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This is the final report of a panel convened as part of the Association of American Medical College's (AAMC's) Mission-based Management Program to examine the use of metrics (i.e., measures) in assessing faculty and departmental contributions to the clinical mission. The authors begin by focusing on methods employed to estimate clinical effort and calculate a "clinical full-time equivalent," a prerequisite to comparing productivity among faculty members and departments. They then identify commonly used metrics, including relative-value units, total patient-care gross charges, total net patient fee-for-service revenue, total volume per CPT (current procedural terminologies) code by service category and number of patients per physician, discussing their advantages and disadvantages. These measures reflect the "twin pillars" of measurement criteria, those based on financial or revenue information, and those based on measured activity. In addition, the authors urge that the assessment of quality of care become more highly developed and integrated into an institution's measurement criteria. The authors acknowledge the various ways users of clinical metrics can develop standards against which to benchmark performance. They identify organizations that are sources of information about external national standards, acknowledge various factors that confound the interpretation of productivity data, and urge schools to identify and measure secondary service indicators to assist with interpretation and provide a fuller picture of performance. Finally, they discuss other, non-patient-care, activities that contribute to the clinical mission, information about which should be incorporated into the overall assessment. In summary, the authors encourage the use of clinical productivity metrics as an integral part of a comprehensive evaluation process based upon clearly articulated and agreed-upon goals and objectives. When carefully designed, these measurement systems can provide critical information that will enable institutional leaders to recognize and reward faculty and departmental performance in fulfillment of the clinical mission.

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PURPOSE: No standardized therapeutic interventions have been reported for patients diagnosed with breast cancer during pregnancy. Of the potential interventions, none have been prospectively evaluated for treatment efficacy in the mother or safety for the fetus. We present our experience with the use of combination chemotherapy for breast cancer during pregnancy. PATIENTS AND METHODS: During the past 8 years, 24 pregnant patients with primary or recurrent cancer of the breast were managed by outpatient chemotherapy, surgery, or surgery plus radiation therapy, as clinically indicated. The chemotherapy included fluorouracil (1,000 mg/m2), doxorubicin (50 mg/m2), and cyclophosphamide (500 mg/m2), administered every 3 to 4 weeks after the first trimester of pregnancy. Care was provided by medical oncologists, breast surgeons, and perinatal obstetricians. RESULTS: Modified radical mastectomy was performed in 18 of the 22 patients, and two patients were treated with segmental mastectomy with postpartum radiation therapy. This group included patients in all trimesters of pregnancy. The patients received a median of four cycles of combination chemotherapy during pregnancy. No antepartum complications temporally attributable to systemic therapy were noted. The mean gestational age at delivery was 38 weeks. Apgar scores, birthweights, and immediate postpartum health were reported to be normal for all of the children. CONCLUSION: Breast cancer can be treated with chemotherapy during the second and third trimesters of pregnancy with minimal complications of labor and delivery.

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Citrobacter species have rarely been described as-etiological factors of intraamniotic infections. Citrobacter is not a normal inhabitant of the female genital tract. Vertical transmission of Citrobacter from mother to fetus has rarely been reported. A 21-year-old primigravida presented to labor and delivery at 40 6/7 weeks' gestation complaining of ruptured membranes, painful uterine contractions, and fever. An intraamniotic infection was diagnosed and antibiotics begun. She was subsequently delivered of a live male infant. Mother and infant had positive cultures for Citrobacter and overwhelming sepsis. Citrobacter species are rarely described as etiological factors of intraamniotic infections, and vertical transmission has rarely been reported. This pathogen should be considered in cases of chorioamnionitis or maternal sepsis as overwhelming maternal and fetal infection are possible sequelae.

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Fetal acid-base status is the end point that all antepartum and intrapartum surveillance tools are designed to assess, either directly or indirectly. Umbilical arterial blood pH is normal in 80% of depressed newborns, thereby proving the absence of birth asphyxia both in the delivery room and in the courtroom. The technique, normal ranges, and risks, benefits and cost analysis of routine versus selected umbilical blood sampling are considered. The American College of Obstetricians and Gynecologists recommends performing umbilical blood sampling for acid-base analysis in selected deliveries. However, in our opinion routine umbilical blood sampling at all deliveries has merit.

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BACKGROUND: The purpose of this investigation was to determine if epidural analgesia, established during active phase labor, results in elimination or reversal of fundal dominance (lower uterine segment pressure equal to or greater than fundal pressure). METHODS: Upper and lower uterine segment intrauterine pressures were prospectively evaluated for 50 min before and 50 min after epidural analgesia using 0.25% bupivacaine in 11 nulliparous women in spontaneous active labor. A total of 958 contractions were evaluated. RESULTS: No significant differences were found in the number of contractions in the interval before epidural analgesia compared to after epidural analgesia. Significantly greater pressure readings were recorded in the upper segment than in the lower segment (consistent with fundal dominance) both before and after epidural analgesia (P<0.01). In addition, fundal dominance increased after epidural analgesia when compared to the preanalgesia period (P<0.01). CONCLUSIONS: Fundal dominance is present both before and after active phase epidural analgesia and is increased during the immediate 50-min postanalgesia period.

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A patient presented at 29 weeks' gestation with severe hemolytic anemia. She was subsequently diagnosed as having renal cell carcinoma and had a radical nephrectomy at 31 weeks' gestation, which demonstrated stage I disease. This was followed by a normal vaginal delivery of a healthy infant at term and complete resolution of her anemia. This unusual presentation of renal cell carcinoma in pregnancy is discussed.

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OBJECTIVE: We hypothesized that prophylactic intrapartum amnioinfusion in pregnancies complicated by thick meconium will not decrease the incidence of fetal distress, cesarean section for fetal distress, or meconium below the cords. STUDY DESIGN: Patients with thick meconium were randomized to amnioinfusion (n = 65) or control (n = 59). The amnioinfusion group received an 800 ml bolus of normal saline solution followed by a continuous infusion at 180 ml/hr. Continuous variables were compared by Student t test, and discrete variables were compared by chi 2 analysis and Fisher's exact test as appropriate. RESULTS: The incidence of fetal distress (16 of 65 vs 8 of 59) and cesarean section for fetal distress (seven of 65 vs seven of 59) was not significantly different between the amnioinfusion and control groups, respectively. The rate of meconium below the cords (one of 65 vs eight of 59) was significantly lower in patients receiving amnioinfusion (relative risk 0.09, confidence interval 0.01 and 0.82, p = 0.02). Two cases of meconium aspiration syndrome occurred in control patients but in none receiving amnioinfusion (p = 0.22). CONCLUSION: Prophylactic amnioinfusion in patients with thick meconium decreases the incidence of meconium below the cords and may subsequently have an impact on the incidence of meconium aspiration syndrome in larger series.

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OBJECTIVE: The objective of this study was to test the hypothesis that cocaine alters placental prostaglandin production in vitro. STUDY DESIGN: Placentas were obtained from healthy women (n = 6) after normal vaginal delivery at term. Placental explants (300 mg) were incubated in duplicate at 37 degrees C in the presence of 0, 30, 300, or 3000 ng/ml cocaine. Thromboxane and prostacyclin production was measured by radioimmunoassay of their stable metabolites (thromboxane B2 and 6-keto-prostaglandin F1 alpha) at 0, 0.5, 1.0, 1.5, 2, 4, 8, and 12 hours. Analysis of variance with Newman-Keuls test was used for statistical analysis. RESULTS: Cocaine increased thromboxane production in a dose-dependent manner (p < 0.001) and decreased prostacyclin production (p < 0.05). Cocaine increased the ratio of thromboxane/prostacyclin production (p < 0.05). CONCLUSION: Cocaine alters the placental production of prostaglandins in vitro, favoring thromboxane production, which may cause vasoconstriction and decrease uteroplacental blood flow.

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BACKGROUND: Right atrial thrombus, a rare but potentially fatal complication of central venous catheter use in total parenteral nutrition, has not been reported during pregnancy. CASE: A pregnant woman with persistent hyperemesis gravidarum developed a right atrial thrombus related to central venous catheter use for total parenteral nutrition. CONCLUSION: Right atrial thrombus can be treated successfully with heparin, leading to its resolution and a normal pregnancy outcome.

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OBJECTIVE: We hypothesized that maternally administered methamphetamine would alter fetal sympathoadrenal activity. STUDY DESIGN: Six chronically catheterized near-term pregnant ewes received an intravenous bolus injection of methamphetamine (1.25 mg/kg). Maternal and fetal arterial blood gas values, glucose, insulin, lactate, and catecholamines were measured in the control period and at 15, 30, 60, 90, 120, and 180 minutes after methamphetamine. RESULTS: Fetal PO2 decreased from 21.4 +/- 1.9 mm Hg at control measurement to 15.3 +/- 3.3 mm Hg after 60 minutes (p < 0.05). Fetal pH declined from 7.35 +/- 0.014 at control to 7.29 +/- 0.024 after 180 minutes. Fetal plasma glucose rose from 15.3 +/- 2.4 mg/dl at control to peak at 51.2 +/- 6.8 mg/dl at 120 minutes. Insulin levels increased from a control of 40.5 +/- 8.06 to a peak of 128 +/- 46 microIU/ml at 180 minutes (p < 0.05). Lactate levels increased from a baseline of 33.5 +/- 2.0 mg/dl to 92.3 +/- 22.8 mg/dl at 180 minutes. Fetal catecholamines rose from a baseline of 153 +/- 20.2 pg/ml for epinephrine and 226 +/- 18.5 pg/ml for norepinephrine to maximum values of 518 +/- 87.3 and 661 +/- 59.3 pg/ml at 15 minutes (p < 0.05), declining thereafter. CONCLUSIONS: Maternal administration of methamphetamine is associated with a short-term increase in circulating fetal catecholamines followed by hyperglycemia, lactacidemia, and hyperinsulinemia. These findings suggest that the alteration of fetal sympathoadrenal activity may contribute to the various perinatal complications associated with methamphetamine use.

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OBJECTIVES: We examined whether pregnancy modulates the expression of prostaglandin endoperoxide synthase, prostacyclin synthase, and thromboxane A2 synthase in the systemic vasculature. Further, we examined whether elevated lipid peroxidation during pregnancy (induced by vitamin E deprivation) affects the normal adaptive process to pregnancy. STUDY DESIGN: Western immunoblotting was performed on aortas from normal and vitamin E-deprived late pregnant (18 to 19 days) and age-matched virgin control rats. RESULTS: Normal pregnancy resulted in an increased expression of prostaglandin endoperoxide synthase (2.91 vs 1.06 fmol/ng deoxyribonucleic acid, p < 0.05). Surprisingly, the expression for both prostacyclin and thromboxane A2 synthases were significantly decreased by pregnancy: prostacyclin synthase 2.60 versus 13.82 units/ng deoxyribonucleic acid and thromboxane A2 synthase 1.32 versus 9.85 units/ng of deoxyribonucleic acid. Elevation of endogenous lipid peroxidation partially reversed this normal pregnancy trend in enzyme expression: prostaglandin endoperoxide synthase 1.85 fmol/ng deoxyribonucleic acid, prostacyclin synthase 9.38 units/ng deoxyribonucleic acid, thromboxane A2 synthase 4.36 units/ng deoxyribonucleic acid. CONCLUSION: Changes in prostanoid activity in the systemic vasculature during pregnancy may be mediated by concerted induction and down-regulation of specific enzymes. Increased lipid peroxidation interferes with this normal pregnant pattern. Further studies on the cell-specific expression of these genes will help to define the cardiovascular role of prostaglandins in pregnancy and in preeclampsia.

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OBJECTIVE: Our purpose in this study was to investigate the effects of rapid intravenous crystalloid infusion on placental implantation-site blood flow and oxygen delivery in the near-term pregnant ewe. STUDY DESIGN: Maternal left ventricular, femoral arterial and venous, and bilateral fetal hind limb arterial catheters were placed in nine near-term ewes 5 days before the start of the study. Maternal and fetal arterial blood gas values, maternal hemodynamic measurements, and maternal organ blood flows (microsphere technique) were obtained before and after the intravenous infusion of 2.0 to 2.5 L of normal saline solution. Myometrial and placental implantation-site vascular resistances and oxygen delivery were calculated. The t test for paired comparisons was used for statistical analysis, with p < or = 0.05 considered significant. RESULTS: Significant postinfusion increases in maternal mean arterial pressure, placental implantation-site blood flow, and skin, skeletal muscle, and renal blood flows were recorded. In the six animals that demonstrated a fall in hemoglobin concentration, a significant increase in placental implantation-site oxygen delivery and a significant decrease in placental implantation-site vascular resistance were also seen. No significant changes were seen in myometrial blood flow or myometrial vascular resistance. CONCLUSION: Rapid intravenous crystalloid infusion selectively increases placental implantation-site blood flow in the near-term pregnant ewe and may improve oxygen delivery to the fetus, especially if hemodilution occurs.

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OBJECTIVES: We sought to characterize risk factors in patients undergoing trial of labor after previous cesarean section and to determine whether a subset of patients at high risk of having an unsuccessful trial of labor consequently suffer greater morbidity. STUDY DESIGN: A 13-month chart review analyzed 264 labors with documented transverse lower uterine segment scars. Historic and physical examination variables were recorded, and a scoring system was constructed to evaluate successful vaginal delivery after cesarean. RESULTS: Successful vaginal delivery occurred in 192 patients, resulting in a rate of vaginal birth after cesarean of 72.7%. Four variables significantly lower the rate of vaginal birth after cesarean. Of patients scoring 0 (no variables present), 91.5% were successfully delivered vaginally. Scores of 1, 2, and 3 to 4 were associated with the success of vaginal birth after cesarean in 73.9%, 66.7%, and 46.1% of patients, respectively. A score of 3 to 4 did not increase maternal or fetal morbidity in trial-of-labor patients. CONCLUSION: We constructed a scoring system to evaluate the success of vaginal birth after cesarean. Trial of labor in the subset of patients with the lowest success rate does not increase morbidity.

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OBJECTIVE: To determine whether fetal fibronectin is a sensitive test for the detection of amniotic fluid (AF) in women with rupture of the membranes. METHODS: In a multicenter clinical trial, pooling, ferning, and nitrazine tests were compared with fetal fibronectin in 339 women at term (study group) with a clinical history of rupture of the membranes and in 67 women at term receiving routine prenatal care (controls). Ruptured membranes was diagnosed if any two of the standard tests were positive. Fetal fibronectin in the cervicovaginal secretions was determined using a qualitative enzyme-linked immunosorbent assay test. Fetal fibronectin was considered positive at 50 ng/mL. RESULTS: The sensitivity of fetal fibronectin in the women with ruptured membranes was 98.2%. No controls had ruptured membranes based on standard test results, but 13 women had fetal fibronectin present. The mean (+/- standard error) interval between sampling and delivery was significantly less in the women positive for fetal fibronectin (169.3 +/- 45.8 hours) than in those with no detectable fetal fibronectin (333.4 +/- 29.0 hours). CONCLUSION: Fetal fibronectin is a sensitive test for detection of AF in the vagina and compares favorably to standard tests. Its low specificity suggests that the assay may detect an alteration in membrane integrity. In addition, in patients without rupture of the membranes, the interval between sampling and delivery is significantly shorter if fetal fibronectin is present. We speculate that the presence of fetal fibronectin in cervicovaginal secretions may be a marker for impending labor in gravidas without gross rupture of the membranes.

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Apgar scores are used routinely to assess early neonatal status, but are less accurate in the preterm neonate because of developmental immaturity. Attention has been directed to umbilical cord gases as a method of neonatal evaluation. Using a retrospective chart review of all viable preterm births (24-36 weeks' gestation) between January 1986 and December 1989, we tabulated the umbilical cord gas indices of these infants. Fetuses with lethal congenital anomalies and those with abnormal heart rate tracings on admission were excluded from the data base, leaving 1872 infants. Cord arterial blood gas values were available for analysis in 74.4% of cases and cord venous gas values in 81.8%. The mean (+/- standard deviation [SD]) arterial and venous umbilical cord blood gas values for the preterm infants, were, respectively: pH, 7.26 +/- 0.08 and 7.33 +/- 0.07; oxygen pressure, 19.0 +/- 7.9 and 29.2 +/- 9.7 mmHg; carbon dioxide pressure, 53.0 +/- 10.0 and 43.4 +/- 8.3 mmHg; bicarbonate, 24.0 +/- 2.3 and 22.8 +/- 2.1 mEq/L; and base excess, -3.2 +/- 2.9 and -2.6 +/- 2.5 mEq/L. Acidemia was defined statistically as 2 SDs or more below the population mean. The incidence of 5-minute Apgar scores below 7 in the preterm infants was 8.5% and within this group, 17.8% were acidemic (arterial pH 7.10 or lower). More than 82% of neonates with 5-minute Apgar scores less than 7 had normal umbilical cord blood gases. There was no significant difference in umbilical arterial blood gas values between preterm infants and 1924 term deliveries at our institution between 1986-1988.(ABSTRACT TRUNCATED AT 250 WORDS)

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The relationship between fetal sepsis and acid-base status is unknown. We hypothesized that in utero sepsis would result in fetal metabolic acidemia. In a retrospective study during a 38-month period, the acid-base status at birth of neonates with in utero sepsis, documented by positive blood cultures, was reviewed. Compared with term neonates, preterm neonates had a 22-fold increase in the risk of bacteremia at birth. In spite of this increased risk of sepsis, there was no significant alteration in arterial pH in preterm septic neonates when compared with preterm controls. Fetal sepsis at term was accompanied by a statistically significant reduction in arterial pH (7.21 +/- 0.07) compared with controls (7.26 +/- 0.06, p less than 0.05). When controlled for other variables, the decrease in arterial pH at term was correlated with an increased duration of labor (7.3 +/- 0.7 in controls vs 10.8 +/- 0.9 hours in neonates with sepsis, p less than 0.05). The classic predictors of chorioamnionitis were found to be poor prognostic indicators of fetal bacteremia. Fetal sepsis at term is associated with a deterioration in the fetal acid-base status and a prolongation of labor.

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We hypothesized that foetal administration of SQ-29,548, a putative thromboxane receptor blocker, would prevent foeto-placental vasoconstriction produced by the thromboxane mimic U46619. Arterial blood gases, continuous monitoring of maternal and foetal heart rates and blood pressures were performed in chronically catheterized pregnant ewes. Foetal blood flows and vascular resistance were determined with radioactive microspheres. SQ-29,548 effectively blocked the expected vasoconstrictive effects of thromboxane. However, prolonged infusion of SQ-29,548 resulted in significant decreases in umbilical-placental blood flow and foetal mean arterial pressure. This was accompanied by a respiratory acidemia. Potential therapy for the vasoconstrictive disorders of pregnancy with SQ-29,548 awaits further investigation of its intrinsic vasoactive properties in the umbilical-placental vasculature.