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Miller S, Fathalla MMF, Youssif MM, Turan J, Camlin C, Al-Hussaini TK, Butrick E, Meyer C.. A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt. International Journal of Gynecology and Obstetrics, Article in Press
Miller S, Fathalla M, Youssif MM, Turan J, Camlin C, Al-Hussaini TK, Butrick E, Meyer C.. A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Egypt. International Journal of Gynecology and Obstetrics 109: 20-25.

Objective: To assess the impact of the non-pneumatic anti-shock garment (NASG) on maternal outcome
following severe obstetric hemorrhage. Methods: A non-randomized pre-intervention/intervention study was conducted in 2 tertiary hospitals in Egypt from June 2006 to May 2008. Women with obstetric hemorrhage (estimated blood loss ≥1000 mL and/or ≥1 sign of shock [systolic blood pressure b100 mm Hg
or pulse N100 beats per minute]) were treated with either a standardized protocol (pre-intervention) or a standardized protocol plus the NASG (intervention). The primary outcome was extreme adverse outcome (EAO), combining maternal mortality and severe morbidity (cardiac, respiratory, renal, or cerebral dysfunction). Secondary outcomes were measured blood loss, urine output, emergency hysterectomy, and (individually) mortality or morbidity. Analyses were performed to examine independent association of the
NASG with EAO. Results: Mean measured blood loss decreased from 379 mL pre-intervention to 253 mL in the intervention group (Pb0.01). In a multiple logistic regression model, the NASG was associated with reduced odds of EAO (odds ratio 0.38; 95% confidence interval, 0.17–0.85). Conclusion: The NASG, in addition to standardized protocols at tertiary facilities for obstetric hemorrhage and shock, resulted in lower measured blood loss and reduced EAO.

Miller S, Ojengbede O, Turan JM, Morhasen-Bello IO, Martin HB, Nsima D.. A comparative study of the non-pneumatic anti-shock garment for the treatment of obstetric hemorrhage in Nigeria. International Journal of Gynecology and Obstetrics 107: 121-125.

Objective: To determine whether the non-pneumatic anti-shock garment (NASG) can improve maternal outcome. Methods: Women were enrolled in a pre-intervention phase (n=83) and an intervention phase (n=86) at a referral facility in Katsina, Nigeria, from November 2006 to November 2007. Entry criteria were obstetric hemorrhage (≥750 mL) and a clinical sign of shock (systolic blood pressure b100 mm Hg or pulse N100 beats per minute). To determine differences in demographics, condition on study entry, treatment, and outcome, t tests and χ2 tests were used. Relative risk (RR) and 95% confidence interval (CI) were estimated
for the primary outcome, mortality. Results: Mean measured blood loss in the intervention phase was 73.5± 93.9 mL, compared with 340.4±248.2 mL pre- intervention (Pb0.001). Maternal mortality was lower in the intervention phase than in the pre-intervention phase (7 [8.1%]) vs 21 [25.3%]) (RR 0.32; 95% CI, 0.14–0.72). Conclusion: The NASG showed potential for reducing blood loss and maternal mortality caused by obstetric hemorrhage-related shock.

el-Solh AA, Grant BJ. A comparison of severity of illness scoring systems for critically ill obstetric patients . Chest 1996; 110: 1299-1304.

STUDY OBJECTIVE: To evaluate the predictive ability of three scoring systems, acute physiology and chronic health evaluation (APACHE II), simplified acute physiology score (SAPS II), and mortality probability models (MPM II) in critically ill obstetric patients compared to a control group of non-obstetric female patients of similar age group (range, 17 to 41 years). DESIGN: A retrospective medical chart review of obstetric and nonobstetric female patients between 17 and 41 years of age. SETTING: Two university hospitals. PATIENTS: Ninety-three obstetric patients and 96 nonobstetric female patients were identified from 12,740 consecutive ICU admissions. RESULTS: The actual mortality of the obstetric and the nonobstetric group was 10.8% (95% confidence interval [CI], 5.3 to 19.0%) and 12.5% (95% CI, 6.6 to 21.0%), respectively. The observed mortality was not statistically different from the mortality predicted by APACHE II, SAPS II, and MPM II (14.7%, 7.8%, and 9.1% for the obstetric group and 10.9%, 9.0%, and 9.9% for the nonobstetric group). Predictive accuracy was assessed by the c-index, which is equivalent to the area under the receiver operator characteristic (ROC) curve. There were no significant differences in the c-index for APACHE II, SAPS II, and MPM II within or between the obstetric group ([mean +/- SE], 0.93 +/- 0.02, 0.90 +/- 0.04, and 0.91 +/- 0.04, respectively) and the nonobstetric group (0.97 +/- 0.02, 0.95 +/- 0.03, and 0.96 +/- 0.02, respectively). CONCLUSIONS: We conclude that APACHE II, SAPS II, and MPM II assess the ICU outcome of critically ill obstetric patients as accurately as nonobstetric critically ill female patients of similar age group.

Petter CM, Thung SF, Raab CA, Donohu KP, Copel JA, Lockwood CJ, Funai EF. A comprehensive obstetrics patient safety program improves safety climate and culture. Am J Obstet Gynecol 204: 216.e1-6.

OBJECTIVE: The purpose of this study was to determine the effect of an
obstetrics patient safety program on staff safety culture.
STUDY DESIGN: We implemented (1) obstetrics patient safety nurse, (2) protocol-based standardization of practice, (3) crew resource management training, (4) oversight by a patient safety committee, (5) 24-hour obstetrics hospitalist, and (6) an anonymous event reporting system. We administered the Safety Attitude Questionnaire on 4 occasions over 5 years (2004-2009) to all staffmembers that assessed teamwork and safety cultures, job satisfaction, working conditions, stress recognition, and perceptions of management.
RESULTS: We observed significant improvements in the proportion of staff
members with favorable perceptions of teamwork culture (39%in 2004 to
63%in 2009), safety culture (33%to 63%), job satisfaction (39%to 53%),
andmanagement (10%to 37%). Individual roles (obstetrics providers, residents,
and nurses) also experienced improvements in safety and teamwork, with significantly better congruence between doctors and nurses.
CONCLUSION: Safety programs can improve workforce perceptions of safety and an improved safety climate.

Geller, S, Adams, MG, Miller, S. A Continuum of Care Model for Postpartum Hemorrhage. International Journal of Fertility & Women's Medicine 52: 97-105.

The leading cause of maternal mortality is hemorrhage, generally occurring in the postpartum period. Current levels of PPH-related morbidity and mortality in low-resource settings result from institutional, environmental, cultural and social barriers to providing skilled care and preventing, diagnosing and treating PPH. Conventional uterotonics to prevent PPH are typically not available or practical for use in low-resource settings. In such deliveries, most often taking place at home or in rural health centers, underestimation of blood loss leads to a delay in diagnosis. Deficiencies in communication and transportation infrastructure impede transfer to a higher level of care. Inability to stabilize a patient who is in hemorrhagic shock rapidly results in death. To address these individual factors, we propose a continuum of care model for PPH, including routine use of prophylactic misoprostol or other appropriate uterotonic, a standardized means of blood loss assessment, availability of a non-pneumatic anti-shock garment, and systemization of communication, transportation, and referral. Such a multifaceted, systematic, contextualized PPH continuum of care approach may have the greatest impact for saving women's lives. This model should be developed and tested to be region-specific.

Dreifus C. A Conversation with Dr. Peter J. Provonost: Doctor Leads Quest for Safer Ways to Care for Patients. New York Times 0:
Franchini M, Franchi M, Bergamini V, Salvagno GL, Montagnana M, Lippi G. A Critical Review on the Use of Recombinant Factor VIIa in Life-Threatening Obstetric Postpartum Hemorrhage. Semin Thromb Hemost Feb 2008; 34: 104-12.

The objective of this review was to evaluate and summarize the current literature on the unlicensed use of the novel agent recombinant activated factor VII (rFVIIa) in the management of major postpartum hemorrhage. After a systematic electronic search without temporal limits on MEDLINE, EMBASE, OVID and SCOPUS, the bibliographic references of all retrieved studies and reviews were additionally assessed for further reports of clinical trials. Unpublished works were also identified by searching abstracts from the most eminent conferences on this topic. In total, there were 31 studies that fulfilled our inclusion criteria. These studies incorporated 118 cases of massive postpartum hemorrhage treated with rFVIIa. The median age of the patients was 31.4 years, and cesarean section appeared to increase the risk of postpartum hemorrhage. At a median dose of 71.6 mug/kg, rFVIIa was reported to be effective in stopping or reducing bleeding in nearly 90% of the reported cases. Based on the evidence from the literature, we give some recommendations on the use of rFVIIa in massive postpartum hemorrhage. Nevertheless, although these reports suggest the potential role of rFVIIa in treating massive postpartum hemorrhage refractory to standard therapy, we advise particular caution in interpreting these results, as they are derived from few and uncontrolled studies. Further evidence is needed using well-designed clinical trials to better assess the optimal dose, the effectiveness, and the safety of rFVIIa in such critical bleeding conditions.

Korst LM, Gregory KD, Lu MC, Reyes C, Hobel CJ, Chavez GF. A Framework for the Development of maternal quality of care indicators. Matern Child Health Sep 2005; 9: 317-41.

BACKGROUND: In collaboration with the California Department of Health Maternal and Child Health Branch, the authors formed a Working Group to identify potential clinical indicators that could be used to inform decision making regarding maternal health care quality. OBJECTIVE: To develop potential indicators for the assessment of maternal health care quality. MATERIALS AND METHODS: A Working Group was convened to review information from the published literature and expert opinion. Selection of potential indicators was guided by the following goals: 1) To identify key areas for routine aggregate monitoring; 2) To include perspectives of relevant stakeholders in maternal health care services; 3) To include measures that are comprehensive and reflect a balance between maternal and fetal interests; and 4) To develop measures that would be valid, generalizable, mutable, and feasible. RESULTS: Ninety potential indicators were identified. Each underwent a thorough review based on: its definition, objective, and validity; its contribution to innovation; the cost and timeliness of implementation; its feasibility, acceptability, and potential effectiveness; and its compatibility with ethics, values, and social policy. This process yielded 24 final indicators from the following categories: Health Status and Access (e.g., availability of 24 h inpatient anesthesia); Preconception and Interconception Care (e.g., Pap smear use); Antenatal Care (e.g., hospitalization for uncontrolled diabetes or pyelonephritis); Labor and Delivery Care (e.g., chorioamnionitis or obstetrical hemorrhage), and Postpartum Care (e.g., rate of postpartum visits). CONCLUSIONS: These potential indicators, representative of the women's health continuum, can serve as a foundation to structure the development of consensus and methods for maternal health care quality assessment.

Bell MJ. A Historical Overview of Preeclampsia-Eclampsia. J Obstet Gynecol Neonatal Nurs 39: 510-518.

Preeclampsia is a hypertensive, multi-system disorder of pregnancy whose etiology remains unknown. Although management is evidence-based, preventative measures/screening tools are lacking, treatment remains symptomatic, and delivery remains the only cure. Past hypotheses/ scientific contributions have influenced current understanding of preeclampsia pathophysiology and guided management strategies and classification criteria. To provide insight into how past hypotheses/scientific contributions have shaped current practice trends, this paper provides a historical overview of preeclampsia-eclampsia.