgeons.

At the ASPRS Annual Meeting in October of 1998, the ASPRS Board of Directors convened the Task Force on Sedation and Analgesia in Ambulatory Settings. This task force was called to address, in detail, concerns that had been identified by many plastic surgery organizations about sedation in outpatient surgery settings. The concern about safety and sedation in outpatient surgery facilities is also a major focus for many state legislatures and medical boards. The task force has provided guidelines that, if followed, will provide safe sedation and analgesia for plastic surgery patients in all types of outpatient surgery settings. The statement from the task force represents an extensive review of the literature and existing guidelines and a critical analysis of clinical experience. The task force members were the following: Ronald Iverson, M.D., Chair; Julio Garcia, M.D., Lipoplasty Society representative; Thomas Joas, M.D., Medical Board of California; Brian Kinney, M.D., ASAPS representative; Dennis Lynch, M.D., ASPRS representative; Charles McLeskey, M.D. (Chair, Anesthesiology, Scott and White Clinic, Temple, Texas); and Robert Singer, M.D., AAAASF representative. I would like to thank the members of the task force for the insights that they brought to this process. The final document represents their significant contributions to these efforts.

Ronald E. Iversion, MD Mark A. Codner, MD Val S. Lambros, MD Gregory S. LaTrenta, MD Dr. Iverson: The first patient is a 59-year-old man who feels that his fatty cheeks and heavy nasolabial folds make him look aged (Figure 1). He would like to look completely rejuvenated. Dr. Lambros, what would your preoperative plan include? Figure 1 Preoperative views of a 59-year-old man who feels that his fatty cheeks and heavy nasolabial folds make him look aged. He desires complete facial rejuvenation. Dr. Lambros: First, we must be sure that he has realistic expectations. In my experience, and in presentations by other surgeons, I have not seen a lot of success in elevating lateral brows in patients with thick foreheads. In this patient, I would elevate the medial brows to get rid of that “cranky” expression, which I believe could be accomplished without brow distortion. One could perform a corrugator resection through the upper lid, come down from above with an endoscope, and get some support. Alternatively, an open-brow lift would be reasonable, as would an upper-lid blepharoplasty. He would need a face and neck lift with the best possible internal support. I would perform a modest amount of jowl liposuction at the same time. My main indication for opening a neck is platysma bands. Otherwise, I would simply liposuction the neck. Dr. Iverson: How would you manage the lower eyelids? Dr. Lambros: This is a patient in whom I think “doing no harm” is a good idea. He has a small amount of lateral sway in his lower lids, and my temptation might be just to perform a canthopexy and not do anything more aggressive with the lower lids. Dr. Iverson: Dr. Codner, what would you do differently? Dr. Codner: This patient has a narrow brow-lash distance, as demonstrated on …

Objective: To test the hypothesis that elevated temperature is more common after abdominal myomectomy than after hysterectomy. Design: Retrospective cohort study. Setting: Academic medical center. Patient(s): One hundred one women who underwent abdominal myomectomy and 160 women who underwent total abdominal hysterectomy for benign disease from 1988–1993. Intervention(s): Abdominal myomectomy. Main Outcome Measure(s): Temperature of ≥38.5°C within 48 hours after operation. Result(s): Although univariate analysis showed that the incidence of elevated temperature was slightly greater among patients who underwent myomectomy (33% versus 26%, relative risk 1.29, 95% confidence interval 0.88–1.90), multivariate logistic regression analysis showed a 3.29 relative risk of elevated temperature (95% confidence interval 1.56–6.96) with myomectomy after controlling for age, parity, estimated blood loss, and treatment by the general gynecology service. Conclusion(s): After controlling for confounders, myomectomy was found to be an independent predictor for fever in the first 48 hours after operation.

The medical profession is besieged by concerns about cost containment. This in turn has focused attention on the use of ambulatory surgical facilities. However, the costs of hospital outpatient surgery programs usually prevent them from being competitive when compared with the costs of using office surgical facilities. To address the question of patient safety in office surgical facilities, the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) sent a questionnaire to its accredited facilities. Two-hundred and forty-one (57.7 percent) of the 418 accredited facilities returned the anonymous questionnaires, a very high response rate. Of interest are the following findings: 400,675 operative procedures were reported during a 5-year period. Significant complications (hematoma hypertensive episode, wound infection, sepsis, hypotension) were infrequent, occurring iii 1 in every 213 cases. Return to the operating room within 24 hours and preventive hospitalization were less frequent. A death occurred in I in 57,000 cases (0.0017 percent). The overall risk is comparable in an accredited office (plastic surgical facility) and in a free-standing or hospital ambulatory surgical facility. This study documents an excellent safety record for plastic surgery done in accredited office surgical facilities by board-certified plastic surgeons.

This article summarizes current information on the risk and the assessment of risks for deep venous thrombosis (DVT) resulting from plastic surgery procedures. Risk assessment is the foundation for recommended methods of prevention of DVT and, in turn, possible pulmonary emboli. If prevention fails, treatment of DVT is required to avoid the major complication of pulmonary emboli. The significant risk of DVT and pulmonary emboli after an abdominoplasty is confirmed in this article.

The Authors discuss the importance of evidence based medicine (EBM) as related particularly to outpatient surgery. They discuss the five core steps in current EBM and take the reader through each of the steps, listing methods the surgeon can follow to achieve a thorough and relevant evidence based plan. Challenges of EBM such as reporting bias and evidence grading are discussed along with solutions and tools to meet those challenges. The article concludes with a look at data sharing as a means of enabling surgeons to access outcomes and specific aspects of care for a surgical procedure.

During pregnancy, women actively seek out health information that promotes the well-being of themselves and their fetuses. For those with health literacy challenges, access to understandable health information can be difficult. Written information, in particular, needs to be readable and usable by the women served. Plain language is an essential component of effective health education material. In an effort to create standardized prenatal education materials for a diverse population of childbearing women, Boston Medical Center's midwifery service led a multidisciplinary initiative to develop a comprehensive plain-language prenatal education book. Midwives, obstetricians, family physicians, nurses, and community doulas contributed to the content of the book; art students provided graphic design skills; and a literacy consultant assisted in the wording and layout. The Hey Mama! book provides women with woman-centered, readable, comprehensive information about pregnancy, labor, postpartum, and newborn care.

Objective : To compare the morbidity of total abdominal hysterectomy and abdominal myomectomy in the surgical management of uterine leiomyomas. Methods : Hospital records were reviewed for all women who underwent hysterectomy ( n = 89) or myomectomy ( n = 103) between May 1, 1988, and May 1, 1993, for the preoperative diagnosis of leiomyoma. Results : There were significant differences between the two groups for average age (hysterectomy 39.2 years, myomectomy 34.4 years; mean difference 4.8, 95% confidence interval [CI] of difference 3.7–5.9), uterine size (hysterectomy 15.2, myomectomy 11.5 weeks; mean difference 3.8, 95% CI of difference 2.0–5.4) and use of a GnRH agonist (hysterectomy 23.6%, myomectomy 55.3%; relative risk [RR] 0.4, 95% CI 0.3–0.6). Myomectomy was associated with decreased estimated blood loss (hysterectomy 796 mL, myomectomy 464 mL; mean difference 331, 95% CI 121–542) and febrile morbidity (risk of temperature 38C or 48 or more hours postoperatively: for hysterectomy 49.4%, for myomectomy 32%; RR 1.5, 95% CI 1.1–2.2). Using multivariate linear regression, estimated blood loss was similar between the groups after controlling for uterine size. There was no difference in blood transfusion rates. There were two ureteral, one bladder, one bowel, and one femoral nerve injury in the hysterectomy group, and there were no intraoperative visceral injuries in the myomectomy group. Conclusion : Myomectomy compares favorably to hysterectomy in the surgical management of leiomyomas, with a possible decreased risk for visceral injury and infection.

Objectives Gestational diabetes mellitus (GDM) greatly increases the risk of developing diabetes in the decade after delivery, but few women receive appropriately timed postpartum glucose testing (PPGT) or a referral to primary care (PC) for continued monitoring. This qualitative study was designed to identify barriers and facilitators to testing and referral from patient and providers' perspectives. Methods We interviewed patients and clinicians in depth about knowledge, values, priorities, challenges, and recommendations for increasing PPGT rates and PC linkage. Interviews were coded with NVIVO data analysis software, and analyzed using an implementation science framework. Results Women reported motivation to address GDM for the health of the fetus. Most women did not anticipate future diabetes for themselves, and focused on delivery outcomes rather than future health risks. Patients sought and received reassurance from clinicians, and were unlikely to discuss early onset following GDM or preventive measures. PPGT barriers described by patients included provider not mentioning the test or setting it up, transportation difficulties, work responsibilities, fatigue, concerns about fasting while breastfeeding, and timing of the test after discharge from obstetrics, and no referral to PC for follow-up. Practitioners described limited communication among multiple care providers during pregnancy and delivery, systems issues, and separation of obstetrics from PC. Conclusions Patients' barriers to PPGT included low motivation for self-care, structural obstacles, and competing priorities. Providers reported the need to balance risk with reassurance, and identified systems failures related to test timing, limitations of electronic medical record systems (EMR), lack of referrals to PC, and inadequate communication between specialties. Prevention of early onset has great potential for medical cost savings and improvements in quality of life.

In reviewing outcomes that are associated with the implementation of a series of labor and delivery patient safety efforts from 2004-2009, we requested data on the number of related professional liability claims that were reserved by our insurance companies that are established with the specific objective of financing risks that emanate from their parent group or groups. While we restructured the manner in which we give care, required training modules, and provided simulations to our providers, our legal risk continued to be monitored independently and in parallel. Retrospective review of the number of cases for which money was held in reserve for claims demonstrated a 20% decrease per year, which was adjusted for delivery volume, over this time period. We believe that the improved care that resulted from our safety projects has led to this decreased legal risk.

Several factors may increase a patient's risk for perioperative pulmonary complications. This practice advisory provides an overview of the preoperative steps that should be performed to ensure appropriate patient selection and patient safety with regard to pulmonary complications. Procedural and patient-related risk factors are discussed, as are recommendations for perioperative management and strategies for minimizing complications.