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Biomedical subjects

D Acker

Publications and source records attributed to D Acker.

At least 19 recordsLinked to original sources
PubMed1998

Applying no-fault compensation criteria to obstetric malpractice claims.

Objective: To determine in obstetric malpractice cases the incidence of adverse events (AE), defined in the litigation literature as an injury caused by medical management, and to determine the proportion of cases that would meet no-fault criteria.Methods: In a retrospective cohort design, all neonatal outcome claims (n = 47) occurring between January 1992 and December 1993 were reviewed from carriers in Massachusetts, Colorado, and Utah. Two obstetricians determined whether an AE occurred, as defined above. The cases were then reevaluated according to Swedish Compensatory Event (SCE) criteria, which compensate AEs due to avoidable or substandard care, and to Florida Neurological Injury Compensation Association (NICA) criteria, which compensate neurologic injury following peripartum oxygen deprivation or mechanical injury.Results: An AE occurred in only 23/47 claims, representing 49% (95% CI 34-64%). SCE criteria were met in all 23 of the cases with an AE. NICA criteria were met in 9/23, or 39% (95% CI 19-61%), of the cases with an AE. Neither SCE nor NICA criteria were satisfied in any of the 24 cases without an AE. There were strong relationships between an occurrence of an adverse event and fulfilling criteria for SCE (P <.001) and NICA (P <.001).Conclusion: Neonatal injury caused by medical management occurs in less than half of the obstetric malpractice claims. No-fault compensation criteria can be successfully applied to claims, and both the SCE and NICA methods are specific in avoiding compensation to claims without an AE. The SCE criteria are more sensitive than the NICA criteria for compensating AEs. Applying the SCE system to claims would result in a larger proportion of claims successfully meeting no-fault criteria than using the NICA system.

Journal Article↗
PubMed1998

Intra-abdominal sacrococcygeal mature teratoma or fetus in fetu in a third-trimester fetus.

This case report describes a fetus with a large intra-abdominal, complex, vascular mass, displacing the normal intra-abdominal organs due to its large size. Extension to the presacral area was also identified, facilitating the diagnosis of a sacrococcygeal teratoma. Because of its highly mature nature, this was considered a fetus in fetu which was totally intra-abdominal.

Abdominal Neoplasms↗
PubMed1998

Multifetal pregnancy reduction of both fetuses of a monochorionic pair by intrathoracic potassium chloride injection of one fetus.

The purpose of this study was to determine if a monochorionic pair of fetuses in a higher-order multiple gestation can be reduced by injecting only one fetus with potassium chloride. Three quadruplet and two quintuplet gestations, each with a monochorionic pair of fetuses, were referred for pregnancy reduction. In each case, reduction was performed by injecting one of the monochorionic pair with potassium chloride. Patients returned for a follow-up sonogram within 1 week of the procedure. The reductions were performed at an average 12.1 weeks' gestation, with a range of 10.7 to 14.0 weeks. Follow-up scans 4 to 7 days after the procedure showed that both monochorionic fetuses were dead and all other fetuses were alive. One quintuplet pregnancy underwent a second reduction procedure to twins. One quintuplet and two quadruplet pregnancies that were reduced to twins resulted in the birth of live twins between 30.8 weeks and 36.8 weeks' gestations. The third quadruplet pregnancy reduced to twins is still ongoing; the mother is pregnant with twins at 20 weeks' gestation. The quintuplet pregnancy reduced to triplets resulted in delivery of live triplets at 24.1 weeks' gestation, but two of the neonates died in the first few days of life. Reduction of both fetuses of a monochorionic pair in a higher-order multiple gestation can be accomplished by intrathoracic injection of potassium chloride into only one of the pair.

Female↗
PubMed1997

The association of fetal sex with the rate of cesarean section.

OBJECTIVE: Our purpose was to evaluate the rate of cesarean deliveries according to fetal sex. STUDY DESIGN: We evaluated method of delivery, indication for cesarean section, and infant outcome according to fetal sex in 2439 low-risk nulliparous women in spontaneous labor. Crude odds ratios and 95% confidence intervals were calculated. Confounding was controlled with use of logistic regression. RESULTS: The overall cesarean section rate was 13.2% among 1246 women carrying male fetuses compared with 9.6% among 1193 women carrying female fetuses (odds ratio 1.4, 95% confidence interval 1.1 to 1.8). There was a 30% increase in cesarean sections for failure to progress (odds ratio 1.3, 95% confidence interval 1.0 to 1.8) and a 70% increase in those for fetal distress (odds ratio 1.7, 95% confidence interval 1.0 to 3.0). When adjusted for gestational age and fetal size, male fetal sex no longer predicted the risk of cesarean delivery for failure to progress (adjusted odds ratio 1.04, 95% confidence interval 0.8 to 1.4) but continued to predict the risk of cesarean section for fetal distress (adjusted odds ratio 2.2, 95% confidence interval 1.3 to 4.0). Among infants delivered by cesarean section for fetal distress, males were more than three times as likely than females to have an Apgar score < or = 7 at both 1 and 5 minutes. CONCLUSION: Increased cesarean deliveries for failure to progress among women with male fetuses is related to the larger size of males, whereas the increase for fetal distress is not, and may relate to other developmental differences between male and female fetuses.

Birth Weight↗
PubMed1993

Variation in hysterectomy rates across small geographic areas of Massachusetts.

OBJECTIVE: Our objective was to determine whether small-area variation in hysterectomy rates exists within Massachusetts and, if so, whether regions with persistently high or low rates can be identified. STUDY DESIGN: By examining data derived from standardized hospital discharge forms between 1982 and 1989, we compared hysterectomy rates among 172 small geographic areas within Massachusetts. The ratios of actual to expected number of hysterectomies for each area were also computed. Statistical significance of rate variation was established by a value of p < 0.01 (chi 3 test). RESULTS: The-hysterectomy rate per 1000 women varies fivefold across small-population areas of Massachusetts. Eight areas had persistently high and five had persistently low rates compared with the statewide average. CONCLUSION: Possible explanations for these rate variations include indigenous population factors, supply of health care resources, income, insurance coverage, methodological problems in data analysis, and variation in professional judgment with regard to the indication for hysterectomy. Only a combination of the study of local causes of high and low rates and the study of the clinical outcomes of different treatment decisions will allow physicians to develop an informed consensus on appropriate indications for surgery.

Female↗
PubMed1993

Treatment of obstetrical hemorrhagic emergencies.

The common hemorrhagic complications of pregnancy remain among the leading causes of maternal mortality. We review new methods of diagnosis and offer suggestions for management. Abruptio placenta, disseminated intravascular coagulation, placenta previa, uterine rupture, and postpartum hemorrhage are included in this review.

Abruptio Placentae↗
PubMed1989

Anesthetic-related maternal mortality, 1954 to 1985.

This is a population-based study of the safety of obstetrical anesthesia in the Commonwealth of Massachusetts between 1954 and 1985. We used data collected by the state Committee on Maternal Mortality, which was founded in 1941. There were a total of 37 maternal deaths during the study period due to anesthetic-related complications. During the same time period, there were 886 maternal deaths. Thus, anesthetic-related mortality comprised 4.2% of all deaths, and the mortality rate was 1.5 per 100,000 live births between 1955 and 1964, 1.5 per 100,000 live births between 1965 and 1974, and 0.4 per 100,000 live births between 1975 and 1984. In the first decade of this study, aspiration during administration of a mask anesthetic was the primary cause of death. During the second decade, cardiovascular collapse associated with regional anesthesia was the primary cause of death. During the last decade of this study, all deaths were associated with general endotracheal anesthesia. As a result of this study and having identified the changes in the standard of care in Massachusetts that led to the reduction in maternal mortality, we offer recommendations to further improve the safety of anesthesia for childbirth in this country.

Adolescent↗
PubMed1988

Hemorrhage, infection, toxemia, and cardiac disease, 1954-85: causes for their declining role in maternal mortality.

Hemorrhage, infection, toxemia, and cardiac disease are no longer the leading causes of maternal death. We studied factors causing their decline in incidence using data collected by the Committee on Maternal Welfare of the Massachusetts Medical Society between 1954 and 1985. The dramatic decline in incidence of these conditions in the Commonwealth during the study period appears to have been due to both legislative actions and improvements in medical practice. The legislative actions included licensing of maternity services, blood banks, and legalization of abortion. Cardiac-related mortality has declined due to a reduction in the prevalence of rheumatic heart disease. Changes in clinical practice that stand out were the aggressive control of the hypertensive component of toxemia leading to a reduced incidence of intracranial hemorrhage, the prompt recourse to blood transfusion for hemorrhage, and the use of broad spectrum antibiotics.

Female↗
PubMed1988

Cesarean section-related maternal mortality in Massachusetts, 1954-1985.

We analyzed the data of the Maternal Mortality Committee of the Massachusetts Medical Society to investigate cesarean section-associated maternal deaths. Between 1954-1985, the number of cesarean section-related deaths per 100,000 live births did not significantly change despite a quadrupling of the cesarean section rate. Between 1976-1984, there were 649,375 births and 121,217 cesarean sections in the state. Seven deaths were directly related to cesarean section, a rate of 5.8 per 100,000 cesarean sections. In contrast, the rate for vaginal deliveries was 10.8 per 100,000 vaginal deliveries. We conclude that the risk of maternal death from cesarean section is low.

Cesarean Section↗
PubMed1987

Maternal mortality in Massachusetts. Trends and prevention.

To identify ways in which the safety of childbirth might be increased, we investigated the causes of death among the 886 women who died during pregnancy or within 90 days post partum ("maternal deaths") in Massachusetts from 1954 through 1985. The maternal mortality rate declined from 50 per 100,000 live births in the early 1950s to the current rate of 10 per 100,000 live births. Between one third and one half of the maternal deaths were considered to have been preventable. The leading causes of maternal death from 1954 through 1957 were infection, cardiac disease, pregnancy-induced hypertension, and hemorrhage. In contrast, from 1982 through 1985 the leading causes of death were trauma (suicide, homicide, and motor vehicle accidents) and pulmonary embolus. We observed a rapid increase in the frequency of death among women who received little or no antenatal care. From 1980 through 1984 the maternal mortality rate for white women was 9.6 per 100,000 live births, whereas for nonwhites it was 35 per 100,000 live births (relative risk, 2.9; 95 percent confidence limits, 2.5 and 3.2). Fifty percent of the nonwhite women who died during pregnancy or within 90 days post partum received little or no antenatal care, in contrast to only 15 percent of the white women. These data show that the leading causes of maternal death have changed markedly in Massachusetts during the past 30 years. Although the overall maternal mortality rate has declined sharply, further improvement may occur with better antenatal care and specific efforts to prevent trauma and pulmonary embolus.

Cesarean Section↗
PubMed1987

Is maternal alkalosis harmful to the fetus?

Normal pregnancy is characterized by a compensated respiratory alkalosis. The effect of maternal alkalosis on the fetus is less well understood than the more common problem of maternal acidosis. We present a case of maternal alkalosis, complicated by bronchial asthma, in which the fetus was stillborn. The pathophysiology of this condition is discussed with data to support the potential harm of maternal alkalosis in pregnancies complicated by a fetus with borderline reserve. In such instances, the fetus should be carefully monitored and consideration might be given to therapy such as the use of acetozolomide, discouraging hyperventilation by the mother and even early delivery of the fetus.

Adult↗
PubMed1987

The incidence of symptomatic intracranial hemorrhage in term appropriate-for-gestation-age infants.

Symptomatic intracranial hemorrhage in term infants is rare. In over 23,000 deliveries the authors were only able to find 12 diagnosed cases for an incidence of 5.9/10,000 livebirths (greater than or equal to 2,500 g and greater than or equal to 37 weeks' gestation). No consistent clinical patterns were identified. However, the obstetrical risk factors were a precipitate delivery, a second stage of more than 2 hours, the use of pitocin, and a forceps delivery. The number of cases of asymptomatic ICH was unknown because routine surveillance was not done. Furthermore, some infants may have become symptomatic following discharge, which may have resulted in an undercounting of the incidence of ICH. Most infants, however, became symptomatic by the second day.

Cerebral Hemorrhage↗
PubMed1986

Diagnostic related groups and the obstetrician: antepartum admission.

A retrospective review was conducted of all pregnant women discharged undelivered during fiscal year 1985. If the current Medicare prospective payment plan were applied to these admissions, Diagnostic Related Group 383 (other antepartum diagnoses with medical complications) and Diagnostic Related Group 384 (other antepartum diagnoses without medical complications) would together generate a negative cash flow. Supplementation for capital costs and direct and indirect medical education costs would result in a positive cash flow; however, the supplementation is vulnerable to political and social forces that will tend to diminish or eliminate it.

Diagnosis-Related Groups↗
PubMed1985

New multipronged fetal scalp electrode: a preliminary report.

Presented is a preliminary report of the use of a new type of scalp electrode (patent pending), which, because of its design, may have the advantage of improved safety. It was used on 40 patients in labor. To confirm the quality of the recording, in all cases, a fetal electrocardiogram was also obtained. Application was achieved on the first attempt in 37 cases in two additional cases on the second attempt. There were no reported cases of the electrode being dislodged during labor. The quality of the recording was reported to be good. There were no reported cases of trauma to the fetal scalp nor were there any cases of infection noted.

Electrodes↗
PubMed1982

High risk antenatal hospitalization.

High risk, antenatal units have been established to provide highly sophisticated obstetric care for women with complications of pregnancy. In an effort to more precisely define the patients requiring this care, and to begin to document the benefits of antenatal hospitalization, a 2-year prospective evaluation of the Antenatal Unit (AU) at the Brigham and Women's Hospital was performed. Between July 1, 1978 and June 30, 1980, 1488 consecutive patients were admitted to the AU. Demographic data, antenatal hospitalization time, hospitalization outcome, and delivery data were determined for these patients. Diabetes mellitus, premature labor, hypertensive disorders, premature rupture of the membranes, and late pregnancy bleeding disorders resulted in over 60% of the admissions. Follow-up data demonstrated that among these 1488 patients admitted to the AU, there occurred 32 stillbirths (21.5/1000), 50 neonatal deaths (33.6/1000), and no maternal deaths. This study demonstrated that a broad spectrum of medical, surgical, and obstetric complications necessitate antenatal hospitalization, resulting in an overall perinatal survival rate of 95%.

Boston↗
PubMed1982

Delivery of the second twin.

A retrospective chart review of all twin deliveries between April 1, 1977, and March 20, 1980, at the Boston City Hospital and the Brigham and Women's Hospital revealed corrected neonatal mortality rates of 0 for 74 twins in nonvertex presentation delivered by cesarean section and 0 for 76 second-born twins extracted vaginally. Breech extraction of 76 second-born twins weighing more than 1499 g at birth was not associated with a statistically significant increase in the incidence of 5-minute Apgar scores of 7 or less when compared to 74 similarly asymptomatic twins in nonvertex presentation delivered by cesarean section. Vaginal delivery may be considered when the second twin, weighing more than 1500 to 2000 g, is in breech presentation.

Apgar Score↗