Teaching obstetric ultrasound at Mulago Hospital - Kampala, Uganda

Background: Mulago Hospital is a high volume referral hospital under the Makerere University School of Medicine and Health Sciences. Basic obstetric ultrasound is a useful skill that can aid patient care.Objectives: The purpose of the study was to assess the effectiveness of an intervention implemented to teach basic ultrasound skills to medical students and house officers at Mulago Hosptial, Kampala, Uganda.Methods: Forty participants, including medical students, junior house officers (JHOs), and senior house officers (SHOs) were enrolled in the study. A didactic and practical hands-on teaching session was evaluated using a pre- and post-test that was administered to all participants.Results: Participants included 12 medical students, 23 JHOs, and 5 SHOs. A significant difference in pre- and post-test scores was demonstrated in the medical students and JHOs (34% to 76%, p <0.0001) and this was retained when the results were stratified into the basic definitions and practical sections of the survey (33% to 71%, p<0.0001). The scores for the senior house officers had a mean increase of 2.3 points.Conclusion: This original teaching intervention is an effective method to improve knowledge and skills for medical students and house officers at Mulago Hospital in the area of basic obstetric ultrasound.Keywords: Ultrasound; obstetric; teaching; Uganda; low-resource; curriculum

Healthcare Provider and Patient Knowledge, Attitudes and Practices (KAP) Regarding Zika Virus

Introduction: Zika virus emergence in the western hemisphere has prompted the critical need for tailored risk counseling. Our team created a KAP survey in order to assess provider and patient awareness of Zika virus symptoms, transmission, treatment, and current and future concerns in order to inform local risk counseling efforts. Methods: The cross-sectional survey was issued in Medical Faculty Associates (MFA) clinics and via online link to healthcare providers and community members. The REDCap Data Collection tool was used to capture responses with subsequent SAS data analysis. Results: A total of 172 responses were collected. Most respondents (97%) were aware of a link between Zika virus and microcephaly. 89% think that a vaccine is important. 52% will restrict travel to Zika endemic regions. 51% will take mosquito protective measures in the US versus 91% in Zika endemic areas. 35% of pregnant women would abstain from sex if their partners traveled to a Zika endemic area whereas 25% would if they themselves were the traveler. 37% plan to delay pregnancy and 58% are concerned about eventually having a child with microcephaly. Of the healthcare providers sampled, about one-fifth could not identify Zika infection symptoms, 16% were unaware of symptom treatment options and 5.4% did not know that Zika virus could be passed transplacentally. 34% believed DEET to be unsafe in pregnancy and 52% were unsure about permethrin safety in pregnancy. Of the 172 survey respondents, most (97%) were aware of a link between Zika virus and microcephaly. 89% think that a vaccine is important. 52% would restrict travel to Zika endemic regions. 51% would practice mosquito safety in the US versus 91% in Zika endemic countries. 35% of pregnant women would abstain from intercourse if their partners traveled to Zika endemic areas whereas 25% would if they themselves were the traveler. 37% plan to delay pregnancy and 58% worry about future children with microcephaly. Of the healthcare providers, 20% could not identify Zika infection symptoms, 16% were unaware of symptom treatment options, 5% were unaware that Zika virus passes transplacentally, and 34% believed DEET to be unsafe in pregnancy. Conclusion: The survey results provide novel insight into the KAP of patients and healthcare providers regarding Zika virus. This data will be used to optimize information distribution to our community, address large knowledge gaps in both patients and providers, and prepare medical providers to offer needed counseling

Teaching obstetric ultrasound at Mulago Hospital - Kampala, Uganda

Background: Mulago Hospital is a high volume referral hospital under the Makerere University School of Medicine and Health Sciences. Basic obstetric ultrasound is a useful skill that can aid patient care. Objectives: The purpose of the study was to assess the effectiveness of an intervention implemented to teach basic ultrasound skills to medical students and house officers at Mulago Hosptial, Kampala, Uganda. Methods: Forty participants, including medical students, junior house officers (JHOs), and senior house officers (SHOs) were enrolled in the study. A didactic and practical hands-on teaching session was evaluated using a pre- and post-test that was administered to all participants. Results: Participants included 12 medical students, 23 JHOs, and 5 SHOs. A significant difference in pre- and post-test scores was demonstrated in the medical students and JHOs (34% to 76%, p <0.0001) and this was retained when the results were stratified into the basic definitions and practical sections of the survey (33% to 71%, p<0.0001). The scores for the senior house officers had a mean increase of 2.3 points. Conclusion: This original teaching intervention is an effective method to improve knowledge and skills for medical students and house officers at Mulago Hospital in the area of basic obstetric ultrasound

Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis

Introduction: Despite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies. Methods: We screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale. Results: We screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women. Pregnant women with SARS-CoV-2 infection—as compared with uninfected pregnant women—were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12). Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias. Conclusions: This analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol

Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis

Introduction Despite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies. Methods We screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale. Results We screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women. Pregnant women with SARS-CoV-2 infection—as compared with uninfected pregnant women—were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12). Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias. Conclusions This analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol

Adverse maternal, fetal, and newborn outcomes among pregnant women with SARS-CoV-2 infection: an individual participant data meta-analysis.

INTRODUCTION Despite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies. METHODS We screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale. RESULTS We screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women.Pregnant women with SARS-CoV-2 infection-as compared with uninfected pregnant women-were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12).Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias. CONCLUSIONS This analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol

Characteristics and outcomes of mothers receiving tranexamic acid during delivery

In October 2017, the American College of Obstetricians and Gynecologists (ACOG) released a practice bulletin endorsing the use of tranexamic acid (TXA) to treat postpartum hemorrhage (PPH). The purpose of this study was to describe characteristics and outcomes of women receiving TXA in the peripartum period. Patients were included as a multicenter retrospective cohort study between January 2015 and June 2018. All delivery types were included. Patients under the age of 18 or above the age of 50 were excluded. Patients were grouped based on whether or not TXA was administered and their demographics and outcomes were compared. Data trends in terms of time periods and geography was also analyzed. Of the 103,617 patients included, TXA was used in 133 patients at the time of delivery. Among our cohort those who received TXA compared to those who did not were more likely to have history of postpartum hemorrhage (26% vs 2%, p\u3c0.0001), placenta previa (4.5% vs 0.3%, p\u3c0.0001), anemia with hematocrit less than 32% (30% vs 16%, p\u3c0.0001) and magnesium for neuroprotection (23% vs 5%, p\u3c0.0001). There was no significant difference in rate of deep venous thrombosis or pulmonary embolism. Perinatal outcomes are also presented. TXA use was also evaluated by date and geographic sector. TXA was used at highest rates in the last quarter of 2018, with the East sector reporting higher rates compared to all other regions. Women who received TXA at delivery were more likely to have cesarean delivery, EBL\u3e1000 cc, blood transfusion, and ICU admission, among other complications or comorbidities. Risk of venous thromboembolism was not increased with peripartum TXA use. More numbers are needed to assess if pre- and post-publication of the ACOG guidelines resulted in lower rates of hemorrhage complications

Perinatal Outcomes After Implementing a Hemorrhage Risk Assessment At Admission

Our objective was to evaluate the impact of a novel assessment of hemorrhage risk at admission on subsequent perinatal outcomes. This project was a retrospective cohort analysis of a multicenter database included women admitted to labor and delivery from January 2015 to June 2018. A novel nursing assessment developed by Association of Women\u27s Health, Obstetric and Neonatal Nurses was used to categorize patients as low, medium or high risk for hemorrhage. This was implemented 6/1/2016 across the centers. Perinatal outcomes related to blood transfusion, estimated blood loss (EBL) ‚â• 1000cc, ICU admission, chorioamnionitis, general anesthesia, oxytocin use and cesarean delivery were evaluated before and after implementation. There were a total of 109,719 women included, with 38,751 women included prior to implementation of the hemorrhage risk assessment and 70,968 women after implementation. Rates of any blood transfusion (0.5 to 0.4%, p=0.02) and EBL ‚â• 1000cc (6.3 to 6.0%, p=0.02) were significantly lower after implementation. Incidence of ICU admission, chorioamnionitis and general anesthesia did not change overall in the time period studied. There were higher rates of oxytocin use (83.4 to 85.2%, p\u3c0.0001) and spontaneous vaginal delivery (58.8 to 59.9%, p=0.01). Details on perinatal outcomes are included (Table). In conclusion, after implementation of a hemorrhage risk assessment at admission, we found a 20% reduction in rates of blood transfusion and EBL ‚â• 1000cc. Significantly increased oxytocin use was also observed. Further analysis must be done to assess if any other changes could account for these trends

How well does assessing hemorrhage risk on admission correspond with peripartum morbidity?

Objective: To evaluate the extent to which a novel assessment of hemorrhage risk on admission corresponds with morbidity in the peripartum period. Study Design: This retrospective cohort analysis of a multicenter database included women admitted to labor and delivery from June 2016 to June 2018. A novel nursing assessment developed by Association of Women\u27s Health, Obstetric and Neonatal Nurses was used to categorize patients as low, medium or high risk for hemorrhage. Outcomes related to blood transfusion, estimated blood loss (EBL) ‚â• 1000cc, ICU admission, general anesthesia and oxytocin use were evaluated based on hemorrhage risk score. Results: Data were available for 56,671 births. There were 14,861 low risk (26%), 26,080 (46%) moderate risk, and 15,730 (28%) high risk. There were a total of 275 women (0.5%) who had blood transfusion and 3,717 women (6.6%) with EBL ‚â• 1000cc. Tracking shell level (low/medium/high) designation is significantly associated with all the outcomes examined (Table). For women with high risk scores, the relative risk ratio compared with low risk women was 4.9 (95% CI 3.2-7.4) for blood transfusion and 5.2 (4.6-5.9) for EBL ‚â• 1000cc. Only 9% of women (26/275) who were categorized as low risk, 42% of women (115/275) originally categorized as medium risk, and 49% of women (134/275) originally categorized as high risk required a blood transfusion . For high versus low risk and the outcome of EBL ‚â• 1000cc, the sensitivity was 85%, specificity was 51%, positive predictive value 10%, negative predictive value 98%. Conclusion: Women who scored high risk for hemorrhage on admission had five times higher risk for blood transfusion and EBL ‚â• 1000cc compared to low risk women. Given the low incidence of the outcomes explored, the hemorrhage risk assessment on admission works moderately well to identify peripartum morbidity

Predicting Venous Thromboembolism in Obese Pregnant Women in a National Study

Venous thromboembolism (VTE) in pregnancy and postpartum is a leading cause of maternal morbidity and mortality in developed countries, where obesity is a known risk for this complication. Current guidelines vary in which patients qualify for VTE prophylaxis, precluding a uniform approach for management. The purpose of this study was to derive a risk prediction model for VTE in obese pregnant women. We performed a retrospective cohort analysis using the Consortium on Safe Labor (CSL) database. The CSL includes detailed information from the electronic medical record for \u3e200,000 deliveries from 19 hospitals across the United States from 2002 through 2008. Women ages 16-45 who were pregnant with singletons and had an obese body mass index (BMI\u3e30kg/m2) were included in our study population. Maternal characteristics and preexisting conditions as well as pregnancy-related conditions and complications were analyzed to identify differences between those had a VTE and those who did not. Multivariable logistic regression was used in order to identify predictors of VTE. Of the 83,500 women who met inclusion criteria, on average women were 27.8 ± 6.0 years old, 38.6 ± 2.21 weeks gestation, with BMI of 35.8 ± 5.45 kg/m2, and cesarean delivery (CD) incidence of 35.2%. The racial makeup of our cohort was 45.1% Caucasian, 27.2% African American and 20.2% Hispanic women. 109 women (0.13%) experienced a VTE event. Independent predictors of VTE in our final multivariable predictive model included: mode of delivery, BMI, pregestational diabetes, chronic heart disease, preeclampsia, blood transfusion (intrapartum or postpartum), prenatal history of thromboembolic disorder, and postpartum maternal length of stay. A receiver operating characteristic curve was developed to assess the model; area under the curve was 0.826. We developed a strong predictive model using a large, retrospective database to distinguish risk of VTE in obese pregnant women, which may provide the foundation for future protocol development of obstetrical thromboprophylaxis in obese women