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Putting the “M” Back in Maternal Fetal Medicine

Mary E. D’Alton, MD

Willard C. Rappleye Professor & Chair

Department of Obstetrics & Gynecology

Columbia University Irving Medical Center, New York, NY

Disclosures

I am on the board of Merck for Mothers.

Clinical Observation

D’Alton ME. Obstet Gynecol. 2010 Dec;116(6):1401-4.

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Pregnancy-related Mortality U.S. 1987-2013

Creanga AA, et al. Obstet Gynecol 2017.

U.S. Burden of Maternal Morbidity

• Severe morbidity 12.9 per 10000

deliveries

• Increase in shock, renal failure,

pulmonary embolus, respiratory

distress, myocardial infarction,

aneurysm, cardiac surgery

• Overall mortality in postpartum period

increased by 66%

• Impacts >50,000 women each year

Callaghan WM et al. Obstet Gynecol. 2012 Nov;120(5):1029-36.

U.S. Burden of Maternal Morbidity

https://www.cdc.gov/reproductivehealth/maternalinfanthealt

h/severematernalmorbidity.html

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Advances in Fetal and Neonatal Medicine

• Prenatal diagnosis and screening programs

• Genetic disorders and congenital anomalies

• Near eradication of Rh disease

• Therapies for women at high risk for PTB

• Steroids, antibiotics for PPROM, magnesium

• Progesterone to decrease recurrent PTB

• Reduction of stillbirth

• Fetal therapy

• TTTS, NAIT, myelomeningocele

Contrasting Maternal and Perinatal Care

ACOG Committee Opinion No. 485

ACOG Committee Opinion No. 475

ACOG Practice Bulletin No. 80

ACOG Practice Bulletin No. 455

Steroids

Group B Strep

Maternal Perinatal

Contrasting Maternal and Perinatal Care

“What are we doing to reduce

maternal mortality and morbidity

in a population with an increasing

incidence of chronic disease?”

D’Alton ME. Obstet Gynecol. 2010 Dec;116(6):1401-4.

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SMFM 2012: Setting the Stage

SMFM 2017: 5-Year Report Card (Publication 2019)

Recommendations for Education & Training

1. Modifications to MFM fellowship

requirements:

a. Time requirement for clinical

rotations

b. Formal rotations on L&D/

inpatient service

c. Formal rotations in ICU

2. Encourage use of simulation and

case-based learning in MFM

fellowship training

Critical Care in Obstetrics: An innovative

and integrative learning model

• Nearly 1800 Ob/Gyns and more than 150

residents and fellows participated in the

Annual Critical Care in Obstetrics course

• Course components:

• Online lectures

• Case studies

• 3-day course with simulation and skill

building

• Faculty certified in both MFM and Critical

CareMichael R. Foley, MD

Chair, Department of Obstetrics and Gynecology at Banner-

University Medical Center Phoenix

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People generally remember…

10% of what they read

90% of what

they do

Simulation @ Columbia’s Vagelos Education Center

• State-of-the-art medical education building

opened in 2016 that reflects how medicine is

taught in the 21st century

• More than 18,000 square feet for simulation

Passive

Learning

Active Learning

OB Emergency Simulation Drills at CUIMC

Dr. Arnold Advincula

Medical Director of the SIM CenterDr. Dena Goffman

Chief of Obstetrics

If we work together, why can’t we learn together?

Recommendations for Obstetrical

Care and Service

1. Establish national, stratified

system for levels of maternal

care

2. Develop specific guidelines

on complications associated

with highest maternal

morbidity and mortality

6. Develop models for

comprehensive, antenatal

care for mothers with

chronic or acute medical

complications

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Levels of Maternal Care

Regional Perinatal

Health Care Centers

Subspecialty Care

Specialty Care

Basic care

Level II

Level I

Level III

Level IV

ACOG and SMFM, Am J Obstet Gynecol, 2015 Mar;212(3):259-71

Lessons Learned from Reviews

• Hemorrhagic Death• 93% of all deaths were potentially preventable• Lack of appropriate attention to clinical signs of

hemorrhage • Failure to restore blood volume, to act decisively with life

saving interventions

• Severe Hypertension • 60% of maternal deaths were potentially preventable• Failure to control blood pressure, to recognize HELLP

syndrome, to diagnosis and treat pulmonary edema• Pulmonary Embolism

• “Single cause of death most amenable to reduction by systematic change in practice”

• Failure to use adequate prophylaxis

Berg CJ, et al. Obstet Gynecol 2005;106:1228-34.

Cantwell R, et al. BJOG 2011 Mar;118 Suppl 1:1-203.

Clark, SL. Semin Perinatol 2012;36(1):42-7.

0

200

400

600

800

1000

12001193

696 690

342

17780

36 23 10 8 3 5

Annual Birth Volume in U.S. Hospitals, 2008

NU

MB

ER

OF

HO

SP

ITA

LS

n = 3,265

Simpson KR, JOGNN 40, 2011.

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Personal Case Presentation

34 y/o G3P0020 at 33 weeks with

Preterm PROM (2012)

• No significant medical history

• Hospital day 3, spontaneous

preterm labor

• Uncomplicated cesarean delivery

for arrest of labor

• Intrapartum compression

devices (SCDs)

Postoperative DVT prophylaxis

• SCDs

• Early ambulation

Post-operative Day (POD) #1

• 0800, Ambulating, normal vitals

• 0900, Acute chest pain,

shortness of breath

• Patient unresponsive

• CPR, sinus rhythm restored

• Right heart failure on echo

• Saddle pulmonary embolism

• Never regained consciousness

On POD #9, support was

removed

NewYork-Presbyterian/CUIMC VTE Guidelines

• Collaboration with Dr. Richard

Smiley and OB Anesthesia team to

address VTE prophylaxis

Personal Case Presentation

33 y/o P2123 at 37+4 weeks with chest tightness

• Used her albuterol inhaler multiple times over the course of the

day

• Wheezy, but feeling better

• Frontal headache

• BP 140/97, HR 124

Medical history

• Mild, intermittent asthma

• No history of corticosteroid use, hospitalizations, or intubations

• BMI 37

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Personal Case Presentation

Triage course of events

• Persistent high BP

• 160-170/109-123

• Pre-eclampsia diagnosis

• Started on Mg

• 1 dose of IV labetalol

• BP down to 146/81

• 11 min later patient cyanotic, unresponsive, seizure like movements, loss

of urine

• Code called

• Delivered by C-section

• Patient stabilized by code team (bronchodilators and IV steroids) and

transported to SICU on ventilator, epi drip, Mg, and Pitocin

POD 10 – Patient declared brain dead due to anoxic brain injury

A Maternal Death Occurring After

Administration of Intravenous Labetalol to an

Asthmatic PatientThe Journal of Reproductive Medicine

Whitney A. Booker MD,1 Soledad Jorge MD,1 Dena Goffman MD,1

Richard L. Berkowitz MD,1 Alexander M. Friedman MD, 1 Mary E. D’Alton1

1 Department of Obstetrics and Gynecology, Columbia College of Physicians

and Surgeons, New York, NY, USA

First reported adverse reaction in

obstetrical literature

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• Need for awareness in obstetric culture and L&D on

risks of bronchospasm with labetalol use in the

asthmatic patient

• If patient with unknown medical history or uncertain

respiratory disease, we recommend the use of

alternative antihypertensives

A Change in the SMI Bundle

A Change in the SMI Bundle

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Recommendations to Close Critical Research

Gaps

1. Developing standardized

methods for national surveillance of

maternal mortality and morbidity

2. Defining significant maternal

morbidity and “near misses”

7. Research on impact of adverse

pregnancy outcomes on long-term

maternal health

Defining Severe Maternal Morbidity (SMM)

• All hospitals should identify women who:

• Are admitted to an ICU during pregnancy (3-4 per 1000

deliveries)

• Have been transfused with ≥4 units of blood (2 per 1000

deliveries)

• Not meant to discourage an individual site to use additional

clinical criteria to define morbidity

• Cases of SMM should be reviewed for ongoing quality

improvement

• “We believe they will serve as a good starting point”

Callaghan WM, et al. Obstet Gynecol. 2014 May;123(5):978-981.

D’Alton ME, et al. Am J Obstet Gynecol. 2013 Jun;208(6):442-8.

NICHD MFM Units Networks

12 U.S. university-

based clinical

centers focus on

clinical questions in

MFM and obstetrics,

in particular the

continuing problem

of preterm birth.

https://mfmunetwork.bsc.gwu.edu/PublicBSC/M

FMU/MFMUPublic/network-centers/

At the request of the NICHD, in 2017 NIH

has added a Maternal Health category to

NIH-wide reporting.

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Selected Publications Since 2013

Maternal Mortality per 100,000 Liveborn Births, 2018

4.5

6.2

11.3

11.7

11.7

11.0

13.013.714.3

14.8

15.6

15.7

15.8

16.3

16.6

16.8

16.8

17.7

17.9

18.8

18.9

19.4

19.4

20.3

21.2

22.6

23.323.4

23.8

24.4

24.6

25.626.5

28.0

32.6

34.2

34.8

41.4

44.8

46.2

20.6

16.8

38.1

6.1

13.218.3

14.023.5

America's Health Rankings. "Maternal Mortality in the

United States in 2018". United Health Foundation.

33

NYP/CU hosted the first working group

In 93% of obstetric

hospitals in NY

2014 2015 2016 2017 20182013 2019

Developed & implemented

3 bundles to address:

Hemorrhage

Severe hypertension

Venous thromboembolism

Led efforts to convene a

Maternal Mortality

Review Board in NY

Safe Motherhood Initiative (SMI) in New York State

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SMI Bundle Development & Implementation

Online In Person

www.acog.org/About_ACOG/ACOG_Districts/District_

II/Safe_Motherhood_Initiative

Implementation Lessons from SMI

“Checklists are boring, but death is worse”

- Atul Gawande, MD, MPH

Surgeon, writer, and public health researcher

Implementation success dependent on clinicians’ and institutions’ “beliefs, attitudes and norms”

• Leadership is vital

• Champions for implementation

needed at every level

• Communication and site visits

with community hospitals

Reviews and a sense of

narrative are essential to

further reducing maternal

mortality and morbidity.

ACOG DII SMI App

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Maternal Mortality in New York State

• Currently ranked 30th in the United States

with a rate of 20.6

• New York State Department of Health

planning maternal mortality reviews

• New York City Department of Health &

Mental Hygiene conducting maternal

mortality and morbidity reviews

www.americashealthrankings.org/explore/2016-health-of-women-and-

children-report/measure/maternal_mortality/state/NY

https://www.governor.ny.gov/news/governor-cuomo-announces-

comprehensive-initiative-target-maternal-mortality-and-reduce-racial

"Maternal mortality should not be a fear anyone in New York should have

to face in the 21st century. We are taking aggressive action to break

down barriers that prevent women from getting the prenatal care and

information they need.”

– Governor Andrew Cuomo

A National Conversation . . . Finally!

“We don’t just practice medicine – We change it”

Discover. Educate. Care. Lead.

The ongoing NPR/ProPublica series “Lost Mothers” shares stories and

photographs from families who lost mothers due to pregnancy-related causes.

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Putting the “M” Back in Maternal Fetal Medicine

Mary E. D’Alton, MD

Willard C. Rappleye Professor & Chair

Department of Obstetrics & Gynecology

Columbia University Irving Medical Center, New York, NY