Considering ways to reduce maternal death rate

All women who undergo cesarean delivery are at risk of venous thromboembolism (VTE), a disease that can lead to long-term complications and even death, a leading perinatal expert stated during a recent webinar hosted by the Institute of Healthcare Improvement.

"Essentially every patient is in moderate risk," said Peter Cherouny, M.D., emeritus professor, obstetrics, gynecology, and reproductive sciences, University of Vermont, and chair and lead faculty of the IHI Perinatal Improvement Community. "The only exceptions to that would be patients under age 40 who have no other risk factors and whose surgeries are less than 30 minutes."

Cherouny added that while some cesarean surgeries are performed in less than 30 minutes, the clock for the procedure starts ticking the moment anesthesia is administered. "If you take that into account, there is really no case of a patient in the low-risk category undergoing a cesarean section," he said.

Michael Wong, executive director of the Physician-Patient Alliance for Health and Safety, pointed to research from the Centers for Disease Control and Prevention that finds that the maternal death rate in the United States has more than doubled in the past 25 years.

The CDC research also shows that 21 deaths occurred for every 100,000 live births in 2010 in the U.S., which had one of the highest maternal death rates among the 50 nations studied. "This ranking is particularly alarming because the U.S. spends more money per capita for maternity care than any other country," Wong said.

Cherouny said that to lower maternal death rates and decrease incidences of VTE-related complications, "we really need to move back into the prevention phase." To that end, he recommended that "All patients having a cesarean delivery should have pneumatic compression devices placed prior to surgery."

Pneumatic compression therapy — such as fitting inflatable compression devices on a patient's legs before cesarean delivery and using inflatable compression sleeves until the patient is able to walk after delivery — improves blood flow in the treated area, which reduces the opportunity for VTE to occur.

To help hospitals and health care providers address the VTE issue in their institutions, PPAHS, in collaboration with IHI and the National Perinatal Association (NPA), has created "Ob/Gyn VTE Safety Recommendations for the Prevention of VTE in Maternal Patients." The recommendations give providers a step-by-step checklist to help assess patient risk for VTE and identify the appropriate prophylaxis regimen to improve health outcomes for maternal patients.

Overuse injuries among young athletes examined

The increased emphasis on success in youth sports has made overuse injuries more common. With concerns mounting as children train harder, compete more frequently and specialize in a single sport earlier, the American Medical Society for Sports Medicine released a position statement that provides guidance to health providers who care for young athletes.

"Sports are such a good thing for kids, teaching them teamwork and helping their growth and fitness. We want to be sure that their participation is positive and healthy," said Andrew Gregory, M.D., associate professor of orthopedic surgery and rehabilitation and pediatrics at Vanderbilt University Medical Center. Gregory is one of seven sports medicine physicians convened by the AMSSM to prepare the position statement. They reviewed 953 papers and cited 208 unique references in their final analysis.

It is estimated that 60 million children ages 6-18 participate in some form of organized athletics, with 44 million participating in more than one sport.

The study found the prevalence of overuse injury varies by specific sport, ranging from 37 percent in skiing and handball to 68 percent in running. The authors believe injury numbers may be under-reported because most injury definitions focus on time lost from sport and not all overuse injuries initially require time off.

The authors found no clear evidence that early sport specialization increases the rates of overuse injury and burnout, but believe that diversified training during childhood may be more effective in developing elite-level skills. "We believe that doing a variety of activities in the early years helps with the fundamentals like balance, coordination, agility and reaction time. Then kids have a solid foundation when they are older and want to focus on one or two sports," Gregory said.

The position statement reveals multiple risk factors for overuse injuries:

  • Priory injury and higher training volumes are strong predictors of future overuse injury.
  • Injuries are more likely to occur during the adolescent growth spurt.
  • Adolescent female athletes who have irregular menstrual cycles are predisposed to bone-stress injuries.
  • Poor-fitting equipment and overscheduling (such as multiple competition events in the same day or over consecutive days) may contribute to overuse injury but lack clinical data.

"The bottom line is that youth sports have gotten very competitive, and the increased pressure to excel has led to higher intensity training at younger and younger ages. But focusing so heavily on a certain sport, instead of more general fundamentals and skills, can lead to overuse injury and burnout," Gregory said.

"Overuse Injuries and Burnout in Youth Sports" was published in the January issue of the Clinical Journal of Sports Medicine.