INTRODUCTION: Healthcare is continuously evolving and very few trainees understand the principles of ICD diagnosis and procedure coding. Few academic programs incorporate documentation, coding and reimbursement training into medical education. We sought to characterize those trainees with self-reported familiarity and understanding of billing and coding in obstetrics. We also identify challenges and strategies for implementing coding education during residency and fellowship. METHODS: Maternal Fetal Medicine fellows, identified through the Society for Maternal Fetal Medicine, were asked to complete an electronic, web-based survey. RESULTS: Of 72 respondents, 36 (50%) were currently in their third year or were recent graduates of fellowship training. 23 (32%) received formal training during their residency or fellowship, however 30% of fellows reported unfamiliarity with E&M and ICD coding. A significant number of trainees (63%) were unaware of the use of modifiers and how they influence acceptance or rejection of medical claims. 93% (67/72) reported an interest in coding education. Challenges cited include lack of awareness during training, time constraints and financial limitations in participating in additional courses. CONCLUSION: With the universal implementation of electronic medical records and the adoption of ICD-10 in the United States, it is imperative that knowledge of appropriate coding and billing practices be upheld. Despite increased utilization of electronic medical records and professional coders, it is important for physicians to have a keen understanding of documentation and coding in clinical practice. These preliminary findings suggest that the current generation of trainees would benefit from coding and billing education during their residency or fellowship curriculum.

OBJECTIVETo determine whether obstetric handoff quality differs morning versus evening, weekend versus weekday, or based on provider type.STUDY DESIGNUsing the American College of Obstetricians and Gynecologists (ACOG) handoff guidelines, we developed an observational tool to assess whether handoffs included its 8 recommended elements. We observed handoffs between attending obstetricians, Obstetrics and Gynecology residents, labor and delivery nurses, and certified nurse midwives. Observation times included a balance of morning, evening, weekdays, and weekends. Participants were blinded to the study objectives. We defined high-quality handoffs as those that included 7 of the 8 recommended ACOG elements.RESULTSA total of 425 inpatient handoffs were observed: 233 (55%) were morning handoffs and 189 (45%) were evening; 251 (59%) were on weekdays and 171 (41%) on weekends. Of the handoffs observed, 201 (48%) were presented by residents, 139 (33%) by nurses, 56 (13%) by attending obstetricians, and 26 (6%) by midwives. Only 169 (40%) of all handoffs met criteria for high quality. A greater percentage of all morning handoffs met criteria as compared to evening handoffs (45% vs. 34%, p < 0.05). There was no significant difference between the overall percentage of weekday and weekend handoffs meeting criteria (39% vs. 42%, p = 0.48). Residents had a higher percentage of high-quality handoffs as compared to nurses (55% vs. 32%, p < 0.001).CONCLUSIONBased on criteria developed for this study, handoff quality may vary based on time of day and provider type. These findings present an opportunity to further assess reasons for variation and propose changes to standardize and improve the handoff process.

Patient care in labor & delivery is intuitively sensitive to the quality of provider sign-out because it spans across different shifts and providers. We sought to determine whether the quality of sign-outs differs between AM versus PM, weekend versus weekday, or with provider type. With institutional review board approval, we developed an observational tool to assess whether the 8 elements of an effective sign-out were present, as described by the American Congress of Obstetricians and Gynecologists (ACOG). We prospectively observed patient sign-outs in labor & delivery between attendings, residents, nurses and certified nurse midwives. Observation times included a balance of mornings, evenings, weekdays and weekends. Participants were blinded to the study objectives. We defined as high quality sign-outs those that included 7 of the 8 recommended ACOG elements. Analysis was at the individual patient level, using Fisher's exact test for statistical analysis where needed. A total of 422 patient sign-outs were observed; 233 (55%) took place in the AM, 189 (45%) in the PM; 251 (59%) were on weekdays, 171 (41%) on weekends. A total of 201 (48%) were presented by obstetrical residents, 139 (33%) by labor & delivery nurses, 56 (13%) by attending obstetricians, and 26 (6%) by certified nurse midwives. Only 169 (40%) of all sign-outs were classified as high quality. A greater percentage of AM sign-outs were high quality compared to PM (45% versus 34%, p=0.04). There was no difference between overall weekday and weekend sign-outs (39% versus 42% p=0.48). Residents had the most high quality sign-outs (55%) compared to attendings (7%) and nurses (32%), p<0.001. The element most commonly distracting from high quality sign-out was the use of technical language (n=316, 75%). Based on criteria used in this study, sign-out quality varied with time of day and provider type. These findings present an opportunity to further assess reasons for this variation and propose changes to improve the sign-out process.

The placenta functions to nourish and protect the fetus. Imaging of the placenta can have a profound impact on patient management, owing to the morbidity and mortality associated with various placental conditions. To fully appreciate placental pathology, its physiology, anatomy, and variant anatomy will be outlined. Placental conditions affecting the mother and fetus include molar pregnancies, placental hematoma, abruption, previa, accreta, vasa previa, choriocarcinoma, and retained products of conception. Ultrasonography remains the definitive modality in diagnosing most of these conditions, with magnetic resonance imaging remaining an adjunctive measure. Computed tomography is occasionally used in cases of trauma and tumor staging.

As a result of the high negative predictive value, there is limited data on pregnancies with a negative fetal fibronectin (fFN) test that deliver preterm. Our objective is to compare pregnancy characteristics between fFN positive and negative patients that delivered within 14 days of testing. All singletons gestations that delivered within 14 days of fFN testing between 2006-2009 at Baystate Medical Center were enrolled. Inclusion criteria included patients with preterm birth due to preterm labor (PTL) or preterm premature rupture of membranes (pPROM). We excluded patients that delivered due to preeclampsia or suspected non-reassuring fetal status without labor. We excluded all but final test results if multiple tests were performed. The clinical impression for preterm birth was categorized into: idiopathic PTL, pPROM, or abruption. Placental pathology reports were reviewed and divided into: normal, ischemic changes, inflammatory changes and chronic villitis. Comparison between groups was conducted using Wilcoxon rank sum test and Fisher's exact test. A total of 1976 patients had fFN testing. 63 had a preterm birth within 14 days of fFN testing. The sensitivity, specificity, positive and negative predictive values for this test were 65, 90, 23 and 98, respectively. Patients that were fFN negative (n=19) were compared to the fFN positive group (n=44). Those who tested negative had a longer duration between testing and time of delivery (7.7 ± 4.5 days vs. 5.1 ± 3.7 days, p=0.049). The table lists fFN results compared to the clinical cause for preterm birth and placental pathology results.Tabled 1Fetal Fibronectin Test ResultNegative fFN n (%)Positive fFN n (%)PPlacental LesionInflammation2 (13)6 (17)0.19Ischemia7 (47)11 (31)Inflammation & Ischemia3 (20)13 (37)Villitis2 (13)0Normal1 (6)5 (14)Clinical Cause for Preterm BirthpPROM6 (32)17 (39)0.96Abruption2 (11)4 (9)pPROM & Abruption1 (5)2 (5)Idiopathic10 (53)21 (49) Open table in a new tab Although fFN has a high negative predictive value, there are still patients that deliver within 14 days of a negative test. This is the largest study to evaluate characteristics of pregnancies that deliver preterm with a negative fFN test. We did not find significant differences in clinical presentations or placental findings between patients with negative verses a positive fFN test.

OBJECTIVE:To evaluate the association of gestational weight gain with the cesarean delivery (CD) rate in term women undergoing induction of labor (IOL).STUDY DESIGN:This is a retrospective cohort study of 2,495 consecutive term women from May 2005 to June 2008 admitted for IOL between 37 and 42 completed weeks of gestation. Labor induction ending in cesarean delivery was defined as a binary outcome. Weight gain during pregnancy was calculated by subtracting prepregnancy weight from weight recorded at delivery. Multiple gestation, malpresentation, stillbirth, planned CD and women with prior CD were excluded. Maternal and obstetric characteristics were examined as predictors of CD using multivariable logistic regression analyses.RESULTS:The risk of CD increased by 13% (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.05-1.23) for each 5 kg increase in gestational weight gain. Other factors associated with an increased risk of CD included maternal age (OR per year 1.05, 95% CI 1.03-1.06), neonatal birth weight (OR 1.06 per 100 g, 95% CI 1.03-1.08), nulliparity (OR 9.13, 95% CI 7.00-11.90), Bishop score at admission < or = 5 (OR 2.3, 95% CI 1.90-2.90), male infant (OR 1.37, 95% CI 1.10-1.70) and unit increase in prepregnancy body mass index (OR 1.08, 95% CI 1.06-1.10).CONCLUSION:The CD rate following labor induction increases significantly with increasing gestational weight gain even after controlling for possible confounding variables.

A 32-year-old multigravida was admitted at 33.9 weeks with respiratory distress. Community-acquired pneumonia was suspected and antimicrobial treatment initiated with ceftriaxone sodium and azithromycin. However, despite these therapies her respiratory status deteriorated. She was subsequently diagnosed with Swine-origin Influenza A (H1N1) Virus pneumonia and treated with oseltamivir. After failing conventional ventilation, high-frequency oscillatory ventilation (HFOV) was utilized. In pregnant patients who fail to respond to conventional ventilation techniques, HFOV should be considered.

Objective. The purpose of this study was to assess the utility of fetal echocardiography (FE) after normal fetal cardiac imaging findings during detailed fetal anatomic ultrasonography (FAU). Methods. We conducted a retrospective cohort review of obstetric ultrasonographic studies from November 2001 through July 2005. We identified women with a singleton gestation with increased risk for congenital heart disease who received FAU performed by a maternal-fetal medicine specialist at 16 to 20 weeks' gestation with subsequent FE. These records were compared with newborn outcomes. Results. Of 789 pregnancies that had FAU and FE, 481 had satisfactory cardiac imaging, Of those, only 1 fetus had abnormal FE findings. After delivery, 4 of the 480 neonates with normal FAU and FE findings had a diagnosis of a heart defect Conclusions. Fetal echocardiography does not substantially increase the detection rate of major cardiac anomalies after normal findings on detailed FAU per-formed by a maternal-fetal medicine specialist.

The goal of this study is determine if fetal echocardiography improves detection rate of cardiac anomalies after adequate cardiac views are obtained after detailed anatomic fetal survey performed by maternal-fetal-medicine specialist. We undertook a retrospective review of records obtained from the ultrasound database at Baystate Medical Center. We identified all patients with singleton pregnancies who received a detailed anatomy survey performed by a perinatologist between 16 to 20 weeks of gestation with a subsequent fetal echocardiogram, in the time period from November 2001 to July 2005. Inclusion criteria included (1) fetal anatomy surveys with adequate and normal fetal cardiac imaging of the 4-chamber view and the outflow tracts, and (2) delivery at Baystate Medical Center. These records were then compared with the hospital discharge database of newborns with a discharge diagnosis of a congenital cardiac defect. Patent foramen ovale and patent ductus arteriosus were excluded from analysis since these conditions cannot be diagnosed prenatally. A total of 789 patients had complete data and completed both a level II ultrasound and fetal echocardiogram. A total of 497 of those patients met the criteria of satisfactory and normal cardiac views on detailed fetal ultrasound. One infant had subsequently abnormal fetal echocardiogram this pregnancy resulted in fetal demise and autopsy in fact confirmed ventricular septal defect. A total of 480 of those patients had also normal heart views on the fetal echocardiogram. At that time of discharge only five neonates were diagnosed with a heart defect. One neonate had Shone's complex, one had an aneurysmal atrial septum, two had a small ventricular septal defect (VSD) and one had a large perimembranous VSD (8 mm). Fetal echocardiography does not increase the yield for major cardiac anomalies after a normal detailed fetal anatomy survey performed by a perinatologist.

To evaluate the influence of weight gain during pregnancy on the cesarean delivery (CD) rate in term patients undergoing induction of labor (IOL). This is a retrospective cohort study of 2,921 patients admitted for IOL between 37 and 42 completed weeks of gestation from May 2001 to June 2008. Failed IOL was defined as labor induction resulting in cesarean delivery. Weight gain during pregnancy was calculated by subtracting pre-pregnancy weight from weight recorded at delivery. Multiple gestation, malpresentation, stillbirth, planned CD and patients with prior CD were excluded. Maternal and obstetric characteristics were examined as predictors of CD using multivariate logistic regression analyses. Statistical significance was set at p < 0.05. The risk of CD increased by 11% (OR 1.11; 95% CI 1.03-1.18) for each 5 kg in weight gain. This increase was significant for multiparous women (OR 1.16; 95% CI 1.02-1.32) but not significant for nulliparous women (OR 1.07; 95% CI 0.99-1.17). Other factors associated with an increased risk of CD included gestational age ≥ 40 weeks (OR 1.34; 95% CI 1.10-1.62), nulliparity (OR 6.15; 95% CI 4.90-7.72), bishop score ≤ 5 (OR 1.92; 95% CI 1.52-2.42), maternal age ≥ 30 years (OR 1.30; 95% CI 1.05-1.60), male infant (OR 1.33; 95% CI 1.09-1.61), neonatal birth weight ≥ 4 kg (OR 1.96; 95% CI 1.48-2.58) and the following pre-pregnancy BMI categories: BMI 25-29.9 (OR 1.53; 95% CI 1.19-1.95), BMI 30-34.9 (OR 2.02; 95% CI 1.49-2.78), BMI 35-39.9 (OR 2.92; 95% CI 2.00-4.24), BMI ≥ 40 (OR 5.86; 95% CI 3.86-8.88). The failure rate of IOL increases significantly with increasing weight gain during pregnancy. The weight gain impact on CD was statistically significant among multiparous but not nulliparous pregnancies.