ACOG and SMFM issue new guidance on Severe Maternal Morbidity: Screening and Review
Washington, DC – Each year, more than 65,000 women in the United States suffer complications during pregnancy or childbirth that are near-fatal. In many cases, these outcomes may have been prevented. Like maternal mortality, defined as the death of a woman during pregnancy, at delivery or soon after delivery, maternal morbidity in the United States has been steadily increasing. A maternal morbidity is an unintended outcome in the process of labor and delivery that results in significant short-term or long-term consequences to a woman’s health.
Today, as part of a continued effort to reduce maternal morbidity and mortality across the country, organizations representing women’s health care providers released new guidance on the screening and review of maternal morbidity. Severe Maternal Morbidity: Screening and Review is the fifth in the joint American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) Obstetric Care Consensus Series.
Maternal morbidity can be considered a “near miss” for maternal mortality because, in some cases, without identification and treatment the conditions that define maternal morbidity would lead to maternal death. Therefore, the importance of identifying a potential maternal morbidity is paramount. Identification can also highlight opportunities to avoid such injuries in other women in the future.
“Obstetrician-gynecologists always want the best, healthiest outcomes for both mother and child. That is why our Obstetric Care Consensus Series aims to improve maternal safety across the country,” said Sarah J. Kilpatrick, M.D./Ph.D., chair of the Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center in Los Angeles, California, and a lead author of the document. “Developing systems that help us identify severe maternal morbidity will ultimately help provide better care. The two-step approach discussed in the document involves a screen to identify potential cases of severe maternal morbidity, followed by a review to help better understand the event, including determining if the morbidity was potentially avoidable.”
Multidisciplinary expert groups have called for all obstetric hospitals to review their cases of severe maternal morbidity in order to recognize opportunities for improvement in care. Building off this recommendation, ACOG and SMFM recommend using a two-step screen and review process to identify severe maternal morbidity.
First, they recommend facilities have a screening process in place to detect potential cases. ACOG and SMFM recommend using the following two criteria as a screen, although institutions may choose to incorporate additional criteria:
1.) Transfusion of four or more units of blood
2.) Admission of a pregnant or postpartum woman to an ICU
Second, facilities should then review all cases that meet at least one of these screening criteria to efficiently detect severe maternal morbidity and determine whether there were opportunities for improvement in care. Institutions may also elect to define additional screening criteria if deemed useful in their setting.
ACOG and SMFM are careful to highlight that not all cases of severe maternal morbidity are preventable. Some cases of morbidity reflect the underlying health of a woman or her pregnancy and are thus unavoidable. Therefore, simply screening positive for one of the two recommended screening criteria does not constitute a sentinel event and rates of occurrence of either criterion should not be used as a quality metric.
While the document provides an example list of conditions that could constitute severe maternal morbidity, there is no consensus on a comprehensive list of conditions. This underscores the importance of institutions and systems either adopting an existing screening criteria or creating their own list of outcomes that merit review.
“The intent of this document is to provide a standard, evidence-based approach to help obstetric providers and their facilities more easily recognize cases of severe maternal morbidity which deserve more detailed review, “Dr. Kilpatrick continued. “These criteria and the examples listed in the document are not categorical definitions and should not be misconstrued as quality measures. Rather, we understand that as women’s health care physicians we need to be at the forefront of developing a reference to identify severe maternal morbidity and that’s what this document is intended to do.”
“Quality improvement is something all obstetrician-gynecologists should be actively involved in—regardless of hospital size, location, or low- or high-risk pregnancy status. There is almost always something to learn about our systems following these types of complex cases. We owe it to our future patients to continuously improve the care we provide and this document will help these efforts,” stated Dr. Sean Blackwell, chair of the publications committee for the SMFM and chair of the Department of Obstetrics, Gynecology and Reproductive Sciences at McGovern Medical School at The University of Texas Health Science Center at Houston.
In addition to this newly-released guidance, ACOG and SMFM have been long-standing lead partners in the Alliance for Innovation on Maternal Health (AIM), a national alliance to promote consistent and safe maternity care to reduce maternal mortality and severe maternal morbidity.
Other recommendations issued in the September Obstetrics & Gynecology:
Insect Repellants During Pregnancy in the Era of the Zika Virus
Based on available data for N,N-diethyl-meta-toluamide (DEET) and permethrin, health care providers and patients should have little reservation about recommended use during pregnancy for Zika virus prevention.
Blair J. Wylie, Marissa Hauptman, Alan D. Woolf, Rose H. Goldman
Committee Opinion #671, Perinatal Risks Associated With Assisted Reproductive Technology
Over the past decades, the use of assisted reproductive technology (ART) has increased dramatically worldwide and has made pregnancy possible for many infertile couples. Although the perinatal risks that may be associated with ART and ovulation induction are much higher in multifetal gestations, even singletons achieved with ART and ovulation induction may be at higher risk than singletons from naturally occurring pregnancies. However, it remains unclear to what extent these associations might be related to the underlying cause(s) of infertility. Before initiating ART or ovulation induction procedures, obstetrician–gynecologists and other healthcare providers should complete a thorough medical evaluation to ensure that patients are in good health and should counsel these women about the risks associated with treatment. Any maternal health problems or inherited conditions should be addressed. Couples at risk of passing genetic conditions on to their offspring, including those due to infertility-associated conditions, should be counseled appropriately. When a higher-order (triplet or more) multifetal pregnancy is encountered, the option of multifetal reduction should be discussed. In the case of a continuing higher-order multifetal pregnancy, ongoing obstetric care should be with an obstetrician–gynecologist or other obstetric care provider and at a facility capable of managing anticipated risks and outcomes.
Committee Opinion #672, Clinical Challenges of Long-Acting Reversible Contraceptive Methods
Long-acting reversible contraceptive methods are the most effective reversible contraceptives and have an excellent safety record. Although uncommon, possible long-acting reversible contraceptive complications should be included in the informed consent process. Obstetrician–gynecologists and other gynecologic care providers should understand the diagnosis and management of common clinical challenges. The American College of Obstetricians and Gynecologists recommends the algorithms included in this document for management of the most common clinical challenges.
Committee Opinion #673, Persistent Vulvar Pain
Persistent vulvar pain is a complex disorder that frequently is frustrating to the patient and the clinician. It can be difficult to treat and rapid resolution is unusual, even with appropriate therapy. Vulvar pain can be caused by a specific disorder or it can be idiopathic. Idiopathic vulvar pain is classified as vulvodynia. Although optimal treatment remains unclear, consider an individualized, multidisciplinary approach to address all physical and emotional aspects possibly attributable to vulvodynia. Specialists who may need to be involved include sexual counselors, clinical psychologists, physical therapists, and pain specialists. Patients may perceive this approach to mean the practitioner does not believe their pain is “real”; thus, it is important to begin any treatment approach with a detailed discussion, including an explanation of the diagnosis and determination of realistic treatment goals. Future research should aim at evaluating a multimodal approach in the treatment of vulvodynia, along with more research on the etiologies of vulvodynia.
Committee Opinion #674, Guiding Principles for Privileging of Innovative Procedures in Gynecologic Surgery
New or emerging surgical procedures and technologies continue to be developed at a rapid rate and must be implemented safely into clinical practice. Additional privileging may be required if substantively new technical or cognitive skills are required to implement an innovative procedure or technology. Guiding principles for privileging should include cognitive and technical assessment to ensure appropriate patient selection and performance of the new procedure. Implementation also should include pertinent institutional and staff support as needed. A dynamic process for assessment and maintenance of current competency will enhance the safety of implementation and continued application of emerging procedures and technologies. The number of cases needed to demonstrate cognitive and technical proficiency will vary depending on many factors, including the health care provider’s baseline expertise and technical acumen.
Practice Bulletin #166, Thrombocytopenia in Pregnancy
Thrombocytopenia in pregnant women is diagnosed frequently by obstetricians because platelet counts are included with automated complete blood cell counts (CBCs) obtained during routine prenatal screening (1). Although most U.S. health care providers are trained using U.S. Conventional Units, most scientists, journals, and countries use Système International (SI) units. The laboratory results reported in U.S. Conventional Units can be converted to SI Units or vice versa by using a conversion factor. The conversion factor for platelet count results is 1.0 (ie, to convert from x 103/μL, multiply by 1.0, to get x 109/L). Thrombocytopenia, defined as a platelet count of less than 150 x 109/L, is common and occurs in 7–12% of pregnancies (2, 3). Thrombocytopenia can result from a variety of physiologic or pathologic conditions, several of which are unique to pregnancy. Some causes of thrombocytopenia are serious medical disorders that have the potential for maternal and fetal morbidity. In contrast, other conditions, such as gestational thrombocytopenia, are benign and pose no maternal or fetal risks. Because of the increased recognition of maternal and fetal thrombocytopenia, there are numerous controversies about obstetric management of this condition. Clinicians must weigh the risks of maternal and fetal bleeding complications against the costs and morbidity of diagnostic tests and invasive interventions.
The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 57,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org
The Society for Maternal-Fetal Medicine (est. 1977) is the premiere membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine. The society is devoted to reducing high-risk pregnancy complications by sharing expertise through continuing education to its 2,000 members on the latest pregnancy assessment and treatment methods. It also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine. The group hosts an annual meeting in which groundbreaking new ideas and research in the area of maternal-fetal medicine are shared and discussed. For more information visit www.smfm.org.