Utility of Fern Test to Determine Rupture of Membranes

Introduction: The fern test was first described by Kardos and Tamasi in 1955 as a test used to determine rupture of amniotic membranes. The test is done by collection of fluid from the vagina which is then allowed to dry for 10 minutes on a slide. The slide is then inspected with microscopy for evidence of ferning. Accurate determination of rupture of membranes is important due to its significant implications on the management of obstetrical patients. Case: EC is a 23 year old G1P0 at 40 and 3/7 weeks gestation who presented to an outpatient facility with a chief complaint of vaginal fluid leaking. Approximately 12 hours prior she had leaked sufficient vaginal fluid to wet her underwear, but not sufficient to soak through her pants. She denied loss of vaginal fluid since then. A speculum exam revealed a small amount of pooling in the vaginal vault. A sample of this fluid was obtained. Fern test was negative and vaginal pH was 4.5. Her history was concerning for premature rupture of membranes (PROM) so she was further evaluated with an Amnisure test which was positive. She was subsequently admitted with PROM for induction of labor. Discussion: The fern test has been noted to have a sensitivity as high as 100%, with most studies reporting a sensitivity at least 90% or greater. These statistics can be very misleading as most of these studies were done in patients who were in labor. The sensitivity of the fern test is much lower in patients who are not in labor. A more recent study reported a sensitivity of 51% and a specificity of 70% for detecting PROM in patients who were not in labor. It was noted that sensitivity was slightly higher and specificity slightly lower for medical students and residents when compared to gynecologists. The sensitivity of the Amnisure test has been reported to be 98% to 99% with specificity ranging from 88% to 100%. Rupture of membranes has previously been diagnosed either by visualization of fluid leaking from the cervical os or having 2 of the following: vaginal pooling, positive fern test, or positive nitrazine test. Conclusion: The fern test is only one of several methods that can be used to assess rupture of membranes. Base on this recent study, ferning should not be relied on to rule out rupture of membranes in a nonlaboring patient with clinical history suspicious for PROM

Acute Hypoxic Respiratory Failure as a Complication of a Urinary Tract Infection During Pregnancy: A Case Presentation

Urinary tract infections (UTI), as well as asymptomatic bacteriuria, have the potential to cause serious morbidity during pregnancy making it imperative to identify and treat them promptly. If left untreated, a UTI can lead to pyelonephritis and sepsis. More importantly, UTIs are independently associated with intrauterine growth restriction (IUGR), premature rupture of membranes (PROM), preterm delivery, pulmonary edema, acute respiratory distress syndrome (ARDS), preeclampsia, and cesarean delivery. We report the case of NC, a 19 year old G1P0 at 36 weeks and 3 days GA who presented to the hospital with concern for rupture of membranes with associated back and abdominal pain. She was febrile to 100.3 and tachycardic on initial presentation. Her prenatal history was significant for recurrent E.coli bacteriuria and non-compliance with antibiotic therapy. The admitting resident was concerned for pyelonephritis and possible bacteremia so, the patient was started on broad spectrum antibiotics. She progressed in labor and delivered a healthy female via vacuum extraction for non-reassuring fetal heart tones. Subsequently, blood cultures came back positive for E.coli. Her postpartum course was complicated by elevated blood pressures and proteinuria with concerns for pre-eclampsia. She received appropriate treatment with magnesium sulfate and anti-hypertensive therapy. Her clinical picture worsened with the development of hypoxemia and pulmonary edema concerning for pre-eclampsia with severe features versus ARDS from her bacteremia. She improved with aggressive diuresis and was discharged home in stable condition. Acute pyelonephritis secondary to ongoing UTI affects 1-2% of women and has, in some cases, been shown to increase the risk of pulmonary edema. In contrast, acute pyelonephritis in non-pregnant women is rarely associated with ARDS. In this case it is almost impossible to know whether the pulmonary edema was a manifestation of preeclampsia or ARDS from the UTI or a combination of both. Nonetheless, this case serves as a reminder of the importance of treating asymptomatic bacteriuria in pregnancy and the potential sequela including preterm delivery, ARDS and preeclampsia. It is important that we, as physicians, continue to educate our patients about the importance of treating asymptomatic bacteriuria and UTIs in pregnancy given the morbidity associated with it

Improving Productivity Through Scheduling at the WMed Family Medicine Residency Clinic

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) requires every family medicine residency program to have a practice site that supports, “continuous, comprehensive, convenient, accessible, and coordinated patient care”. The WMed Family Medicine Resident Clinic (Team Oakland), located within the Family Health Center (FHC) – Paterson location, has long been plagued by scheduling difficulties, as evidenced by high no-show rates, empty appointment slots, and frequent cancellations threatening the ability of our residents to achieve the required number of outpatient visits mandated by the Family Medicine Residency Review Committee (RRC) and the requirement for continuity from the ACGME. We believe many of these issues arise from the FHC’s open-access scheduling template, which heavily favors same day and walk in visits. PURPOSE: This quality improvement project aims to assess the productivity of the Western Michigan Family Medicine Clinic through a scheduling analysis to determine how we can better meet the needs of our patients while also meeting the visit numbers required of the RRC for our residents. STUDY DESIGN: This study is a retrospective scheduling analysis in which our no show rate and unfilled appointments will be considered. Scheduling data for Team Oakland was collected from December 1st, 2016 to January 31st, 2017 through customizable EPIC reports. RESULTS: Data shown below exhibits the total number of appointment slots for Team Oakland broken down by the number of appoints filled, unfilled appointment slots and no show appointments. Data was subsequently broken down by day of the week and hour of the day. The fill rate for the 8:00 hour is 51% compared to 80-90% for most other hours. Image Table 1. Scheduling data for Team Oakland December 2016 through January 2017 DISCUSSION: Literature review revealed conflicting evidence in support of open-access scheduling. We found limited alternative scheduling approaches and limited data specific to residency clinic productivity. Data analysis confirmed that we have a high proportion of appointments that go unfilled as well as a significant no-show rate. Proposed changes to the scheduling template include increasing the number of advanced scheduled appointments-particularly during early morning hours, obtaining an independent scheduler for the resident clinic, and a novel scheduling model targeted at filling no-show appointments with walk-in patients. CONCLUSION: The current scheduling model used at the FHC does not adequately meet the needs of the Family Medicine Residency clinic and data-driven alternative scheduling models should be explored